Evaluation of nurse training to deliver an integrated care review for patients with inflammatory rheumatological conditions in primary care: a mixed methods study Machin AR1,, Herron D1, Jinks C1, Hider SL1,2, Cooke K3, Ediriweera Desilva E1,4, Chew-Graham CA1,5 1 Research Institute, Primary Care and Health Sciences, Keele University 2 Haywood Academic Rheumatology Centre, Staffordshire 3 Clinical Trials Unit, David Weatherall Building, Keele University 4 Faculty of Medicine, University of Colombo, Sri Lanka 5 Midlands Partnership Foundation Trust

Overview Nurse training package developed for a pilot trial, INCLUDE (INtegrating and improving Care for patients with infLammatory rheUmatological DisordErs in the community) Mixed methods evaluation of training Qualitative interviews with nurses Fidelity checks on audio-recorded consultations

Conditions of interest Inflammatory Rheumatological Conditions Rheumatoid arthritis Ankylosing spondylitis Psoriatic arthritis Polymyalgia rheumatica Giant cell arteritis

Important comorbidities …which often aren’t recognised or treated Inflammatory rheumatological conditions Cardiovascular disease Anxiety and depression Smoking/ obesity/ lifestyle factors Osteoporosis

INCLUDE Study INCLUDE - a pilot trial, which aimed to evaluate the feasibility and acceptability of a nurse-led integrated primary care review for patients with inflammatory rheumatological conditions

INCLUDE review content PATIENT CENTRED CONSULTATION Cardiovascular disease BMI/ BP QRisk Lifestyle factors Smoking Alcohol intake Osteoporosis FRAX Mood PHQ-9 GAD-7

Training to deliver the review Two rheumatology nurses participated in training over 2.5 days to deliver the review A management algorithm was developed collaboratively by by GPs and rheumatologists to support the nurses to deliver the review and written materials provided An EMIS template was specifically developed for the review Presentation slides, simulated patients and in practice training on EMIS computer software were utilised

The Fidelity Checklist A fidelity checklist outlining key components of the review was developed and applied to a convenience sample of 12 audio-recorded consultations

Nurse Interviews Consent gained to conduct face-to-face interviews with both nurses after completion of their training Thematic analysis with constant comparison Overarching themes agreed amongst research team Interviews transcribed and coded using NVivo

Perspectives of training Very good [training], …it was very structured, very organised, erm a wealth of experience with [trainer 1] you know and [trainer 2]. Nurse 1 So, I’ve never worked on the EMIS System before I did this, and I’m pleased to say that I’m starting to get used to it. I’d never worked in a GP practice either… and the training’s equipped me for both. Nurse 2 [Simulated patient work in training] it’s the perfect bridge between theoretical underpinning and actually applying the knowledge. Nurse 1

Understanding comorbidities …we carefully covered cardiovascular risk…osteoporosis and carefully went through anxiety and depression so they were each given the same amount of time… and each of those problems was identified through a simulated patient…so we had the chance to trial it a little bit as well. Nurse 1 I know about the comorbidities but I wasn’t aware of the assessments that they use currently now…and I wasn’t quite sure how to explain to the patient about their risk…it’s great to have that, you know, throw it about and let’s decide what we’re going to say... Nurse 2

Results of fidelity checks Inflammatory condition and comorbidities not always linked Proposed content of review described well Opening the consultation Raised BMI sometimes normalised and diet not always explored Appropriate advice about smoking and alcohol intake given Physical Health BP, pulse rate and rhythm assessed and QRisk2 communicated well Some borderline raised BP readings not acted on Cardiovascular disease

Results of fidelity checks FRAX inappropriately calculated for a patient who should have been on treatment regardless of fracture risk FRAX scores interpreted correctly and explained well Osteoporosis Occasional leading use of the case-finding questions Meaning of patient responses to GAD-2 /PHQ-2 questions often not explained Mood Occasionally patient preferences were not accounted for Advice and follow-up communicated well using a summary sheet Advice and follow-up

Conclusions Rheumatology nurses can deliver an integrated primary care review for patients with inflammatory rheumatological conditions following a specifically designed training package Fidelity checks have highlighted important areas that need more attention in the training, particularly around mood and BMI, in a future trial Integrated review Fidelity checks Training

Funding acknowledgement WM CLAHRC and Haywood Foundation This research was supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care West Midlands (NIHR CLAHRC WM). The views expressed in this article are those of the author(s) and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care. This research was also supported by the Haywood Foundation. CLAHRC West Midlands

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