An exploration of the experiences of rheumatology nurses counselling patients on methotrexate therapy

Viewpoint: Nurses educating patients about drugs

Educating patients about the drugs they take is essential for them to take them safely and effectively. This education is now commonly given by nurses as part of the huge expansion in the nurse specialist role. However, training for this role has not kept pace with practice. Nurses have expressed variable confidence in this role and expressed a wish for more formal training. Current practice often puts the information rather than the patient at the centre of the consultation with the nurse dominating the conversation. Cues to address the patient agenda are commonly missed. An animated patient who interrupts is probably not having their educational needs met. Education of the professionals around how to perform this task in an optimal way is necessary and should result in better efficacy and safety of the drugs. This could be achieved by incorporating features of Shared Decision Making and the Calgary-Cambridge consultation techniques into training and the consultation. Personalization by attention to patient preferences, language and health literacy is essential.

Towards a consensus for nurse education of methotrexate for people with rheumatic and musculoskeletal diseases: A scoping review

INTRODUCTION

Patient education (PE) is a key role of nurses, which includes providing information, training, and support about methotrexate (MTX), an anchor drug in rheumatology. However, there is a wide variation in the access to rheumatology nurse consultations in Europe, and there is a lack of consensus regarding the delivery, context and timing of PE in these cases. This study aimed to provide a comprehensive overview of the existing research on nurse education of MTX for children/youth and adults with Rheumatic and Musculoskeletal Diseases (RMDs).

METHODS

This scoping review was conducted in accordance with Arksey and O'Malley's framework. A search on PubMed (MEDLINE), Scopus and Cochrane Database, and CINAHL, from inception until March 2022 was conducted. Articles on PE with a focus on MTX exclusively were included. Published and unpublished studies, from any world region, conducted with a qualitative, quantitative, or mixed-methods design and focused on defined research questions, were eligible for inclusion. Broad inclusion criteria were used if a research paper on PE focused on MTX for people with RMDs (PE or patient engagement, self-management, medication knowledge, or health literacy in patients). The reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses - Extension for Scoping Reviews (PRISMA-ScR) checklist. Two independent reviewers performed standardized data extraction and synthesis.

RESULTS

From 292 references identified, the total number of studies which met the inclusion criteria was relatively small (n = 14). The results identified that knowledge of MTX improves when education by nurses is provided.

CONCLUSION

This scoping review showed that there is no universal worldwide strategy for MTX education of children/youths and adults with RMDs. However, PE regarding MTX can be delivered in different forms, resulting in better satisfaction and adherence. More randomized controlled trials with powered samples are required.

Quantitative interpretation of utterances and movements from videoed interactions between rheumatology nurses and patients commencing methotrexate: a pilot study

BACKGROUND

Educating patients about methotrexate is a core role of rheumatology nurses. We have previously reported the scoring of videoed interviews of rheumatology nurses educating patients prior to commencing methotrexate in comparison with the Calgary-Cambridge consultation model, and the qualitative analysis of the transcripts (Robinson et al. Musculoskeletal Care 2021). We were interested to investigate what could be learned from a more quantitative analysis of utterances and movements in these consultations and how they related to the qualitative interpretations.

AIM

To investigate the frequency of utterances and body movements during interactions between rheumatology nurses and patients commencing methotrexate and to relate these to the qualitative interpretations of the interviews.

METHODS

Video-recordings of ten patients receiving methotrexate education from four different rheumatology nurses were available from the previous study. They were analysed using the Medical Interaction Process System (MIPS). This involved coding all utterances and body movements minute-by-minute by multiple inspections of the recordings. The first 10 min of each consultation was coded. The utterances and movements of the nurses and patients were compared. The thematic analysis based on the structure and content of the Calgary-Cambridge (C-C) consultation model was available from the previous study. This enabled the results from the MIPS to be compared between the interviews that scored higher on the C-C model and those scoring lower.

RESULTS

The inter-rater reliability between 2 raters for one video was satisfactory (80-100% agreement). Numerically, giving information dominated the nurse contribution and assent by positive utterances and head nodding dominated for the patients. The results were consistent with the nurse agenda dominating the interaction with little opportunity for patient involvement. Nurses in high-scoring interviews made more illustrative gestures and fewer batonic movements while patients did the opposite. Nurses in high-scoring consultations asked more open questions, with more checking of understanding and summarising but fewer interruptions. Patients in low-scoring consultations were much more animated with head movements and illustrative gestures. Patients also checked and interrupted more.

CONCLUSIONS

In this pilot study, the MIPS was usable and demonstrated verbal and non-verbal behaviours consistent with the qualitative assessments. It also showed some behaviours that are not intuitive but may indicate how effectively the interview was progressing. Some nurse behaviours identified that were associated with the higher scoring interviews may be useful indictors for training including making illustrative rather than batonic gestures and checking understanding. Patient behaviours, such as greater animation, were exhibited in low-scoring consultations, and could indicate that the interview was not addressing the patient perspective. Quantification of utterances and movements can be done and may give insights into the consultation process.

An exploratory study using video analysis of rheumatology specialist nurses conducting methotrexate education consultations with patients

BACKGROUND

Prior to commencing methotrexate, patients routinely attend an education consultation with a rheumatology nurse. The purpose of the consultation is to discuss the patients' expectations and concerns related to commencing methotrexate, the benefits of treatment, potential side effects and monitoring requirements. The aim of this study was to use video analysis to assess the structure, content and mode of delivery of the consultation.

METHODS

Video recordings of 10 patient-nurse consultations, involving four specialist rheumatology nurses, were analysed and transcribed. The consultations were compared with the Calgary-Cambridge (CC) consultation model. Transcripts were thematically analysed. Data were quantitatively assessed for verbal and non-verbal behaviours.

FINDINGS

Assessment of the video data using the CC model demonstrated good structure, content and flow of the consultation, influenced by the use of an information leaflet. Consultations generally consisted of communication from nurse to patient rather than a dialogue; the nurse spoke for 69%-86% of the time; clarification of the patient's understanding of the information did not take place in any of the consultations. Thematic analysis also showed that the nurse agenda dominated and the nurse was aware of 'overloading' the patient with information. Cues from the patients to discuss items of importance were often missed.

CONCLUSION

Video analysis can be used to identify the aspects of the consultation that work well and those areas of the consultation that could be improved with specific training.