Rheumatology Specialist Nurses Research Articles

P072 The management of hand osteoarthritis in the NHS: a national UK clinician-based study

Abstract Background/Aims Hand Osteoarthritis (HOA) is a condition causing significant pain and disability in those affected. Treatments include pharmacological/non-pharmacological approaches, including splinting, pain management with non-steroidal anti-inflammatory drugs (NSAIDs), intra-articular corticosteroid (ICS) injections and surgery. There may be variability in ICS use, since few trials have compared efficacy of ICS over placebo. We conducted a UK-wide study of practising clinicians regarding their management of HOA. Methods An online survey was conducted from September 2022 - May 2023. Practising clinicians who are members of their respective societies were contacted by email. Participants provided information about their job role, region of work, nature of their clinical practice, subtypes of HOA managed and preferred management options. Results A total of 132 complete responses were obtained from the survey. Responding clinicians included Consultant Rheumatologists (43.2%), Consultant Hand Surgeons (34.8%), Rheumatology Specialist Nurses (6.1%), Rheumatology trainees (7.4%), Occupational Therapists (4.6%), Consultant Radiologists (1.5%), Physiotherapists (0.8%), General Practitioners (0.8%) and Physician Associates (0.8%). Responses were obtained from London (25%), South East (12.9%), South West (4.5%), East of England (6.8%), Midlands (12.1%), North West (3.8%), North East (3.8%), Yorkshire and the Humber (28%), Scotland (0.8%) and Wales (2.3%). There were 48.5% of respondents working in tertiary care services, 37.1% in district general hospitals, 13.6% across multiple sites in secondary care and 0.8% in primary care. Ninety-eight per cent of responders were seeing patients with HOA and the most common number of patients seen with HOA was 1-10 per month, reported by 40.3% of respondents. The most common type of HOA observed was first CMC joint or DIP/PIP joint involvement (more than 50%), with a lower proportion for erosive HOA (up to 10%). More than 90% of respondents reported that NSAIDs/hand therapy/intra-articular steroid injections/surgery were the treatments most likely to be offered. Eighty per cent of respondents reported an awareness of splinting, 31% were aware of taping. Regarding ICS, 62.9% performed ICS injections and 37.1% preferred injections under ultrasound (US) guidance. Reasons for preferring injections in clinic included time taken for US guided injections due to pressure on radiology services. Some clinicians preferred US guided confirmation of inflammation before proceeding to injection. Conclusion We obtained a high response rate from clinicians managing HOA. The most common HOA subtype observed was the first CMC, PIP/DIP joints. Recent EULAR (European Alliance of Associations for Rheumatology) recommendations state that ‘intra-articular injections of glucocorticoids should not generally be used in hand OA’, but can be considered in patients with painful PIP/DIP joints. We found high use of ICS injections as an adjunct to other therapies. Injection in clinic was preferred due to pressures on Radiology services. Our data suggest a higher use of ICS in clinical practice in comparison with published guideline recommendations. Disclosure N. Sofat: None. L. Ahmed: None. A. Radulovic: None. S. Cerovac: None. S. Umarji: None.

P109 Personalised comprehensive care packages for people with rheumatoid arthritis: a survey-based study

