1. 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

2. 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

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

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

5. 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

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

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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. Questions?