LAUSR

Background: Nurse-led care in early RA is not well defined in the literature and the current recommendations. Objectives: This study aimed to develop an understanding of what comprises nurse-led care in early RA from the perspective of rheumatology nurse specialists. Methods: This was a qualitative study using semi-structured telephone interviews with rheumatology nurse specialists in England (Summer 2020). Interviews were audio-recorded, transcribed verbatim and analysed using inductive thematic analysis.[1] Results: Sixteen nurses were recruited and interviews lasted between 30 to 60 minutes. Seven themes were identified. Early disease management Care was characterised by evidence-based RA management provided by experienced nurse specialists with a high degree of autonomy, in the context of a rheumatology multidisciplinary team. The aims of care were to: start treatment, keep in treatment, educate and support. 'So treat to target.escalating treatment as necessary, and addressing any concerns that the patients might have' (CNS14) Addressing psychosocial needs Patients with early RA experience shock, fear, anger, grief and denial while feeling unwell with pain and fatigue. Nurses use a holistic, person-centred and empathetic approach to address psychosocial needs, building a working relationship, listening and creating trust. 'Because it all relates, and if they're stressed because they're not coping at work, then their arthritis isn't going to be so good. So everything relates to one another really' (CNS06) Monitoring treatment, disease impact and patient outcomes Nurses monitor disease activity and disease impact using validated outcome measures and by asking questions during the consultation. Good outcomes are disease control, managing disease impact, medication and side effects, wellbeing and keeping in work. 'When you get them stable, when you get them into remission, when they're happy, when they're feeling well, I think there's lots of ways you can measure that'. (CNS13) Coordinating care, referring and signposting Nurses coordinate care, refer to other health professionals and signpost patients to relevant services and charities. Lack of access to psychology expertise was highlighted. 'And whilst most of us have got some degree of understanding of.self management, or psychology.we're not psychologists' (CNS02) Providing a 'lifeline' Nurse-led telephone advice services provide a 'lifeline' for patients. If patients struggle, they can call and speak with a specialist who knows them and their RA well. 'The advice line has been a lifeline to them, to be able to speak to someone, to be able to get a response quickly to their questions, they feel very well supported, they know that they can always call us' (CNS16) Service evaluation and auditing The individual clinics are reviewed regularly. Patients are asked for feedback on their experience of appointments, if their needs were met and about changes to the service. .'It's really important to ask them initially what they expect to have from the consultation.We've always had really good feedback in general'. (CNS02) COVID-19 challenges and opportunities The pandemic caused major disruptions to the services, prohibiting most faceto-face consultations which was an essential aspect of clinical assessments. Despite the challenges imposed by the pandemic, the services adapted fast, using telephone, video clinics and digital solutions, which streamlined procedures and improved documentation and communication. 'I do have to rely on them telling me what's going on, because I can't see it at the moment' (CNS14) 'With Covid we're doing it over the telephone, and we're getting them to watch the video [injection tutorial] before we have the appointment with them' (CNS04) Conclusion: Nurse-led care in early arthritis is a specialist service, addressing complex needs of patients, using evidence based and person-centred approaches. Innovation and service improvement are seen as part of the role.