Abstract Background/Aims Socioeconomic and clinical factors are closely associated with long-term disease outcomes in rheumatoid arthritis (RA). There is increasing evidence for holistic, targeted management of people with RA, including at first presentation. This study aimed to determine how people with, and those involved in the treatment of RA, benefit from personalised care packages and treatment programmes. Methods An online survey was developed by an expert panel comprising physicians, psychologists, epidemiologists and patients, following three multidisciplinary workshops which included patients. Questions were designed to evaluate participants’ views on multidisciplinary Team (MDT) involvement in the care of patients at early-stage RA and onwards. The online survey underwent extensive revisions by patients and clinicians, before dissemination to patients and healthcare professionals (HCPs) in the UK. Results We received 41 complete responses: 23 (57.5%) rheumatology consultants/trainees, seven (17.5%) rheumatology specialist nurses, five (12.5%) occupational therapists, three (7.5%) physiotherapists, one dietician (2.5%) and one patient (2.5%). 82.9% of respondents agreed that people with RA need access to the same “early” care package (comprising a core MDT) at time of diagnosis. On subsequent clinical reviews, 85.4% of respondents agreed that the care package for people with early RA may need to be tailored to an individual’s clinical, psychological and social needs. 58.5% of respondents confirmed that a standard core packaging with input from a consultant rheumatologist, clinical nurse specialist/patient educator, general practitioner and pharmacist is appropriate for patients with early RA, irrespective of patient or disease-related factors; 36.6% disagreed and 4.9% were unsure. Of those disagreeing with this statement, 36.7% agreed not all of these healthcare professionals are relevant to patient care at time of diagnosis, whilst 53.3% gave another reason and 10% were unsure. 68.3% of participants suggested additional involvement of 1-6 MDT members in patient care, specifically occupational therapists, physiotherapists and psychologists. Other posited that primary care may be included occasionally, and additional MDT members’ expertise in early disease may be overwhelming and require frequent review. There was strong agreement (median 10/10 on Likert scale) for the following two statements: ‘A care package with core members of the multidisciplinary rheumatology team need to be available to people newly diagnosed with RA’; ‘Personalised comprehensive care packages, comprising a core plus various additional members of the multidisciplinary team, need to be offered and adapted according to a person’s individual disease characteristics and socio-economic circumstances’. Conclusion HCPs caring for people with RA overwhelmingly agree with a tailored MDT involvement from an early stage of disease, reviewed regularly and adapted. Care packages need to be personalised to account for bio-psycho-social factors. HCPs need to acknowledge that the “ideal” care package may vary markedly between patients to maximise impact and benefit for patients. Disclosure M. Dey: None. A.D. Busby: None. H. Lempp: None. E. Nikiphorou: None.

E048 A review of published data on reported staffing ratios for rheumatology specialist physiotherapists in rheumatology departments

Abstract Background/Aims The NHS England Getting It Right First Time (GIRFT) Rheumatology Report published in 2021 identified that Rheumatology departments in England were not getting best use of the multidisciplinary skills mix of their teams and that this expertise could be harnessed to address capacity challenges, optimise services and increase service resilience and sustainability. The British Society for Rheumatology (BSR) Workforce Report, published the same year, suggests that services require approximately one Rheumatology Consultant per 60,000-80,000 population and a one-to-one ratio of Rheumatology Specialist Nurses to Consultants. There were no suggestions in either report for Allied Health Professionals' staffing levels. Data presented in the BSR Report show that 50% of UK departments do not have a physiotherapist embedded in their multi-disciplinary team, and 7% of Trusts reported not having access to physiotherapy services. The aim of this project was to review published data on ratios of Rheumatology Specialist Physiotherapists per 100,000 population and to estimate current ratios of Rheumatology Specialist Physiotherapists per Consultant Rheumatologist in UK rheumatology services. Methods A literature review was undertaken, date range 2012-2022, on UK rheumatology staffing ratios for physiotherapists including full papers and abstracts. In addition, the BSR Workforce Report data on the average UK rheumatology department Whole Time Equivalent (WTE) staffing was used to calculate current average ratio of rheumatology physiotherapists to 100,000 population. Results Review of published literature identified one full paper and two conference abstracts. A cross-sectional study in 2017 found an average adjusted mean WTE of 0.3 per 100,000 population. The raw data from published conference abstracts on a repeated survey, in 2017 and 2021, of north-west England Rheumatology Specialist Physiotherapists was reviewed and calculated to show 0.34 and 0.32 WTE respectively for rheumatology physiotherapy per 100,000 population. Analysis of the BSR Workforce Report shows that the current UK average is 0.27 Rheumatology Specialist Physiotherapists per 100,000 population. These BSR data equate to 1 WTE Rheumatology Specialist Physiotherapist for every 5.25 WTE Rheumatology Consultants. Or for every full-time Rheumatologist, a requirement of approximately 1 day per week of rheumatology physiotherapy provision. The data from the three sets of survey data found on literature review, with an average of 0.32 WTE per 100,000 population, equate to 1 WTE rheumatology physiotherapist for every 4.5WTE rheumatology consultants. Conclusion Despite the established wide variation in staffing ratios with regard to multi-disciplinary teams in Rheumatology and a dearth of published information, the data that are available show a remarkable consistency in reported current Rheumatology Specialist Physiotherapist staffing ratios. These data are from surveys of current provision and do not replace evidence-based recommendations, which are still very much required as well as a standard for commissioning as part of an essential package in high-quality service provision. Disclosure W.J. Gregory: None.

