SHORT REPORT
The Current Knowledge and Confidence of Rheumatology Nurses in Providing Advice on Pain Management Sarah Ryan1* PhD, RGN, FRCN, Candida S. McCabe2 PhD, RGN & Jo Adams3 PhD, MSc, DipCOT 1
School of Nursing and Midwifery, Keele University, Keele, UK
2
University of the West of England, Bristol, UK
3
Centre for Innovation and Leadership Health Sciences, University of Southampton, Southampton, UK
*Correspondence Sarah Ryan, Nurse Consultant Rheumatology, Haywood Hospital, High Lane, Burslem, Stoke on Trent, ST6 7AG, UK. Email: [email protected]
Published online 7 July 2015 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/msc.1113
Introduction
Methods
Pain is a common symptom reported by people living with rheumatoid arthritis (RA), and guidance on how to manage pain is frequently sought by patients and health professionals (Dixon et al., 2007; Trudeau et al., 2010; Ryan et al., 2012). The management of RA involves controlling synovitis as well as educating patients on how to cope with symptoms such as pain and fatigue (Luqmani et al., 2006; National Institute for Health and Care Excellence, 2013). There is good evidence to support the use of both pharmacological and non-pharmacological pain management techniques for people with RA (King’s Fund 2010; Vliet Vlieland and van der Ende, 2011). Following diagnosis, most patients are referred to the rheumatology nurse specialist for education about the condition and to coordinate ongoing care (Ryan et al., 2010). In 2011, a national focus group of people with RA identified that nurses should possess the knowledge and skills to provide advice on pain management (Arthritis Research UK, 2012). A subsequent national survey of nurses and allied health professionals found that some participants did not have the knowledge or were unsure about providing advice on exercise and pain medications for people with RA (Lillie et al., 2013). There are no existing studies that have focused on the role and confidence of the rheumatology nurse in providing advice on pain management to people with RA. The aim of the present study was to identify the current knowledge and confidence of rheumatology nurses in providing advice on pain management to people with RA.
A questionnaire was developed and distributed electronically to rheumatology nurses via the Royal College of Nursing Rheumatology Forum and British Health Professionals in Rheumatology membership databases. The questionnaire content was derived from the existing literature and the rheumatology specialist nurse activity profile (SNAP) questionnaire (Ryan et al., 2010), which has been used successfully in other rheumatology nursing surveys (Royal College of Nursing, 2009). Ethical approval was obtained from Keele University ethical review panel on 17 February 2014. The questionnaire was piloted, using cognitive debriefing, with 11 rheumatology nurses working in different rheumatology services in the UK. The main objective of the pilot was to ensure that the questionnaire was clear and easy to follow, and to identify any questions that could be perceived by participants as uncomfortable to answer. Feedback from the cognitive debriefing confirmed the challenges of assessing knowledge, as expressed in the quote from one respondent below:
62
‘No questions made me feel uncomfortable but I was not sure whether any of my selected answers were the right ones, which made me feel slightly worried and made me feel that I need to increase my knowledge on pain control. But that is not the fault of the questionnaire. It is a fault with my knowledge’. Following the pilot, the research team altered the format of the questionnaire to focus on what occurs in current practice, by providing case scenario exemplars. This was Musculoskelet. Care 14 (2016) 62–66 © 2015 John Wiley & Sons, Ltd.
Ryan et al.
considered by members of the pilot group to make the questionnaire appear less threatening. The components of the final questionnaire included: 1. Nine multiple choice and/or multiple response questions regarding current role, job band, number of years within rheumatology, qualifications, identification of members within the rheumatology team who are involved in pain management and barriers to providing advice on pain management; 2. Two rating scales to identify: a) role activities currently used by the nurse to provide advice on pain management (including relaxation, exercise, medication advice, sleep, pacing and goal setting) and b) the level of perceived confidence of nurses in providing advice in these areas; 3. Four case scenarios to assess current practice in clinical situations where patients were experiencing both chronic and acute pain, and knowledge on the role of sleep, exercise, non-steroidal anti-inflammatory drug (NSAID) therapy and relaxation in managing pain in patients with RA; 4. A free text section for suggestions as to how the practice of and/or confidence of rheumatology nurses in providing advice on pain management might be improved. The content of the questionnaire was put into an electronic format using Questionmark Perception by iSolutions at the University of Southampton and distributed nationally. The sample The membership of the Royal College of Nursing (RCN) Rheumatology Forum and the nursing membership of the British Health Professionals in Rheumatology (BHPR) received an email invitation to take part in the electronic survey. The invitation contained an electronic link to the survey.
