Rheumatology advanced nurse practitioners are now an essential part of the multidisciplinary team caring for patients with a rheumatological condition. Over the last decade a great emphasis has been placed on specialised nursing and expanding the nursing role in the rheumatology setting. 

As a result of new treatment interventions and organisational changes the role of the nurse is also undergoing change. The advanced nurse practitioner (ANP) has evolved over time and is recognised as addressing the needs of different population groups with chronic illness. The ANP role overlaps with other health professionals to give holistic care and also provides leadership in clinical practice through the development of service, as well as practice and research.

The role of a rheumatology ANP encompasses assessment, diagnosis, management and preventative care of both acute and chronic rheumatological conditions. The ANP’s training enables them to provide advanced nursing expertise to patients.

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Nurse-led clinic

As the rheumatology ANP, I have set up a dedicated nurse-led clinic and I manage my own caseload of both new and follow-up rheumatology patients. I treat patients with inflammatory arthritis from their diagnosis until disease control is established with a wide variety of therapies. 

In particular I manage acute flares and dose titrate disease modifying antirheumatic drugs (DMARD) therapy. I review this cohort of patients approximately every six weeks, including:

• Assessment of their disease activity
• Undertaking a comprehensive history and physical examination
• Ordering and interpreting laboratory examinations 
• Determining whether they need a bolus dose of steroid based on their functional impairment. 

A key advantage of being a nurse prescriber is that I can autonomously increase patients’ DMARD therapy to contribute to long-term disease control and also taper patients’ steroid dose accordingly.

There is substantial evidence in the literature to support the effectiveness of early nurse-led care in treating patients with various chronic and acute disorders. Laurant et al demonstrated that patients had enhanced outcomes when cared for by the ANP nurse-led clinic than those cared for solely by physician.¹ As part of my research activity I have published data comparing the above ‘treat to target’ approach to the standard of care; it was very reassuring to see that patients had more rapid disease control with reduced steroid therapy.^2,3

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Bone Densitometry Unit 

I also established and continue to manage the Bone Densitometry Unit. This unit has a busy throughput of 100 patients weekly. It is my role to supervise, train and manage the nurses and administration staff at this unit. I promote their continued professional development. 

An extensive database at this unit has been collected enabling audit and research activities. This is one of the few units which undertakes vertebral fracture assessment (VFA) to confirm and diagnose vertebral fractures; this identifies patients who may require parathyroid therapy (PTH). The cohort of patients who may benefit from PTH therapy are assessed and screened. 

A recent internal audit has highlighted much higher adherence rate compared to the literature. I have concluded that this is due to a combination of patient selection and also the close monitoring provided to this patient cohort. 

Protocols and guidelines

As an ANP I have written protocols and local guidelines for the Department of Rheumatology at Cork University Hospital for all disease categories. These guidelines are essential for all healthcare professionals to ensure safe and high quality care. 

A significant advance at the CUH was the opening of a dedicated Infusion Unit. I played a key role in organising the efficient delivery of care setting up the protocols and guidelines with the infusion nurses who work in this unit. I am now delivering educational lectures to these nurses on all aspects of managing a patient with RA. I liaise with the senior nurse at this unit to coordinate patient care in a timely fashion.

As the rheumatology ANP, I am consulted directly on patients who may have issues with infusion therapies, including infection or disease flares. My training in radiology enables me to monitor disease more closely, and autonomously screen patients for tuberculosis and/or infection.

Liaison with primary care

Increasingly general practitioners and practice nurses contact my unit to assist in the management of patients with rheumatological disorders as they may not be familiar with some of the newer biologic therapies. I play a critical role between the hospital and primary care by acting as a point of contact which reduces A&E presentations.

Counselling

My role, in addition to the clinical nurse specialists’ duties, is to counsel patients and promote self management which would include the monitoring of comorbidities, including hypercholesterolaemia, smoking, diabetes and osteoporosis.

Connective tissue disease 

The cohort of patients with mixed connective tissue disease (including lupus, scleroderma, vasculitis and pulmonary hypertension) presents with complex and challenging conditions and require comprehensive care. They are at high risk of complications due to their condition and immunomodulatory therapies. 

I act as the liaison contact between the patients and the consultants. I co-ordinate the efficient running of the combined Interstitial Lung Disease/Connective Tissue Disease clinic with a visiting expert, Prof Sean Gaine of the Mater Hospital, Dublin. This clinic has advanced my knowledge significantly in this area and we received an innovation award for the work carried out by the clinic. This remains to be the only such dedicated combined clinic in the Republic of Ireland. 

Flexible delivery of care

The collaborative relationship with physicians, nurses, physiotherapist, occupational therapists and other disciplines is essential to the role. Rheumatology ANPs are now part of the interdisciplinary healthcare team caring for patients with a rheumatological chronic condition. 

Increased life expectancy and also the rise in chronic diseases in the western world have led to greater demand for healthcare both in the hospital and community setting.⁴

Nurses and other healthcare professionals have extended their roles which sometimes include work previously carried out by doctors. This approach has given a more flexible delivery of care especially in the rheumatology setting with the innovation of nurse-led clinics and their effectiveness has been shown to bring added value to patients’ outcomes. 

Nurse-led care has been described “as a model of care where nurses who practice at an extended role, assume their own patient case loads and perform nursing interventions which include monitoring patient’s condition, providing patient education, giving psychosocial support referring and discharging appropriately”.⁵

Multi-faceted role

In conclusion, the ANP is pivotal in supporting and influencing improvements in patient care. My role as ANP in rheumatology allows me to develop supportive relationships with patients and their families, to facilitate new initiatives within the department and to raise peer awareness of issues such as clinical supervision, skill mix and multi-skilling.

This role has given me the opportunity to perform a multi-faceted advocacy role, purely by occupying the unique position of functioning at a clinical and management level, and continuing to have direct contact with the patient.

The development of the ANP role in my department sought to increase quality consultations and to develop a more proactive approach to patients with chronic illness; a large cohort of this population group present with complex complications of their disease and therefore require complex care and disease management.

The field in advanced nursing practice is evolving and changing rapidly, especially in the areas of advanced practice specialties.

References

1. Laurant M, Reeves D, Hermens R et al. Substitution of doctors by nurses in primary care. Cochrane Database Syst Rev 2005 (Apr 18); 2: CD001271
2. Smolen JS, Aletaha D, Bijlsma JW. Treating rheumatoid arthritis to target: recommendations of an international task force. Ann Rheum Dis 2010; 69: 631-7
3. Silman A, Oliver J. Epidemiology of the rheumatic diseases. In: Adebajo A (Ed), ABC of Rheumatology. BMJ Publishing Group: Oxford, 2009
4. Tulchinsky TH, Varavikova E. The New Public Health. Elsevier: London, 2009
5. Nursing and Midwifery Council. The Prep Handbook. NMC: London, 2005