Treatment of axial spondyloarthritis with biologic and targeted synthetic DMARDs: British Society for Rheumatology guideline scope.

Pharmacological management has advanced considerably since the 2015 British Society for Rheumatology axial spondyloarthritis (axSpA) guideline to incorporate new classes of biologic DMARDs (bDMARDs, including biosimilars), targeted synthetic DMARDs (tsDMARDs) and treatment strategies such as drug tapering. The aim of this guideline is to provide an evidence-based update on pharmacological management of adults with axSpA (including AS and non-radiographic axSpA) using b/tsDMARDs. This guideline is aimed at health-care professionals in the UK who care directly for people with axSpA, including rheumatologists, rheumatology specialist nurses, allied health professionals, rheumatology specialty trainees and pharmacists; people living with axSpA; and other stakeholders, such as patient organizations and charities.

OA27 Growth of the UK and Ireland paediatric rheumatology nurses’ group

OA27 Growth of the UK and Ireland paediatric rheumatology nurses’ group

P70 Improving safety and efficiency of biologic and DMARD therapy prescribing through development of a multi-disciplinary virtual clinic

P70 Improving safety and efficiency of biologic and DMARD therapy prescribing through development of a multi-disciplinary virtual clinic

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

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. 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. 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. 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.

P99 National competency framework for rheumatology nurse specialists

Abstract Background The first edition of the RCN Competency Framework for Rheumatology Nurse Specialists (RNS) will be published in February 2019. The role of the RNS is highly complex and several issues have driven the need for this work. The importance of RNS was highlighted by the National Rheumatoid Arthritis Society (NRAS 2017). The British Society for Rheumatology (BSR) outlined the need for education, training supervision and work force development. There are no overarching paediatric rheumatology nurse competencies other than the biologic competencies (BSPAR 2019). Education for rheumatology nurses is not currently centralised but is key to improving skills and developing our workforce for the future improving services. Both RNS and rheumatologists are in short supply resulting in problems of access to services and delays in care (BSR 2019). In all four UK nations the titles of RNS roles and proficiency vary greatly (Titrate trial 2019) which is likely to have an impact on patient experience and outcomes. The European League Against Rheumatism (EULAR) developed recommendations for the role of the RNS in the management of chronic inflammatory arthritis which were recently updated (Bech et al, 2019). They outline three key overarching principles and 8 key recommendations. This framework maps all of these requirements. Methods Online data sources were searched for the most relevant and current evidence. Where research evidence wasn’t available, existing and new knowledge was utilised from a consensus of clinical expert and patient opinions, several rounds of consensus discussions took place virtually and face to face. RCN Rheumatology Nurse Forum Workshop attendees in June 2019 also answered a questionnaire to elicit views and demographic information regarding roles. Results The workshop questionnaire results demonstrated 100% (n37) agreement with the development of the framework and that only 2 respondents had completed a competency process. 60% were RNS. Of these 52% (n13) were band 6, 47% (n9) were band 7, and 1% were band 8 consultant nurses. The questionnaire highlighted the need to develop the framework. Results were fed back to the working party to inform the domains to be included. Conclusion We will launch the document at BSR 2020 having successfully submitted a session proposal and also hope to disseminate updates on the impact of the document at subsequent events. Evaluation will begin with a call for expressions of interest. We will use 4 pilot sites (in all 4 nations) designing a questionnaire. We measure dissemination success using a variety of methods including membership Facebook pages and the questionnaire at point of download request. We will measure where and how the competency is being used and adoption of the framework throughout the UK at 6 -12 months from the launch. We hope this abstract submission will increase dissemination opportunities. Disclosures D.I. Finney Honoraria; DF has received an honorarium for presenting at a symposium. L. Parker None. H. Smith None. L. Howie None. T. Cornell Corporate appointments; Trish Cornell is a consultant nurse working for Abbvie ltd. J. Begum None. P. Livermore None. R. Wyllie None.