Current Knowledge and Confidence of Rheumatology Nurses
frequent qualification was a diploma (57%) and 24 respondents (40%) had a post-graduate prescribing qualification. The main method of training in pain management was through attendance at a conference, with only 27 respondents (46%) completing a dedicated course/module in pain management. The two main barriers to providing advice on pain management were lack of time (42%) and lack of knowledge (40%) The rheumatology nurse was perceived as the primary person responsible for providing advice on managing pain (66%); other members of the rheumatology team involved in this activity included physiotherapists (62%), doctors (62%) and occupational therapists (55%). Results: role activities The majority of respondents were involved in pain assessment (98%), providing advice on pain medication (93%) and referring to other members of the multidisciplinary team (88%) as part of their current practice (see Table 1). Nurses rated their confidence levels as ’confident’ or ’fairly confident’ in these activities. Activities carried out less frequently by respondents included: giving advice on non-pharmacological interventions such as sleep (64%), relaxation (64%) and setting goals for pain management (61%). Activities that were rated as minor or not part of the current role (Table 2) included providing advice on exercise (59%), referring to pain services (55%) and prescribing pain medication (51%) Results: perceived confidence in providing advice on managing pain The majority of respondents were confident in assessing how a patient manages their pain (96%), taking a pain history (86%) and providing advice on pain medication (81%; see Table 3). The only role activity that respondents were ’unsure’ or ’not confident’ in was providing advice on exercises to help pain (44%). Results from the case scenarios
Results
Providing advice on managing pain
Fifty-nine rheumatology nurses completed the survey (44 nurses from the RCN Rheumatology Forum and 15 from the BHPR). The majority of respondents were working as clinical nurse specialists (73%) at band 7 (73%) in outpatients (91%) and had worked within rheumatology for over ten years (76%). The most
The majority of respondents (81%) said that they would provide advice on pacing, sleep and pain medication (68%) to a patient with chronic pain and fatigue. Most respondents (71%) said that they would provide advice on pain medication (71%) and exercise (76%) to a patient with knee pain with no signs of active
Musculoskelet. Care 14 (2016) 62–66 © 2015 John Wiley & Sons, Ltd.
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Ryan et al.
Current Knowledge and Confidence of Rheumatology Nurses
Table 1. Role activities that were a major or moderate part of the nurses’ role Major and moderate role activities Assessing how a patient is managing their pain Providing advice on pain medication Referring to other multidisciplinary team members Explaining what causes pain Taking a pain history Providing advice on pacing Providing advice on sleep Providing advice on relaxation Setting goals for managing pain
Number of respondents [n (%)] 58 (98) 55 (93) 52 (88) 49 (83) 47 (80) 45 (76) 38 (64) 38 (64) 36 (61)
Table 2. Activities that were rated as minor or not part of the nurses’ role Minor role activities Providing advice on exercises for pain Referring to pain services Prescribing pain medication
Number of respondents n (%)] 35 (59) 32 (55) 30 (51)
Table 3. Perceived confidence in activities related to providing pain advice Areas where respondents were confident or fairly confident in: Assessing how a patient is managing their pain Taking a pain history Providing advice on pain medication Providing advice on sleep Providing advice on relaxation Providing advice on pacing Setting goals for managing pain Explaining what causes pain
Number of respondents [n (%)] 57 (96) 51 (86) 48 (81) 47 (80) 45 (76) 45 (76) 45 (76) 43 (73)
RA. Seventy-six per cent of respondents said that they would give advice on relaxation, if requested, to a patient with chronic neck pain. The majority of respondents (68%) said that they would provide advice on pain medication and the use of ice (61%) to a patient with an inflamed wrist. Knowledge Regarding the relationship between sleep and pain, 74% of respondents identified reduced muscle tenderness 64
and increased energy as a benefit of improved sleep but only 56% identified reduced joint pain as a likely benefit of improved sleep. Eighty-six per cent of respondents identified that exercise would improve muscle strength but only 17% identified that exercise could improve circulation. The majority of respondents identified reduced muscle tension (93%), pain (80%) and distraction from pain (73%) as potential benefits of relaxation. Although 85% of respondents commonly warned patients of the possibility of indigestion as a side effect of taking diclofenac, only 49% alerted patients to the potential risk of heart attacks and only 30% discussed the possibility of a rash related to NSAID therapy.
