An exploration of the clinical practice of Rheumatology specialist nurses undertaking consultations with patients starting Methotrexate

Robinson, Sandra M. (2021) An exploration of the clinical practice of Rheumatology specialist nurses undertaking consultations with patients starting Methotrexate. Doctoral thesis, Northumbria University.

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Abstract

Background
Rheumatology nursing roles have evolved over the last 25 years to include educating patients prior to commencing drugs such as Methotrexate in consultations. The expansion of their role has not been supplemented by specific training in order to prepare them for this undertaking. Thus, this study was developed to explore how Rheumatology Specialist nurses gained knowledge about consulting with patients on Methotrexate, how they delivered information to patients, and to identify elements of their consultation for further
development.

Methods
This was a mixed-methods practice based study undertaken in three phases. Training, confidence and knowledge were explored with a questionnaire, which constituted Phase I. Phase II explored the lived experiences of the nurses with semi-structured interviews. Phase III explored the interaction between the nurses and patients during a consultation which was video-recorded and analysed using qualitative and quantitative approaches, with the interaction scored against items in the Calgary Cambridge consultation model.

Findings
The results of the survey (n=97) and the semi-structured interviews findings (n=6) revealed significant variability in training received by Rheumatology Specialist nurses. Confidence took three to 12 months to develop and was related to experience, knowledge and training, with nurses expressing a clear desire for more training. Written information was used by all participants during consultations, usually in the form of the Methotrexate information booklet, which had some benefits, including allowing the nurses to structure their consultations, ensuring that all of the information in the booklet was given to patients. However, it also had the disadvantage of becoming the nurses’ agenda which dominated the consultation, leading to overloading the patients with information and restricting discussion and questions from the patients. Analysis of consultation videos (n=10) supported these findings, demonstrating that whilst all of the important information from the booklet was given, there was a lack of involvement during the consultation of the patient agenda such as ideas, concerns and expectations, with little checking by the nurses to ensure the patients understood the information given. The effect of limited time was apparent. Cues from patients were often ignored or missed which may have been as a result of perceived time pressures or lack of confidence in dealing with questions. The comparison of the nurses’ consultations with the Calgary Cambridge consultation model showed variations in the nurses’ scores. It also raised new observations such as in those consultations which scored higher, the nurses used more illustrative and fewer batonic gestures, whilst the patient did the opposite.

Conclusions
Whilst Rheumatology Specialist nurses are clearly doing many things well, the education of patients starting drugs such as Methotrexate could be improved by training aimed at improving consultation techniques with the adoption of a modified Calgary Cambridge model consultation technique. Such an approach would benefit from further research to identify whether it results in improving patients’ involvement in the consultation process. The findings from this thesis have led directly to the development of “Top Tips”, published online by Versus Arthritis, to guide nurses during their consultations when giving information to patients about Methotrexate. Further work will include writing a handbook that aims to give nurses more knowledge about how to conduct a consultation with patients based on the Calgary Cambridge consultation model.

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