E01 A Survey of Patient-Reported Experience, Patient-Reported Outcome and Work in Patients Seen in Rheumatology Nurse-Led Clinics on Behalf of the West Midlands Rheumatology Nurse Specialist Network (Wmrnsn)

E01 A Survey of Patient-Reported Experience, Patient-Reported Outcome and Work in Patients Seen in Rheumatology Nurse-Led Clinics on Behalf of the West Midlands Rheumatology Nurse Specialist Network (Wmrnsn)

AB1139-HPR How Rheumatology Specialist Nurses Help Patients to Cope with Reumatoid Arthritis. A Qualitative CASE Study

BackgroundThere is evidence of the effectiveness of rheumatology nurse led clinics, but little research about the nature of the scope of the nursing activity undertaken.ObjectivesThe aim of the study was...

AB1149-HPR Pretreatment Education of Patients Treated with Biologicals

BackgroundThe introduction and rapid escalation in the use of biologicals has required a steep learning curve for rheumatology specialist nurses, who are at the forefront of patient assessment and long-term...

Moving the Injectable Methotrexate Service Closer to Home: A Practice Development Initiative

The aim of this practice development project was to make it quicker and easier for patients to switch to subcutaneous (s/c) methotrexate and thereby introduce a nurse-led methotrexate clinic into a district general hospital, which would make the best use of the advanced knowledge and skills of the rheumatology specialist nurses; empower patients and improve their experience; and introduce cost savings for the Trust. Over a period of four months, meetings were held with pharmacists, clinicians, administrative and support staff to formulate a plan to introduce the changes and agree the benefits to patients. A detailed plan for the practice development project addressed the procedures to follow, the safety issues for patients and the revision of current documentation. A review of service in the year before and after the change revealed that the number of rheumatoid arthritis patients who had switched to s/c methotrexate had increased by 80%. This was a significant difference (p = 0.049), which strongly suggested that the change in service was the reason for the increased number of patients who were able to switch their route of administration of methotrexate. This project demonstrated that not only do nurse specialists have the skills to make clinical decisions and judgements, prescribe medications and escalate therapies with no detriment to the patients, but also that this practice can lead to a more efficient and effective service, at a reduced cost to the Trust.

Nurse management of cardiovascular risk factors in rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic, multi-system inflammatory disease. The incidence and prevalence of RA varies considerably between geographic areas and over time; the prevalence of RA in adults aged > 20 years in Spain is around 0.5% (Carmona et al, 2002). People with RA also have extra-articular manifestations, presenting an increased cardiovascular morbidity and mortality risk; therefore, cardiovascular risk screening and management strategies are necessary in individuals with RA. The importance of interventions in the management of people with RA and cardiovascular risk factors is recognised by the European League Against Rheumatism (EULAR) recommendations (Peters et al, 2010). Rheumatology specialist nurses are well placed to include routine cardiovascular risk assessment for people with RA attending clinic, and to provide educational interventions to reduce cardiovascular risk, such as smoking cessation, weight loss, eating a balanced, low-fat diet and exercising regularly.

FRI0172 The perioperative use of anti-tnf therapies in patients with rheumatoid arthritis undergoing elective orthopaedic surgery: a survey of current practice

BackgroundAn increasing number of patients with RA are now being managed with anti-TNF therapies. However, there appears to be some confusion amongst health care professionals working in both Rheumatology and...

Return on investment: workload, complexity and value of the CNS

The rheumatology nurse specialist (RNS) has become an integral and vital part of the multidisciplinary team and is valued by patients. Yet, a number of challenges regularly face all clinical nurse specialists (CNS) in the UK. The perception that CNS are an expensive and poorly defined nursing resource results in regular threats to their sustainability, particularly that of the RNS. This study examined return on investment of the RNS. An interrelational Structured Query Language (SQL) database collected data on the day-to-day activities of the RNS based on previous models of CNS and RNS work, and qualitative narrative data were then subjected to data mining. The RNS represented an excellent return on investment, in terms of income generation activity, patient safety and efficiency. These outcomes were achieved using key principles of proactive case management using vigilance, rescue work and brokering. The mean average per whole time equivalent (WTE) RNS per annum represents £ 175,168 in terms of income/savings to an employing NHS Trust. This figure is likely to be an underestimation, as calculations on reduction in bed days in hospital have not been included.