Results: improving knowledge and confidence Opinions on how to improve knowledge and confidence for nurses in providing advice on pain management identified two main themes: providing more learning opportunities (e.g. pain modules, online learning, pain sessions at conferences) and having more access to resources (e.g. information leaflets on exercise and relaxation).
Discussion The present study examined the current knowledge and confidence of rheumatology nurses in providing advice on pain management to patients with RA. Pain is rated as one of the most troublesome symptoms by patients with RA. The results of this small survey showed the key areas where rheumatology nurses had a continued need for further and ongoing education in: providing advice on exercise, the side effects of NSAIDs, and the relationship between pain and sleep. The rheumatology nurses in our survey identified lack of knowledge as being one of the main factors that acted as a barrier to providing advice on pain management. It may not always be possible (or necessary) to refer all patients with RA to see a physiotherapist for general advice on the role of exercise in managing pain. If the patient is being reviewed regularly by the nurse, it would seem the ideal opportunity for the nurse to provide basic advice on keeping active in order to help with the pain. Although patients are often aware of the benefits of exercise, they have concerns about exercise causing joint pain and harm to their joints (Law Musculoskelet. Care 14 (2016) 62–66 © 2015 John Wiley & Sons, Ltd.
Ryan et al.
et al., 2010), and require support and guidance from an informed health professional as to how to undertake physical activity when they are experiencing pain (Wang et al., 2014). If the nurse is the primary healthcare professional in the rheumatology team responsible for providing advice on pain management (as indicated in the present survey), it would seem reasonable to explore ways to increase knowledge and confidence in nurses regarding the role of physical activity in pain management. NSAIDs are commonly used in pain management in inflammatory conditions such as RA. In accordance with National Institute for Health and Care Excellence guidance (2015), all NSAIDs should be used at the lowest effective dose, for the shortest possible time, and patients should be informed of possible side effects. There is robust evidence (Pawlosky, 2013) linking diclofenac with cardiovascular events but greater emphasis is often given to their potential effect on the gastrointestinal system (Adam et al., 2011). If rheumatology nurses are assessing how patients are managing their pain (and in the present survey, 96% were), they require the knowledge to be able to discuss the side effects of medication to enable the patient to make an informed decision based on the benefits and risks involved with taking an NSAID. As time was identified as a barrier to providing advice on pain management, there needs to be a greater awareness of the use of resources that are available for nurses to share or ’signpost’ patients to, such as the Arthritis Research UK online educational materials, and leaflets on pain management, exercise and NSAIDs.
Limitations of the survey There were several limitations to the present survey. Firstly, the small sample size limited the generalizability of the survey, and the low response rate may have related to the assessment of knowledge, which can make respondents feel uncomfortable and potentially threatened. Secondly, there may have been a bias in the results, with the most confident, experienced rheumatology nurses being the ones most likely to respond to the survey. As such, the results may represent the ’best possible’ case scenarios. Thirdly, the survey measured rheumatology nurses’ perceptions of what occurs in their practice, and these may not equate with actual practice.
Musculoskelet. Care 14 (2016) 62–66 © 2015 John Wiley & Sons, Ltd.
