Opinion: Role of Rheumatology Nurse Should Be Expanded

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The care of patients with rheumatic diseases has undergone a great transition, with high expectations for both patients and healthcare professionals to achieve quality outcomes for the many different disorders. Integral to this goal is the development of new care models, with evolving roles for the various care providers on the multidisciplinary team.^1-3 A new vocabulary of driving factors is being incorporated into these care models, including quality metrics, precision medicine, affordable care, physician/extender partnerships, motivational interviewing and health coaching.^4-6

In addition, the defined responsibilities of the healthcare system and providers are expanding and need to be addressed. Providers are responsible for activities and outcomes across the continuum of patients’ lives—pharmaceutical and non-pharmaceutical management, psychosocial issues, compliance and cost.

The role of each member of the healthcare team is being intensely evaluated, with additional focus on efficiency and care coordination. Adapting to these new roles is quite challenging and requires a major paradigm shift from the traditional care models that have long been ingrained through training curriculums and experience.

The Rheumatology Nurse

The traditional role of the rheumatology nurse has evolved tremendously over the past three decades. In the past, rheumatology nurses functioned primarily as patient caregivers, with their activities within the ordering direction of physicians. Primary in these responsibilities were limited history and exam data collection, medication administration, assistance in activities of daily living, and disease education and counseling. Decision making was limited.

Increasingly, nursing education has expanded to advanced degrees and specialization, with the registered nurse’s role including more comprehensive gathering of clinical information, interdisciplinary care coordination, focusing on patient engagement and self-management, in-depth treatment education and monitoring, and paper and electronic record documentation.

Nurse practitioners have even greater activities in their scope of practice.

Although the Bureau of Labor Statistics reports 2.7 million registered nurse positions, there is a critical shortage of trained rheumatology nurses.⁷ The ARHP has approximately 1,300 members, of whom 520 are nurse/advanced practice nurse members.

In practice, there is significant variation in the specific roles of rheumatology nurses related to a number of factors, including education and training requirements, geographic location, cultural definitions, attitudes of their healthcare professional colleagues, and policies of their administrators and professional societies.

Nurse-led care in the outpatient setting can achieve comparable or better results than physicians alone.

Further advances in diagnostic technology and therapeutic tools, more complex health delivery systems and greater expectations for favorable outcomes have created tremendous pressures on time management for all healthcare professionals. For example, in the anatomy of a follow-up office visit, necessary elements include patient registration and insurance verification; rooming; history review, including chief complaint; interval history; medication use; and vital signs by the nurse or medical assistant. This is followed by physician history, physical exam, outside record review, decision making, discussion, visit documentation and creation of referral communication. The patient checks out, schedules their next appointment and settles their bill. All this must be completed in 15–30 minutes in order to stay on time.

Research on the Nurse’s Role

A gradual increase in specific care activities for nurses in rheumatic disease has occurred since the 1990s, more so in Europe and Canada with a focus particularly on rheumatoid arthritis. However, the research evidence has been limited.

In 2012, the European League Against Rheumatism (EULAR) published an evidence-based position paper developed by a multidisciplinary consensus task force that suggested 10 recommendations for the nurse’s role in the management of chronic inflammatory arthritis to “help determine practice, education and research activities.”⁸ Of these, four had an A (best) category strength of recommendations:

1. Provision of patient access to a nurse for education about the disease and its management;
2. Provision of patient access for nurse consultations to improve communication, continuity and satisfaction with care;
3. Nurse participation in comprehensive disease management and outcome activities; and
4. Nurse assessment and intervention for psychosocial issues to reduce the risk of patients experiencing anxiety and depression.

Fewer data were available about assessing rheumatology nursing activities for performing telephone counseling, using care protocols and guidelines, promoting an expanded practice role, assisting in cost control, participating in continuing education and providing patient self-management.

The role of each member of the healthcare team is being evaluated, with focus on efficiency & care coordination.

Since this paper was released, significant clinical research on nursing activities in rheumatoid arthritis has been published, showing the potential positive impact of motivational interviewing, demonstrating that nurses and physicians have good interrater correlation in performing the 28-joint count and showing that nurse-led care in the outpatient setting can achieve comparable or better results than physicians alone.^6,9-17

The time is now to aggressively further investigate and implement the role of nurses in rheumatologic care, not only in rheumatoid arthritis, but also in the other rheumatic diseases.

Let’s do it.

Terence Starz, MD, is a clinical professor of medicine in the Division of Rheumatology at the University of Pittsburgh School of Medicine and is in practice at Arthritis and Internal Medicine Associates–UPMC in the Western Pennsylvania Area. In addition, he is involved in clinical research projects, including rheumatoid arthritis outcome studies, and has participated in classification and intervention studies in fibromyalgia and healthcare utilization in low back pain. He serves on the Board of Directors of the Great Lakes Region of the Arthritis Foundation and the Pennsylvania Rheumatology Society.

Brandon Young, DNP, FNP-C, is a family nurse practitioner who practices in the Rheumatology and Osteoporosis Center for Excellence at North Mississippi Medical Center in Tupelo, Mississippi. In addition, she serves as a sub-investigator in numerous clinical research trials and precepts nurse practitioner fellows interested in rheumatology. She is involved with the Association of Rheumatology Health Professionals and has served on various ACR and ARHP subcommittees and committees.

References

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4. Larry JL, Longo DL. Precision medicine—personalized, problematic and promising. N Engl J Med. 2015 Jun 4;372(23):2229–2234.
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7. Bureau of Labor Statistics, US Department of Labor. Occupational Outlook Handbook. 2012–13 ed. Registered Nurses.
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17. Dougados M, Soubrier M, Perrodeau E, et al. Impact of a nurse-led programme on comorbidity management and impact of a patient self-assessment of disease activity on the management of rheumatoid arthritis: Results of a prospective, multicentre, randomised, controlled trial (COMEDRA). Ann Rheum Dis. 2015 Sep;74(9):1725–1733.