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VBCR - February 2014, Volume 3, No 1 - The Rheumatology Nurse
Wayne Kuznar

By Wayne Kuznar

San Diego, CA—Rheumatology nurs­ing is in its infancy but is evolving rapidly as demand increases for modern services and new complex medications require skilled providers to administer and manage them, said Kori A. Dewing, DNP, ARNP, Rheumatology Nurse Practitioner, Virginia Mason Medical Center,
Seattle, WA, at the 2013 American College of Rheumatology meeting.

The additional millions of Americans that are acquiring healthcare coverage and the rapid increase in Medicare-eligible patients will strain specialty services, creating shortages in rheumatology providers. As such, rheumatology nurses will assume a more prominent role as part of an interdisciplinary team of providers.

“With the Affordable Care Act, there’s a lot of push legislatively to increase the scope of nurse practitioners to help provide care to a growing number of patients who were previously uninsured who will be seeking care,” Dr Dewing said.

Complex Medicines Require Complex Skills
Few licensed nurses were working in rheumatology a decade ago, but the complexity of modern treatment options has created a need for skilled nurses in this specialty.

The newer rheumatologic therapies that came to market in the 1990s demanded that nurses learn about them, and effectively communicate their risks and benefits to patients. “Nurses at this time needed help understanding these complex issues—the immune system and understanding how it worked, the diseases in intricate detail, and the treatments available,” said Dr Dewing.

Administration of infusible medications in particular requires the expertise of a rheumatology nurse who is competent in intravenous (IV) infusion techniques, specific drug infusion criteria, and management of adverse and serious infusion reactions, as well as to identify insufficient therapeutic effects, according to the 2013 Rheumatology Nursing: Scope and Standards of Practice.

“We need to be familiar with multiple drug combinations and the protocols to treat rheumatic diseases, how we measure outcomes, the side effects of these medications, the comorbidities associated with these diseases, how to monitor these medications, and the interactions between different drugs,” she said.
One of the most important duties is patient education. “I believe that it is one of the best things rheumatology nurses do for our patients,” she said. “I think it’s truly what they appreciate.”

Scope of Practice
In November 2012, the American Nurses’ Association Board of Directors recognized rheumatology nursing as a new specialty, and approved the rheumatology nursing scope of practice statement (Table). This scope includes the outpatient setting, said Dr Dewing. Patient education and injection teaching is the core of duties. Physical assessment, medication monitoring, knowledge of insurance, coordination of care, and psychosocial support and assistance, are other core duties.

table_rheumatology_nurse_p5

“Advance practice nurses may have other roles in the clinical setting in the US,” she said. “The scope of practice of an APRN varies from state to state. In Washington…my practice is fully autonomous. I have full prescriptive authority. I can work independently if I choose. I choose to work with a group of rheumatologists as part of an interdisciplinary team but it’s not required that anybody reviews my notes or signs off on what I do. However, we remain a team and we work together.”

Rheumatology nurses may also participate in infusion suites in a clinical and management capacity. They prepare medication for IV infusion; access the IV site; assess the patients before, after, or during the infusions; manage infusion site reactions—often independently—provide patient education, manage inventory, and develop infusion suite protocols.

Many nurses in rheumatology work in research facilities, possibly as trial coordinators. “In the advanced practice role, I have served as a subinvestigator and a primary investigator in some clinical trials,” she said. “Nurses are also responsible for maintaining records and administering medications…what’s needed to make the trial happen. They obtain blood tests or other measurements according to study protocols. Nurses can be involved in study recruitment and assist in providing consent and educating study participants.”

Rheumatology nurses can be involved in a rehabilitation setting, long-term care, home health, hospice, palliative care, faith community, and as school nurses. A rheumatology nursing core curriculum has been developed. It is the core knowledge that must be in a nurse’s armamentarium to practice in a specialty. It is the basis on which a certification examination is being developed, written, and submitted to the American Nurses Association. The test should be available by the summer of 2015, and should eventually separate into 2 tracks: registered nurses and advanced practice nurses.

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