Current Knowledge and Confidence of Rheumatology Nurses
REFERENCES Adam RJ, Appleton SL, Gill TK, Taylor AW, Wilson DH, Hill CL (2011). Cause for concern in the use of nonsteroidal anti-inflammatory medications in the community: A population based survey. BMC Family Practice 12: 70. doi 10. 1186/1471-2296-12-70. Arthritis Research UK (2012). The absent health professional. Chesterfield: Arthritis Research UK. Dixon KE, Kefe FJ, Scipio CD, Perri LM, Abernethy AP (2007). Psychological interventions for arthritis pain management in adults: A meta-analysis. Health Psychology 26: 241–50. King’s Fund (2010). Managing people with long term conditions: An enquiry into the quality of general practice in England. London: The King’s Fund. Law RJ, Breston A, Oliver E, Mawn L, Markland DA, Maddison P, Thom JM (2010). Perceptions of effects of exercise on joint health in RA. Rheumatology 49: 2444–51. Lillie K, Ryan S, Adams J (2013). The educational needs of nurses and allied healthcare professionals caring for people with arthritis: Results from a cross-sectional survey. Musculoskeletal Care 11: 93–8. Luqmani R, Hennell S, Estrach C, Birrell F, Bosworth A, Davenport G, Fokke C, Goodson N, Jeffreson P, Lamb E, Mohammed R, Oliver S, Stableford Z, Walsh D, Washbrook C, Webb F (2006). BSR/BHPR guidelines for the management of RA. Rheumatology 48: 436–9. National Institute for Health and Care Excellence (2015). Key therapeutic topics: Non-steroidal anti-inflammatory drugs. London: National Institute for Health and Clinical Excellence. National Institute for Health and Care Excellence (2013). Rheumatoid arthritis: The management of RA in adults. Clinical Guideline 79 (issued in February 2009; modified August 2013). London: National Institute for Health and Clinical Excellence. Pawlosky N (2013). Cardiovascular risk: Are all NSAIDs alike? Canadian Pharmacist Journal 146: 80–3. Royal College of Nursing (2009). Rheumatology nursing: Results of a survey exploring the performance and activity of rheumatology nurses. London: Royal College of Nursing. Ryan S, Hassell AB, Carpenter E (2010). Characterising the clinical practice and professional behaviour of rheumatology nurse specialists: A pilot study. Musculoskeletal Care 8: 136–42. Ryan S, Lillie K, Adams J, Haq I (2012). ’What I want the health professional to know’: The experiences of people with osteoarthritis and rheumatoid arthritis. Rheumatology 57: S3: iii53.
65
Current Knowledge and Confidence of Rheumatology Nurses
Trudeau KJ, Ainscough JL, Pujol LA, Charity S (2010). What arthritis pain practitioners and patients want in an online self-management programme. Musculoskeletal Care 8: 189–96. Vliet Vlieland TP, van der Ende CH (2011). Nonpharmacological treatment of RA. Current Opinion in Rheumatology 23: 259–64.
66
Ryan et al.
Wang M, Donovan-Hall M, Haywood H, Adams J (2014). People’s perceptions and beliefs about their ability to exercise with RA: A qualitative study. Musculoskeletal Care D0I.10.1002/MSC.1087.
Musculoskelet. Care 14 (2016) 62–66 © 2015 John Wiley & Sons, Ltd.
The Current Knowledge and Confidence of Rheumatology Nurses in Providing Advice on Pain Management Sarah Ryan1* PhD, RGN, FRCN, Candida S. McCabe2 PhD, RGN & Jo Adams3 PhD, MSc, DipCOT 1
School of Nursing and Midwifery, Keele University, Keele, UK
2
University of the West of England, Bristol, UK
3
Centre for Innovation and Leadership Health Sciences, University of Southampton, Southampton, UK
*Correspondence Sarah Ryan, Nurse Consultant Rheumatology, Haywood Hospital, High Lane, Burslem, Stoke on Trent, ST6 7AG, UK. Email: [email protected]
Published online 7 July 2015 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/msc.1113
Introduction
Methods
Pain is a common symptom reported by people living with rheumatoid arthritis (RA), and guidance on how to manage pain is frequently sought by patients and health professionals (Dixon et al., 2007; Trudeau et al., 2010; Ryan et al., 2012). The management of RA involves controlling synovitis as well as educating patients on how to cope with symptoms such as pain and fatigue (Luqmani et al., 2006; National Institute for Health and Care Excellence, 2013). There is good evidence to support the use of both pharmacological and non-pharmacological pain management techniques for people with RA (King’s Fund 2010; Vliet Vlieland and van der Ende, 2011). Following diagnosis, most patients are referred to the rheumatology nurse specialist for education about the condition and to coordinate ongoing care (Ryan et al., 2010). In 2011, a national focus group of people with RA identified that nurses should possess the knowledge and skills to provide advice on pain management (Arthritis Research UK, 2012). A subsequent national survey of nurses and allied health professionals found that some participants did not have the knowledge or were unsure about providing advice on exercise and pain medications for people with RA (Lillie et al., 2013). There are no existing studies that have focused on the role and confidence of the rheumatology nurse in providing advice on pain management to people with RA. The aim of the present study was to identify the current knowledge and confidence of rheumatology nurses in providing advice on pain management to people with RA.
