The role of the clinical nurse specialist/advanced nurse practitioner in rheumatology practice: Past, present and future
Rheumatology is a relatively young field in medicine that developed during the 20th century to become well-recognized specialty. Moreover, it is a specialty which can boast an almost parallel specialist nursing development, with nurses undertaking expanded and advanced practice roles in caring for patients with chronic rheumatic conditions. Evidence of specialist rheumatology nursing practice, albeit scant, is documented as far back as the 1960s. Since the 1980s, the nursing professions in the UK and US have recognized rheumatology as a subspecialty . Despite differences between and within countries, this development continues apace internationally [2-5].
Nurses working as clinical metrologists for rheumatology drug trials during the 1970s coordinated and documented measurements of response to drugs according to study protocols. In this role they recognized and embraced the opportunity for learning as well as frequent contact with patients. From this, the value of the inherent nurse-patient education, advice and support were increasingly recognized by clinicians as well as patients as an important component of patient care. Subsequently, during the 1980s, the first nurse-led arthritis clinics were established; driven by issues such as an increasing service need, waiting lists, and a shortage of medical staff. Moreover the readiness among nurses to expand and advance their roles was a major driver to specialist and advanced practice development .
In the 1990s in Ireland, the UK and the US, rheumatology centers replicated this model of care, establishing the role of clinical nurse specialist; whose remit had evolved to include medication monitoring, education and counseling for patients with stable disease, along with peer education . The growing contribution of nursing to comprehensive patient care became more visible within the literature. Reported nursing activities included physical care along with education, counseling, drug monitoring and service co-ordination. This support and education extended to include family members. The overarching aim of nursing was to promote self-management and help patients cope with their chronic disease. Over time nurses’ clinical experience grew and their roles expanded to include clinical and technical patient-management skills, previously the remit of the medical practitioner. Skills nurses expanded their practice to include were the therapeutic procedures of arthrocentesis and intra-articular and soft tissue injections .
Over the last two decades, three key drivers have contributed to further specialist and advanced nurse practitioner role development. One driver is the clinical and therapeutic advancements in the management of patients with autoimmune rheumatic conditions. These have improved treatment options, while making treatment decisions much more complex. The advent of modern biologic therapies has required nurses to expand their skills and competences to include the pre-treatment screening, assessment and management of patients, and monitoring of biologic as well as conventional disease modifying therapies for inflammatory arthritis .
A second driver is the global movement by the nursing profession to develop advanced practice nursing. Generic advanced practice refers to a registered nurse, educated to master’s degree level, with the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the local context and/or country of practice. Countries, as well as specialty areas, are at different stages in the development of legislation, scope of practice, roles, responsibilities, education and clinical preparation. This contributes to ambiguity around titles, definition, role, scope and function , and is beyond the scope of this review. Advanced practice in rheumatology is described as a model of care where nurses who practice an extended role assume their own patient caseloads and perform nursing interventions which include monitoring of patients condition, providing patient education, giving psychosocial support and referring appropriately . This involves working at a higher level than that of the registered nurse, demonstrating higher levels of autonomy, decision making, skills and accountability than first level registered nurses . The literature is replete with evidence of such higher level of nursing practice in rheumatology, including nurse prescribing in rheumatology, and undertaking musculoskeletal ultrasound.
Health policy internationally is the third driver behind the development of advanced practice in rheumatology . Key issues behind such policy development towards the re-definition of nursing roles, and perhaps doctors roles, include concerns about shortages of health workers and access to care, particularly in primary care; about patient safety and quality of care, about growth in health spending, about aging populations and increase in chronic disease. Studies confirm that advanced practice nurses in rheumatology impact positively on patient access, quality and satisfaction in a cost effective manner .
History and current practice dictate that the decades ahead will continue to see rheumatology specialist and advanced nurse practitioners at the forefront of delivery of quality person-centered care, working to enhance patient outcomes and reduce the personal and societal burden of rheumatic musculoskeletal diseases. Guidance documents for future practice and performance include the 2012 European League Against Rheumatism (EULAR) recommendations (currently being updated) , the American Nurse Association 2013 Scope and Standards for Practice , as well as current treatment strategies for the optimization of patient outcome in this area of chronic disease management . Three of the ten EULAR recommendations, derived from 54 studies, stipulate that patients should have access to nurses for education on the disease course and its management, improved communication, continuity, and satisfaction with care, and for ongoing support via nurse-led telephone services. The seven other recommendations stipulate that nursing practitioners participate in comprehensive management of patients’ disease and psychosocial issues; promote patient self-management skills to enhance control, self-efficacy and empowerment; practice according to evidence based protocols and guidelines; maintain and develop knowledge and skills through continuing education; undertake education and clinical preparation to assume extended roles; and strive to deliver cost effective clinical care . These recommendations and standards [10, 3] serve as a benchmark for all future specialist and advanced practice nurses.
