The expanding role of the nurse in rheumatology

Development of generic core competences of health professionals in rheumatology: a systematic literature review informing the 2018 EULAR recommendations

Objective

To identify generic competences on the desired knowledge, skills and of health professionals in rheumatology (HPRs) to inform the respective EULAR recommendations.

Methods

A systematic literature review was performed on the generic core competences (defined as knowledge, skills or attitudes) of HPRs (nurses, physical therapists (PTs) or occupational therapists (OTs)). Literature was obtained from electronic databases, published EULAR recommendations and via personal communication with representatives of national rheumatology societies and experts in the field. Qualitative, quantitative and mixed methods studies were included, and their methodological quality was scored using appropriate instruments.

Results

From 766 references reviewed, 79 fulfilled the inclusion criteria. Twenty studies addressed competences of multiple HPRs: 15 were of qualitative design, 1 quantitative, 1 mixed-methods, 2 systematic reviews and 1 opinion paper. The methodological quality of most studies was medium to high. Five studies concerned the development of a comprehensive set of competences. Key competences included: basic knowledge of rheumatic diseases, holistic approach to patient management, effective communication with colleagues and patients and provision of education to patients. The proposed competences were confirmed in studies focusing on one or more specific competences, on a rheumatic disease or on a specific profession (nurses, PTs or OTs).

Conclusion

Generic competences were identified for HPRs. Data were mostly derived from qualitative studies. All identified studies varied and were at national level, highlighting the need for the harmonisation of HPR competences across Europe. These findings underpin the development of EULAR recommendations for the core competences of HPRs.

2019 EULAR recommendations for the generic core competences of health professionals in rheumatology

Background/objectives

To maintain and optimise the quality of care provided by health professionals in rheumatology (HPRs), adequate educational offerings are needed. This task force (TF) aimed to develop evidence-based recommendations for the generic core competences of HPRs, with specific reference to nurses, physical therapists (PTs) and occupational therapists (OTs) to serve as a basis for their postgraduate education.

Methods

The EULAR standardised operating procedures for the development of recommendations were followed. A TF including rheumatologists, nurses, PTs, OTs, patient-representatives, an educationalist, methodologists and researchers from 12 countries met twice. In the first TF meeting, 13 research questions were defined to support a systematic literature review (SLR). In the second meeting, the SLR evidence was discussed and recommendations formulated. Subsequently, level of evidence and strength of recommendation were assigned and level of agreement (LoA) determined (0–10 rating scale).

Results

Three overarching principles were identified and 10 recommendations were developed for the generic core competences of HPRs. The SLR included 79 full-text papers, 20 of which addressed the competences, knowledge, skills, attitudes and/or educational needs of HPRs from multiple professions. The average LoA for each recommendation ranged from 9.42 to 9.79. Consensus was reached both on a research and educational agenda.

Conclusion

Evidence and expert opinion informed a set of recommendations providing guidance on the generic core competences of HPRs. Implementation of these recommendations in the postgraduate education of HPRs at the international and national level is advised, considering variation in healthcare systems and professional roles.

Randomized controlled trial of a nurse-led rheumatology clinic for monitoring biological therapy

AIM

To compare and evaluate the treatment outcomes of a nurse-led rheumatology clinic and a rheumatologist-led clinic in patients with low disease activity or in remission who are undergoing biological therapy.

BACKGROUND

Patients with chronic inflammatory arthritis treated with biological therapy are usually monitored by rheumatologists. Nurse-led rheumatology clinics have been proposed in patients with low disease activity or in remission.

DESIGN

Randomized controlled trial.

METHODS

A 12-month follow-up trial was conducted between October 2009 and August 2011, where 107 patients were randomized into two groups with a 6-month follow-up to a nurse-led rheumatology clinic based on person-centred care (intervention group; n = 53) or to a rheumatologist-led clinic (control group; n = 54). The hypothesis was that the nurse-led clinic outcomes would not be inferior to those obtained from a rheumatologist-led clinic at the 12-month follow-up. The primary outcome was disease activity measured by Disease Activity Score 28.

RESULTS

A total of 47 patients in the intervention group and 50 in the control group completed the 12-month trial. The trial revealed no statistically significant differences between groups in mean change of Disease Activity Score 28, Visual Analogue Scales for pain, the Health Assessment Questionnaire, satisfaction with or confidence in obtaining rheumatology care.

CONCLUSION

Patients with stable chronic inflammatory arthritis undergoing biological therapy could be monitored by a nurse-led rheumatology clinic without difference in outcome as measured by the Disease Activity Score 28.

Changing structure and resources in a rheumatology combined unit during 1977–1999

OBJECTIVE

The aim was to study the changing structure and resources in a rheumatism hospital during the period 1977-1999 when rheumatology care was decentralized and new treatment strategies were introduced.

METHODS

Data on hospital management and production were retrieved retrospectively.

RESULTS

The number of beds was stepwise reduced from 133 to 44 and the average length of stay declined from 48 to 16 days. The combined unit and multidisciplinary team organization was kept, ensuring the combined effort of rheumatologists, rheumasurgeons, registered nurses, physiotherapists, occupational therapists, and social workers. One-third of the total staff was rheumateam members in 1977 compared to one-half in 1999. The proportions of physicians and registered nurses increased while the proportion of physiotherapists was stable. The number of discharges remained relatively unchanged and the number of outpatient consultations increased. Inflammatory rheumatic diseases remained the largest diagnostic group of in- and outpatients. Hospitalized care was received primarily by patients with arthritis and spondylitis. Patients with vasculitis and diffuse disorders of connective tissue accounted for an increasing proportion of the outpatient clinic production. Surgical procedures became more prevalent. Since 1995 approximately 50 large joint replacements have been performed annually.