A questionnaire was developed and distributed electronically to rheumatology nurses via the Royal College of Nursing Rheumatology Forum and British Health Professionals in Rheumatology membership databases. The questionnaire content was derived from the existing literature and the rheumatology specialist nurse activity profile (SNAP) questionnaire (Ryan et al., 2010), which has been used successfully in other rheumatology nursing surveys (Royal College of Nursing, 2009). Ethical approval was obtained from Keele University ethical review panel on 17 February 2014. The questionnaire was piloted, using cognitive debriefing, with 11 rheumatology nurses working in different rheumatology services in the UK. The main objective of the pilot was to ensure that the questionnaire was clear and easy to follow, and to identify any questions that could be perceived by participants as uncomfortable to answer. Feedback from the cognitive debriefing confirmed the challenges of assessing knowledge, as expressed in the quote from one respondent below:
62
‘No questions made me feel uncomfortable but I was not sure whether any of my selected answers were the right ones, which made me feel slightly worried and made me feel that I need to increase my knowledge on pain control. But that is not the fault of the questionnaire. It is a fault with my knowledge’. Following the pilot, the research team altered the format of the questionnaire to focus on what occurs in current practice, by providing case scenario exemplars. This was Musculoskelet. Care 14 (2016) 62–66 © 2015 John Wiley & Sons, Ltd.
Ryan et al.
considered by members of the pilot group to make the questionnaire appear less threatening. The components of the final questionnaire included: 1. Nine multiple choice and/or multiple response questions regarding current role, job band, number of years within rheumatology, qualifications, identification of members within the rheumatology team who are involved in pain management and barriers to providing advice on pain management; 2. Two rating scales to identify: a) role activities currently used by the nurse to provide advice on pain management (including relaxation, exercise, medication advice, sleep, pacing and goal setting) and b) the level of perceived confidence of nurses in providing advice in these areas; 3. Four case scenarios to assess current practice in clinical situations where patients were experiencing both chronic and acute pain, and knowledge on the role of sleep, exercise, non-steroidal anti-inflammatory drug (NSAID) therapy and relaxation in managing pain in patients with RA; 4. A free text section for suggestions as to how the practice of and/or confidence of rheumatology nurses in providing advice on pain management might be improved. The content of the questionnaire was put into an electronic format using Questionmark Perception by iSolutions at the University of Southampton and distributed nationally. The sample The membership of the Royal College of Nursing (RCN) Rheumatology Forum and the nursing membership of the British Health Professionals in Rheumatology (BHPR) received an email invitation to take part in the electronic survey. The invitation contained an electronic link to the survey.
Current Knowledge and Confidence of Rheumatology Nurses
frequent qualification was a diploma (57%) and 24 respondents (40%) had a post-graduate prescribing qualification. The main method of training in pain management was through attendance at a conference, with only 27 respondents (46%) completing a dedicated course/module in pain management. The two main barriers to providing advice on pain management were lack of time (42%) and lack of knowledge (40%) The rheumatology nurse was perceived as the primary person responsible for providing advice on managing pain (66%); other members of the rheumatology team involved in this activity included physiotherapists (62%), doctors (62%) and occupational therapists (55%). Results: role activities The majority of respondents were involved in pain assessment (98%), providing advice on pain medication (93%) and referring to other members of the multidisciplinary team (88%) as part of their current practice (see Table 1). Nurses rated their confidence levels as ’confident’ or ’fairly confident’ in these activities. Activities carried out less frequently by respondents included: giving advice on non-pharmacological interventions such as sleep (64%), relaxation (64%) and setting goals for pain management (61%). Activities that were rated as minor or not part of the current role (Table 2) included providing advice on exercise (59%), referring to pain services (55%) and prescribing pain medication (51%) Results: perceived confidence in providing advice on managing pain The majority of respondents were confident in assessing how a patient manages their pain (96%), taking a pain history (86%) and providing advice on pain medication (81%; see Table 3). The only role activity that respondents were ’unsure’ or ’not confident’ in was providing advice on exercises to help pain (44%). Results from the case scenarios
Results
Providing advice on managing pain
Fifty-nine rheumatology nurses completed the survey (44 nurses from the RCN Rheumatology Forum and 15 from the BHPR). The majority of respondents were working as clinical nurse specialists (73%) at band 7 (73%) in outpatients (91%) and had worked within rheumatology for over ten years (76%). The most
The majority of respondents (81%) said that they would provide advice on pacing, sleep and pain medication (68%) to a patient with chronic pain and fatigue. Most respondents (71%) said that they would provide advice on pain medication (71%) and exercise (76%) to a patient with knee pain with no signs of active
Musculoskelet. Care 14 (2016) 62–66 © 2015 John Wiley & Sons, Ltd.