Modern established treat-to-target (T2T) strategies for rheumatic diseases draw from concepts used in other chronic disease areas such as diabetes and hypertension . Rheumatology T2T strategies aim to significantly reduce the overall burden of disease through monitoring patients closely and titrating medication in order to achieve either the agreed goal of clinical remission or low disease activity, usually within the first 6 months of diagnosis . Not only are specialists and advanced nurse practitioners ideally placed to lead the implementation of a T2T strategy but also to instil comorbidity screening into comprehensive care management of this chronic disease group . While the long-term prognosis of inflammatory arthritis has improved since the availability of highly effective medications, this is contingent upon close monitoring and regular treatment adjustment to achieve the targets of low disease activity or remission, as well as the systematic measuring of vital signs and laboratory measures, to detect otherwise unrecognized and sometimes silent comorbid conditions . Ireland is at the forefront of advanced practice development and regulation . A new policy  and education program for advanced nursing practice in Ireland will result in 22 new advanced nurse practitioners in rheumatology by 2021, leading the implementation of T2T strategies, and care and case management for this chronic disease patient group.
Within rheumatology services, nurse-led care continues to grow as a model of care delivery in the backdrop of the global shortage of rheumatologists, increased need for patient monitoring in out-patient departments and the community, and the increasing standard of education and experience of rheumatology nurses. Parallel robust studies of specialist and advanced practice nursing interventions are required to further optimize the role of the nurse in the care of patients with rheumatic musculoskeletal diseases [3, 13].
- Hill J (ed.). Rheumatology Nursing : A Creative Approach, 2nd edition. Chichester, England; Hoboken, NJ: John Wiley & Sons, 2006.
- Wang J, Zou X, Zhou L, Liu H. Patient satisfaction after nurse-led care in Chinese patients with rheumatoid arthritis: A China study. Biomed Res (India), 2017. 28(11): 4972-4978.
- van Eijk-Hustings Y, van Tubergen A, Boström C et al. EULAR recommendations for the role of the nurse in the management of chronic inflammatory arthritis. Ann Rheum Dis, 2012. 71(1): 13-19.
- Australian Healthcare and Hospital Association. Rheumatology nurses: adding value to arthritis care. Available at http://www.arthritisaustralia.com.au/images/stories/documents/news/2017/Nurses%20the%20key%20to%20caring%20for%20arthritis/AA_RheumatologyNursesReport_screen.pdf. [Accessed 1 February 2018]
- Carter SC, Ruffing V, Patty-Resk C, Hicks D (eds.). Core Curriculum for Rheumatology Nursing. USA: Rheumatology Nurses Society, 2015; 472.
- Minnock P. Intra-Articular Injections in Specialist Rheumatology Nursing Practice. The All Ireland Journal of Nursing and Midwifery, 2002. 2: 31-35.
- Royal College of Nursing. Assessing, managing and monitoring biologic therapies for inflammatory arthritis: RCN Guidance for Rheumatology Practitioners. Updated (2017). Available at www.rcn.org.uk/professional-development/publications/pdf-005579. [Accessed 1 February 2018]
- Carney, M. Advanced practice literature review: International perspectives on Advanced Nurse and Midwife Practice, regarding advanced practice, criteria for posts and persons and requirements for regulation of Advanced Nurse /Midwife Practice. Undertaken for Nursing and Midwives Board of Ireland (NMBI). Available at www.nmbi.ie/nmbi/media/NMBI/Publications/Literature-review-advanced-practice.pdf?ext=.pdf. [Accessed 1 February 2018]
- Ndosi M, Lewis M, Hale C et al. The outcome and cost-effectiveness of nurse-led care in people with rheumatoid arthritis: a multicentre randomised controlled trial. Ann Rheum Dis, 2014. 73(11): 1975-82.
- American Nurses Association and Rheumatology Nurses Society, Rheumatology Nursing: Scope and Standards of Practice. Maryland: nursesbooks.org, 2013.
- Smolen JS, Treat-to-target: rationale and strategies. Clin Exp Rheumatol, 2012. 30(4 Suppl.73) S2-6.
- Office of the Chief Nurse. Department of Health. Developing a Policy for Graduate, Specialist and Advanced Nursing & Midwifery Practice Consultation Paper. Available at http://health.gov.ie/wp-content/uploads/2017/11/Developing-a-Policy-for-Graduate-Specialist-and-Advanced-Practice-Consultation-Paper.pdf. [Accessed 1 February 2018]
- Minnock P, McKee G, Kelly A et al. Nursing sensitive outcomes in patients with rheumatoid arthritis: A systematic literature review. Int J of Nurs Stud, 2018. 77: p. 115-129.