Task Force Members:

Ann Marie MacIsaac, RN, ANP, MS - Chair

Rita Colicchia, RN, ANP, MS

Jutta Helm, RN, PNP, MS

J. Cairn Marrale, RN, ANP, Ph.D.

Deborah McCloskey, RN, BSN

Sharon Tamburello, RN

Professional Nursing Competencies in Rheumatology

This document is designed to provide health professionals, educators, and potential employers of health care providers with guidelines for nursing practice in the care of persons with rheumatologic disorders. It was developed, using as a theoretical construct, the "Outcome Standards for Rheumatology Nursing Practice", a document developed by the American Nurses’ Association and the Arthritis Health Professionals Association (Appendix A).

There are a number of roles for the professional nurse in rheumatology. Each distinct role allows the nurse to make a unique contribution to patient care management. The scope of practice for each role (e.g. registered nurse, nurse practitioner, clinical nurse specialist) is determined by legal authority through licensure and/or certification, as well as by individual competence and experience. The role of the rheumatology nurse is ultimately defined by formal and informal educational preparation and is further influenced by the practice setting and the availability of other professionals involved in the care of individuals with rheumatologic disorders. Participation in activities and organizations that foster professional development is expected.

The competencies outlined in this document apply to all registered professional nurses providing care to individuals with rheumalogic disorders. These items are considered to be the minimum competencies necessary for the registered nurse to practice in a rheumatology setting. Items in bold are competencies that are desirable, but that may need to be acquired with experience and education. These competencies reflect a continuum of knowledge and skill acquisition and will allow for nursing role evolution within a practice setting.

Basic Knowledge

The rheumatology nurse is:

• Knowledgeable about the disease processes and practice principles germane to the specialty of rheumatology.
• Able to identify and manage the following problems that patients with rheumatic diseases may encounter:
  1. Pain management
  2. Alteration in comfort: stiffness
  3. Alteration in energy level: fatigue
  4. Self-care
  5. Physical mobility (ambulation)
  6. Self-management decisions
  7. Ineffective coping, individual or family
  8. Disturbance in self-concept
• Aware of the influences of interpersonal characteristics, family dynamics, and ethnocultural diversity on the patient’s perception of illness and self-care abilities.
• Capable of collaborating effectively with other disciplines in the management of patient problems.
• Knowledgeable and capable of participating in health care policy, planning, and development

Patient Evaluation

• Recognize symptoms and functional disabilities associated with the various rheumatologic disease processes.
• Demonstrate understanding of the possible differential diagnoses that may mimic rheumatologic problems.
• Demonstrate understanding of the differential diagnosis associated with the patient’s presenting signs.
• Differentiate the signs of acute versus chronic pain, stiffness, and fatigue.
• Outline past and present medication regimens in regard to side effects, adverse reactions, and efficacy.
• Identify factors such as sleep, energy, mobility, posture, nutrition, interpersonal relationships, and general health that may contribute to the perception of pain, fatigue, stiffness, and other symptoms associated with rheumatic disease.
• Detect subtle changes in patient behaviors that may suggest alteration in disease.
• Identify preventive or therapeutic interventions helpful in addressing patient problems.
• Perform an appropriate physical exam to assess the patient's problem.
  1. Recognize signs associated with various rheumatic disease processes.
  2. Recognize psychological and physical indicators suggestive of disease process.
  3. Recognize deviation from the normal.
  4. Differentiate the signs of pain, stiffness, and fatigue.
• J. Compile and document a comprehensive data base from information gathered from history, physical exam, x-rays, and laboratory tests.

Develop A Treatment Plan

• Develop appropriate management strategies to address specific patient disease processes.
• Demonstrate an understanding of the pharmacologic and nonpharmacologic modalities appropriate for management of patient problems.
• Understand and evaluate laboratory parameters necessary for monitoring disease progression and providing guidance in pharmacologic management.
• Develop and/or implement an established toxicity screening protocol to monitor medication regimens.
• Understand and employ D.
• Utilize appropriate functional assessment scales.
• Demonstrate understanding of psychological factors that may be related to chronic disease states and the subsequent adjustment process, (including pain perception, body image, and depression).
• Evaluate the patient's capability and motivation to participate in plan of care.
• Select appropriate teaching modalities for patient and/or support system.
• Demonstrate sensitivity to the importance of family dynamics, communication styles, and cultural differences that may affect patients dealing with a chronic illness.
• Identify appropriate preventative and therapeutic measures needed to preserve and/or improve function.
• Collaborate with physicians, nurses, dietitians, social workers, psychologists, occupational therapists, physical therapists, and community agencies required to develop the plan.
• Establish behavioral outcomes in conjunction with patient and/or support system.

Implement a Treatment Plan

• Implement appropriate management strategies needed to address specific patient disease processes.
• Teach and implement principles of self-care.
• Interpret functional assessment scales.
• Establish behavioral outcomes to address patient problems in collaboration with patient and/or support system.
• Assist in securing appropriate adaptive devices necessary for the performance of activities of daily living.
• Utilize preventive and therapeutic measures needed to preserve and/or improve function.
• Implement a comprehensive educational program as addressed below.
• Recognize the impact of nontraditional and unproven treatments in dealing with patients.
• Counsel the patient and member(s) of the support system regarding the effects of chronic illness on self and interpersonal relationships.
• Access community resources that offer the patient the physical, psychological, spiritual, vocational, and economic assistance required to maintain quality of life.
• Collaborate with physicians, nurses, nutritionists, social workers, psychologists, occupational and physical therapists, and community agencies to implement the plan.
• Assess the plan's effectiveness relative to patient outcome standards (*reference #3).
• Recognize and respond to changes in the patient's status by making appropriate modifications in the plan of care.

Patient Education

• Assess the patient and/or support system in terms of educational needs and readiness to learn.
• Prioritize needs.
• Formulate a comprehensive educational plan incorporating patient’s physical, psychosocial, and developmental needs.
• Apply appropriate learning principles for the patient population.
• Educate patient and/or support system regarding medications, problem-solving, communication skills, stress management, coping mechanisms, and safety issues.
• Access community resources that complement educational efforts.
• Assess the ability of the patient and/or support system to appropriately utilize the health care system.
• Evaluate behavioral outcomes of educational interventions.

Research

• Demonstrate knowledge of the literature as it applies to rheumatology and rheumatology nursing practice.
• Evaluate the literature in regard to practice issues.
• Apply research findings to practice.
• Initiate and/or contribute to clinical research.
• Share research findings with colleagues through professional publications.

Bibliography

Balasco EM, Black AS: Advancing nursing practice: description, recognition, and reward. Nurs Adm Q 12(2):52-62, 1988.

Labunski AJ: Behavioral competencies for nursing practice. Nurs Outlook 39(4):174-177, 1991.

Outcome standards for rheumatology nursing practice. ANA publication, (MS-12):i-ii, 1-10, 1983.

Pastorino C, Baire-Holmes S, Dunwoody C, Wienke K: Scope of orthopaedic nursing practice. Orthop Nurs 9(6):11-13(6 ref, 4 bib), 1990.

Pigg JS: Rheumatology nursing. Evolution of the role and functions of a subspecialty. Arthritis Care Res 3(3):109-115, 1990.

Sharp N: National practice guidelines: what do they mean for nurses? Nurs Manage 21(11):22,24, 1990.

Standards of Clinical Nursing Practice, ANA publication, 1-21, 1991.

Task force on nursing practice standards and guidelines: working paper. J Nurs Qual Assur 5(3):1-17, 1991.