63
Ryan et al.
Current Knowledge and Confidence of Rheumatology Nurses
Table 1. Role activities that were a major or moderate part of the nurses’ role Major and moderate role activities Assessing how a patient is managing their pain Providing advice on pain medication Referring to other multidisciplinary team members Explaining what causes pain Taking a pain history Providing advice on pacing Providing advice on sleep Providing advice on relaxation Setting goals for managing pain
Number of respondents [n (%)] 58 (98) 55 (93) 52 (88) 49 (83) 47 (80) 45 (76) 38 (64) 38 (64) 36 (61)
Table 2. Activities that were rated as minor or not part of the nurses’ role Minor role activities Providing advice on exercises for pain Referring to pain services Prescribing pain medication
Number of respondents n (%)] 35 (59) 32 (55) 30 (51)
Table 3. Perceived confidence in activities related to providing pain advice Areas where respondents were confident or fairly confident in: Assessing how a patient is managing their pain Taking a pain history Providing advice on pain medication Providing advice on sleep Providing advice on relaxation Providing advice on pacing Setting goals for managing pain Explaining what causes pain
Number of respondents [n (%)] 57 (96) 51 (86) 48 (81) 47 (80) 45 (76) 45 (76) 45 (76) 43 (73)
RA. Seventy-six per cent of respondents said that they would give advice on relaxation, if requested, to a patient with chronic neck pain. The majority of respondents (68%) said that they would provide advice on pain medication and the use of ice (61%) to a patient with an inflamed wrist. Knowledge Regarding the relationship between sleep and pain, 74% of respondents identified reduced muscle tenderness 64
and increased energy as a benefit of improved sleep but only 56% identified reduced joint pain as a likely benefit of improved sleep. Eighty-six per cent of respondents identified that exercise would improve muscle strength but only 17% identified that exercise could improve circulation. The majority of respondents identified reduced muscle tension (93%), pain (80%) and distraction from pain (73%) as potential benefits of relaxation. Although 85% of respondents commonly warned patients of the possibility of indigestion as a side effect of taking diclofenac, only 49% alerted patients to the potential risk of heart attacks and only 30% discussed the possibility of a rash related to NSAID therapy.
Results: improving knowledge and confidence Opinions on how to improve knowledge and confidence for nurses in providing advice on pain management identified two main themes: providing more learning opportunities (e.g. pain modules, online learning, pain sessions at conferences) and having more access to resources (e.g. information leaflets on exercise and relaxation).
Discussion The present study examined the current knowledge and confidence of rheumatology nurses in providing advice on pain management to patients with RA. Pain is rated as one of the most troublesome symptoms by patients with RA. The results of this small survey showed the key areas where rheumatology nurses had a continued need for further and ongoing education in: providing advice on exercise, the side effects of NSAIDs, and the relationship between pain and sleep. The rheumatology nurses in our survey identified lack of knowledge as being one of the main factors that acted as a barrier to providing advice on pain management. It may not always be possible (or necessary) to refer all patients with RA to see a physiotherapist for general advice on the role of exercise in managing pain. If the patient is being reviewed regularly by the nurse, it would seem the ideal opportunity for the nurse to provide basic advice on keeping active in order to help with the pain. Although patients are often aware of the benefits of exercise, they have concerns about exercise causing joint pain and harm to their joints (Law Musculoskelet. Care 14 (2016) 62–66 © 2015 John Wiley & Sons, Ltd.
Ryan et al.
et al., 2010), and require support and guidance from an informed health professional as to how to undertake physical activity when they are experiencing pain (Wang et al., 2014). If the nurse is the primary healthcare professional in the rheumatology team responsible for providing advice on pain management (as indicated in the present survey), it would seem reasonable to explore ways to increase knowledge and confidence in nurses regarding the role of physical activity in pain management. NSAIDs are commonly used in pain management in inflammatory conditions such as RA. In accordance with National Institute for Health and Care Excellence guidance (2015), all NSAIDs should be used at the lowest effective dose, for the shortest possible time, and patients should be informed of possible side effects. There is robust evidence (Pawlosky, 2013) linking diclofenac with cardiovascular events but greater emphasis is often given to their potential effect on the gastrointestinal system (Adam et al., 2011). If rheumatology nurses are assessing how patients are managing their pain (and in the present survey, 96% were), they require the knowledge to be able to discuss the side effects of medication to enable the patient to make an informed decision based on the benefits and risks involved with taking an NSAID. As time was identified as a barrier to providing advice on pain management, there needs to be a greater awareness of the use of resources that are available for nurses to share or ’signpost’ patients to, such as the Arthritis Research UK online educational materials, and leaflets on pain management, exercise and NSAIDs.
