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Rheumatology nursing

Author(s): Mary Hodakievic, MSN, RN

A career path that can leave a lasting impression.

Takeaways:

  • Nurses have a variety of career options in range of care settings, including rheumatology nursing in ambulatory care.
  • Rheumatology nursing is a rewarding career that allows nurses to help patients manage autoimmune diseases.

Editor’s note: This article is an early release web exclusive article for the November 2020 issue of the American Nurse Journal

Millions of U.S. adults have challenging chronic autoimmune diseases such as rheumatoid arthritis (RA), psoriatic arthritis (PsA), ankylosing spondylitis (AS), osteoporosis, and systemic erythematosus lupus. They need rheumatology nurses with patience, compassion, and excellent communication and advocacy skills to care for them in ambulatory settings. So you can consider this role as a career option, learn about what you would be doing as a rheumatology nurse in the areas of medication and pain management, communication, insurance and financial assistance facilitation, and care coordination.

Medication management

Rheumatology nurses administer and monitor medications and educate patients about them. Biologics, anti-inflammatory agents, disease-modifying antirheumatic drugs (DMARDs), corticosteroids, and Janus kinase inhibitors are high-risk drugs that require following specific protocols, so your knowledge—including routes of administration (I.V., oral, subcutaneous)—will help ensure patient safety. (See I.V. infusions.)

If the rheumatologist elects to administer joint injections (which consist of a steroid and a local anesthetic) to relieve inflammation and pain, you’ll check the patient’s allergy history, gather medications and supplies, and monitor the patient after the injection. For medications administered subcutaneously, you’ll teach patients how to perform injections, including correct injection sites and safe needle disposal. Your effective teaching techniques will ease patients’ anxiety and help them successfully administer injections at home.

I.V. infusions

Many medications used to treat rheumatologic disorders are administered as I.V. infusions. In some offices, rheumatology nurses administer infusions onsite, while in others, patients go to an infusion center. The process for administering infusions may differ in each healthcare facility, but monitoring and educating patients about infusion reactions or complications—including signs and symptoms of side effects, when to call the provider, and when to go to the emergency department—remain constant.

Some patients visit an ambulatory care setting every 4 weeks for an infusion, so nurses can use this time to teach patients about their medications, infection risks, and the disease process, as well as get a sense of how patients are managing at home.

Pain management

As a rheumatology nurse, you’ll help patients manage pain and fatigue at home, frequently providing advice over the phone. You’ll share information, based on provider orders and organization protocols, about pharmacologic and nonpharmacologic pain management strategies. Many patients with RA have occasional flare-ups that can be managed with prednisone, nonsteroidal anti-inflammatory drugs (NSAIDs), or other medications they may already have at home. RA flare symptoms include joint pain, swelling, fatigue, and muscle aches and pains. Patients may be familiar with using prednisone for an RA flare-up, but they may be skeptical about taking it when in pain without consulting their rheumatologist’s office first.

You’ll review the provider’s instructions about how to manage flare-ups and explain how to correctly take other prescribed medications (such as NSAIDs, muscle relaxers, and narcotics) for pain relief. When you provide this education, you’ll help reduce patients’ anxiety and improve their self-confidence in managing their chronic condition at home. 

Insurance and finance assistance facilitation

Nurses aren’t taught the intricacies of insurance, deductibles, out-of-pocket costs, and coverage gaps in nursing school; they learn about them on the job. However, understanding patient insurance (including prior authorization) and financial responsibilities is an important role of rheumatology nursing. (See Prior authorization.)

The cost of treatment for rheumatologic diseases can be astronomical. For example, the cost of a rituximab infusion can be as much as $60,000. Imagine the sticker shock patients experience when they receive the explanation of benefits? You’ll help by referring patients to the appropriate assistance programs offered for each medication and reviewing which treatments their insurance covers. Many drug company assistance programs are offered only to patients with commercial insurance, which means those receiving Medicare or Medicaid coverage will incur out-of-pocket costs. Most Medicare Part D plans will cover at least one biologic DMARD, but many commercial insurance plans require that patients absorb some of the costs, leaving them with a significant financial burden. Frequently, patients can’t afford these biologic medications or are forced to switch therapy because of a change in insurance coverage.

Prior authorization

Rheumatology nurses need to be familiar with the prior authorization process. Almost all medications prescribed for autoimmune diseases require prior authorization from the patient’s insurance company to determine if the medication is covered, and whether it will be billed under medical or pharmacy benefits. This process can involve filling out lengthy forms using information from the patient’s medical record to substantiate why the medication should be authorized. Fortunately, most offices now use a more efficient and less time-consuming electronic prior (E-prior) authorization process developed by pharmacies. E-prior authorization decreases time on the phone, increases response times from insurance companies, and improves clinician and patient satisfaction.

Communication skills

Your therapeutic communication skills will be invaluable when interacting with patients who have chronic illnesses such as RA, PsA, and AS. Active listening and empathy can positively impact their coping skills, and your calm voice while triaging symptoms over the phone can be reassuring.

Patients may call when they’re acutely ill, which can affect how they take their medication. As part of your patient education, you’ll teach patients how to identify acute illness symptoms that may warrant holding medications until they feel better. This education can reduce the need for an office, urgent care, or emergency department visit.

Patients may not see a provider at every infusion visit, so you’ll act as their advocate, reporting any changes, complications, or treatment concerns. You’ll develop a close, trusting, honest, relationship with patients that will leave a lasting impression.

Care coordination

Rheumatology nurses frequently act as care coordinator, scheduling infusion appointments around other important interdisciplinary appointments. For example, a patient’s rheumatologist may make a referral to other services—such as physical and occupational therapy, pain management, nutrition consults, and primary care—and patients will need help scheduling and coordinating those appointments. In addition, patients may miss work due to infusion appointments, condition flare-ups, and illnesses related to immunosuppressive medications. They also may need special accommodations (such as frequent breaks or ergonomic desk modifications) at school or work as disease progression imposes physical limitations. You’ll help providers compile and complete Family and Medical Leave Act forms and letters to employers. In addition, many immunosuppressive medications used to treat rheumatologic conditions require frequent lab monitoring. You’ll retrieve and transmit standing lab orders and send patient reminders when lab work is due.

Lasting impressions

Because rheumatology patients may have complex needs and comorbidities, nurses working in this specialty area must possess excellent therapeutic communication and I.V. insertion skills, as well as medication, pain management, and insurance knowledge. As a rheumatology nurse, you’ll have opportunities to touch patients’ lives every day, whether it’s over the phone or during office visits. These nurse-patient relationships can last for several years, leaving an impression that you’ll remember throughout your career.

When this article was written, Mary Hodakievic was an RN in the rheumatology department at Cleveland Clinic Solon Family Health Center in Solon, Ohio. 

References

American College of Rheumatology. Role of the registered nurse in the management of rheumatic disease. rheumatology.org/I-Am-A/Patient-Caregiver/Health-Care-Team/Registered-Nurse

Ryan S, McCabe CS, Adams J. The current knowledge and confidence of rheumatology nurses in providing advice on pain management. Musculoskeletal Care. 2016;14(1):62-6.

Yazdany J, Dudley RA, Chen R, Lin GA, Tseng C-W. Coverage for high-cost specialty drugs for rheumatoid arthritis in Medicare Part D. Arthritis Rheumatol. 2015;67(6):1474-80.

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