CONCLUSION

The length of stay declined and patient care was shifted towards the outpatient clinic. The multidisciplinary team was strengthened. More resources were dedicated to physician-led and nurse-dependent procedures, but physiotherapy and rehabilitation remained part of inpatient care throughout the period. The expertise concentrated on inflammatory rheumatic disorders. The modesty of the large joint replacement caseload may challenge decentralized care.

Outcomes for patients with RA: a rheumatology nurse practitioner clinic compared to standard outpatient care

OBJECTIVES

The study aimed to extend our previous work by comparing the outcome of patients with rheumatoid arthritis (RA) attending a rheumatology nurse practitioner (RNP) clinic with those of patients attending the more traditional junior hospital doctor's clinic (JHD).

METHOD

A randomised controlled trial of 80 people with RA were allocated to either an RNP or JHD clinic and seen six times in 12 months. The primary outcome measure was the DAS28. Secondary measures included stiffness, fatigue, physical function, psychological status, knowledge and satisfaction.

RESULTS

Number of patients: RNP 39 (8 males); JHD 41 (9 males). Age of patients: RNP 36-76 years (median 57); JHD 35-74 years (median 57). Median disease duration: RNP 12 years (range 2-40); JHD 17 years (range 1.5-41). Years of full time education: RNP 8-17 years (median 10); JHD 9-20 years (median 10). Week 48 DAS scores compared to baseline: RNP 19 unchanged, 6 worse and 11 better; JHD 22 unchanged, 7 worse, 6 better. Length of morning stiffness increased significantly at week 24 (p = 0.05) in the JHD cohort but improved to become non-significant at week 48 (p = 0.09). By week 48 fatigue had improved in the RNP cohort (p = 0.038) and deteriorated in JHD patients (p = 0.008). The AIMS showed decreases in pain in the RNP cohort (p = 0.044) and worsening physical function in JHD patients (p = 0.038). Patient satisfaction in the RNP cohort increased significantly (overall satisfaction p = 0.000). The JHD cohort showed a decrease in satisfaction with access and continuity (p = 0.027).

CONCLUSIONS

The findings from this research confirm that care from the RNP is both effective and safe. Furthermore, a specialist RNP can bring additional benefits in the form of greater symptom control and enhanced patient self-care.

Tailored cognitive-behavioral therapy in early rheumatoid arthritis for patients at risk: a randomized controlled trial

Recent developments in chronic pain research suggest that effectiveness of cognitive-behavioral therapy (CBT) may be optimized when applying early, customized treatments to patients at risk. For this purpose, a randomized, controlled trial with tailor-made treatment modules was conducted among patients with relatively early rheumatoid arthritis (RA disease duration of <8 years), who had been screened for psychosocial risk profiles. All participants received standard medical care from a rheumatologist and rheumatology nurse consultant. Patients in the CBT condition additionally received an individual CBT treatment with two out of four possible treatment modules. Choice of treatment modules was determined on the basis of patient priorities, which resulted in most frequent application of the fatigue module, followed by the negative mood, social relationships and pain and functional disability modules. Analyses of completers and of intention-to-treat revealed beneficial effects of CBT on physical, psychological and social functioning. Specifically, fatigue and depression were significantly reduced at post-treatment and at the 6-month follow-up in the CBT condition in comparison to the control condition, while perceived support increased at follow-up assessment. In addition, helplessness decreased at post-treatment and follow-up assessment, active coping with stress increased at post-treatment, and compliance with medication increased at follow-up assessment in the CBT condition in comparison to the control condition. Results indicate the effectiveness of tailor-made CBT for patients at risk in relatively early RA, and supply preliminary support for the idea that customizing treatments to patient characteristics may be a way to optimize CBT effectiveness in RA patients.

Use of discrete choice experiments to elicit preferences

This paper considers the application of discrete choice experiments for eliciting preferences in the delivery of health care. Drawing upon the results from a recently completed systematic review, the paper summarises the application of this technique in health care. It then presents a case study applying the technique to rheumatology outpatient clinics. 200 patients were questioned about the importance of six attributes: staff seen (junior doctor or specialist nurse); time in waiting area; continuity of contact with same staff; provision of a phone-in/advice service; length of consultation; and change in pain levels. The systematic review indicated that discrete choice experiments have been applied to a wide number of areas and a number of methodological issues have been addressed. Consistent with this literature, the case study found evidence of both rationality and theoretical validity of responses. The approach was used to establish the relative importance of different attributes, how individuals trade between these attributes, and overall benefit scores for different clinic configurations. The value of attributes was estimated in terms of time, and this was converted to a monetary measure using the value of waiting time for public transport. Discrete choice experiments represent a potentially useful instrument for eliciting preferences. Future methodological work should explore issues related to the experimental design of the study, methods of data collection and analysis, and satisfaction with the economic axioms of the instrument. Collaborative work with psychologists and qualitative researchers will prove useful in this research agenda.