Characterizing the clinical practice and professional behaviour of rheumatology nurse specialists: a pilot study

There is a need to characterize the practice of nurse specialists, for several reasons: to identify the skills and knowledge required for the role, to safeguard the role and to facilitate appropriate remuneration of activities. To develop an instrument, which characterizes the clinical and professional activities of rheumatology nurse specialists (RNSs). A questionnaire was produced, informed by the Nursing and Midwifery Council (NMC), to assess competencies in advanced nursing practice and completed by senior clinical rheumatology nurses in the UK undertaking an MSc in rheumatology nursing. Consenting respondents were also interviewed, to enable triangulation of the data. A 38-item questionnaire was produced. It comprised four sections: clinical activities, non-patient-based activities, professional behaviour and perceived confidence in a number of areas of practice. Thirteen nurses completed the questionnaire and seven of these took part in a telephone interview. All RNSs were engaged in the follow-up care of patients with rheumatoid arthritis, providing education, psychological support, monitoring and changing of drug treatments, and referrals to other health professionals. The RNSs produced guidelines, conducted audits and provided mentorship. They had low levels of confidence in seeing new patients, presenting the results of an audit at a conference, and writing a business case. We have begun the process of developing a questionnaire that can identify the clinical activities, perceived self-competence and professional behaviour of RNSs. This method of characterizing advanced nursing practice offers potential as a model for nurse specialists in other disciplines. Further work is required to validate the questionnaire on a large cohort of RNSs.

Biological nurse specialist: goodwill to good practice

The extensive use of biological agents in recent years for the treatment of rheumatological diseases has required a steep learning curve for the specialist nurses who manage and work in this specialty. Safe prescribing of biological therapies requires good infrastructure and specialist nursing personnel. With additional training, the specialist nurse may take responsibility for a number of tasks in the patient pathway including screening, treatment administration, patient education, prescription coordination for home drug delivery, patient support, monitoring and data collection. Biological treatment is becoming more widely used in several specialities, in particular gastroenterology, dermatology and ophthalmology. Since 2002, rheumatology specialist nurses have taken the lead in assessment and providing biologic therapy, not only for patients suffering from rheumatic diseases but also for those with immune-mediated inflammatory disorders. The unique nature and variable safety profiles of these agents led to the development of immune-mediated inflammatory disease infusion (IMID) centres and highlighted the importance of having biological specialist nurses. This article will discuss the evolution of the IMID/biologic specialist nurse role and how IMID services started with goodwill from the rheumatology nurse specialists to develop into a main component of the holistic approach to care.

A survey of rheumatology nurse specialists providing telephone helpline advice within England and Wales

To characterize provision of telephone helpline services in rheumatology units in England and Wales. A questionnaire study of rheumatology nurse specialists (RNS) providing advice by a designated telephone helpline in England and Wales. Responses were obtained from 164/185 rheumatology units (89%). Of the responding units, 154 (94%) employed RNS and 146 units provided telephone advice either by Allied Health Professionals or RNS. A total of 135 units confirmed that only RNS gave telephone advice via a designated helpline. Completed questionnaires were analysed from 126 RNS working in 121 rheumatology units with a designated telephone helpline. Most RNS implemented both a manned and answerphone helpline service. The average number of calls varied from <10 to >100 per week. Fifty-six percent of RNS had performed an audit of the service. Twenty-four percent possessed helpline protocols or standards. RNS' rheumatology experience ranged from 4 months to 25 yrs. Seventy-five percent had undertaken post registration study. Three out of 126 RNS reported having specific training in giving telephone advice and 25% had received in-house training or supervision. Seventy-eight percent had not been assessed in providing this service. The telephone helpline is an established service in many rheumatology units. Provision varies throughout England and Wales and a lack of protocols, formal training and assessment in giving telephone advice is common. This prompted the Royal College of Nursing Rheumatology Forum to form a working party to compile a guidance document for nurses and practitioners providing telephone advice.