Limitations of the survey There were several limitations to the present survey. Firstly, the small sample size limited the generalizability of the survey, and the low response rate may have related to the assessment of knowledge, which can make respondents feel uncomfortable and potentially threatened. Secondly, there may have been a bias in the results, with the most confident, experienced rheumatology nurses being the ones most likely to respond to the survey. As such, the results may represent the ’best possible’ case scenarios. Thirdly, the survey measured rheumatology nurses’ perceptions of what occurs in their practice, and these may not equate with actual practice.
Musculoskelet. Care 14 (2016) 62–66 © 2015 John Wiley & Sons, Ltd.
Current Knowledge and Confidence of Rheumatology Nurses
REFERENCES Adam RJ, Appleton SL, Gill TK, Taylor AW, Wilson DH, Hill CL (2011). Cause for concern in the use of nonsteroidal anti-inflammatory medications in the community: A population based survey. BMC Family Practice 12: 70. doi 10. 1186/1471-2296-12-70. Arthritis Research UK (2012). The absent health professional. Chesterfield: Arthritis Research UK. Dixon KE, Kefe FJ, Scipio CD, Perri LM, Abernethy AP (2007). Psychological interventions for arthritis pain management in adults: A meta-analysis. Health Psychology 26: 241–50. King’s Fund (2010). Managing people with long term conditions: An enquiry into the quality of general practice in England. London: The King’s Fund. Law RJ, Breston A, Oliver E, Mawn L, Markland DA, Maddison P, Thom JM (2010). Perceptions of effects of exercise on joint health in RA. Rheumatology 49: 2444–51. Lillie K, Ryan S, Adams J (2013). The educational needs of nurses and allied healthcare professionals caring for people with arthritis: Results from a cross-sectional survey. Musculoskeletal Care 11: 93–8. Luqmani R, Hennell S, Estrach C, Birrell F, Bosworth A, Davenport G, Fokke C, Goodson N, Jeffreson P, Lamb E, Mohammed R, Oliver S, Stableford Z, Walsh D, Washbrook C, Webb F (2006). BSR/BHPR guidelines for the management of RA. Rheumatology 48: 436–9. National Institute for Health and Care Excellence (2015). Key therapeutic topics: Non-steroidal anti-inflammatory drugs. London: National Institute for Health and Clinical Excellence. National Institute for Health and Care Excellence (2013). Rheumatoid arthritis: The management of RA in adults. Clinical Guideline 79 (issued in February 2009; modified August 2013). London: National Institute for Health and Clinical Excellence. Pawlosky N (2013). Cardiovascular risk: Are all NSAIDs alike? Canadian Pharmacist Journal 146: 80–3. Royal College of Nursing (2009). Rheumatology nursing: Results of a survey exploring the performance and activity of rheumatology nurses. London: Royal College of Nursing. Ryan S, Hassell AB, Carpenter E (2010). Characterising the clinical practice and professional behaviour of rheumatology nurse specialists: A pilot study. Musculoskeletal Care 8: 136–42. Ryan S, Lillie K, Adams J, Haq I (2012). ’What I want the health professional to know’: The experiences of people with osteoarthritis and rheumatoid arthritis. Rheumatology 57: S3: iii53.
65
Current Knowledge and Confidence of Rheumatology Nurses
Trudeau KJ, Ainscough JL, Pujol LA, Charity S (2010). What arthritis pain practitioners and patients want in an online self-management programme. Musculoskeletal Care 8: 189–96. Vliet Vlieland TP, van der Ende CH (2011). Nonpharmacological treatment of RA. Current Opinion in Rheumatology 23: 259–64.
66
Ryan et al.
Wang M, Donovan-Hall M, Haywood H, Adams J (2014). People’s perceptions and beliefs about their ability to exercise with RA: A qualitative study. Musculoskeletal Care D0I.10.1002/MSC.1087.
Musculoskelet. Care 14 (2016) 62–66 © 2015 John Wiley & Sons, Ltd.
