EULAR Guidelines: Core Competences in Rheumatology Health Professionals

1. EULAR Recommendationsfor the Generic Core Competences of Health Professionals in Rheumatology (HPR)

2. Task Force L.M. Edelaar, E. Nikiphorou, G.E. Fragoulis, A. Iagnocco, C. Haines, M. Bakkers, L. Barbosa, N. Cikes, M. Ndosi, J. Primdahl, Y. Prior, P. Pchelnikova, V. Ritschl, V.S. Schäfer, H. Smucrova, I. Storrønning, M. Testa, D. Wiek, T.P.M. Vliet Vlieland

3. Target population/Aim Target Population: • HPR and other health care providers in the field of RMDs • Patients with RMDs, as well as their (inter)national organizations • Institutions and clinical educators providing education for HPR • All other relevant stakeholders other than service providers, including health insurers and policy makers Aim: • To develop EULAR-endorsed recommendations for generic core competences of HPR at the postgraduate level • Focus on nurses, physical therapists (PTs) and occupational therapists (OTs)

4. Methods/Methodological approach • Methods: According to the EULAR Standardized Operating Procedures* 1st Task Force meeting 9 experts in HPRs’ education (3 nurses, 2 PTs, 3 OTs, 1 rheumatologist), 2 EMEUNET members, 3 patient representatives and a steering group managing the process Definitions agreed & Research questions formulated Consensual approach Systematic literature research SLR based on the Research Questions Consensual approach 2nd Task Force meeting SLR findings discussed Recommendations agreed Research and educational agendas discussed FINAL Recommendations Final Recommendations Level of Evidence and Strength of Recommendations determined by the steering group Level of agreement defined after e-voting byf all TF members * van der Heijde et al Ann Rheum Dis 2016,75:3-15

5. Methods: SLR PRISMA Flow diagram

6. Overarchingprinciples (OAP) • A. Effective communication skills and a biopsychosocial approach in the assessment, treatment and care of people with RMDs are of paramount importance for HPRs • B. Person-centred care and patient advocacy are fundamental in the care delivered by HPRs for people with RMDs • C. An evidence-based approach, ethical conduct and reflective practice are essential for HPRs

7. Recommendation 1. LoEQLIb, SoR A, LoAMean (SD) 9.42 (1.07) • HPRs should have knowledge of the aetiology, pathophysiology, epidemiology, clinical features and diagnostic procedures of common RMDs, including their impact on all aspects of life. • Updated knowledge of the normal structure and function and the pathophysiology of the MSK system • Knowledge should include the prognosis and progression of RMDs QL Indicates a LoE based onstudies that used qualitative methods. SoR: Strength of Recommendation, LoA: Level of Agreement

8. Recommendation 2. LoEQLIIa, SoR B, LoAMean (SD) 9.68 (0.58) • Using a structured assessment, HPRs should identify aspects that may influence individuals with RMDs and their families, including: · clinical characteristics, risks, red flags and comorbidities· limits to their activity and participation · personal and environmental factors • HPRs should be able to perform a structured, comprehensive assessment to understand the impact of the RMD on the individual; and also on relationships with family and friends, and on societal participation. • The structured assessment includes an exploration of the individuals’ perceptions, concerns, ideas or beliefs about their symptoms and condition QL Indicates a LoE based onstudies that used qualitative methods. SoR: Strength of Recommendation, LoA: Level of Agreement

9. Recommendation 3. LoEQLIIa, SoR B/C, LoAMean (SD) 9.74 (0.73) • HPRs should communicate effectively: · to make contributions to other health care providers and stakeholders in RMD care· to collaborate with other health care providers, signpost or refer where appropriate to optimise the interdisciplinary care of people with RMDs. • Collaboration is important to optimize care and to make appropriate referrals • HPRs must understand, respect and draw on each other’s roles and competences • Effective communication includes being able to serve as a patient advocate: explain and advise people with RMDs about the importance of relevant health care professionals and organizations QL Indicates a LoE based onstudies that used qualitative methods. SoR: Strength of Recommendation, LoA: Level of Agreement

10. Recommendation 4. LoEQLIb, SoR B, LoAMean (SD) 9.47 (0.84) • HPRs should have an understanding of common pharmacological and surgical therapies in RMDs, including their anticipated benefits, side-effects and risks, and use this knowledge to advise or refer as appropriate. • HPRs should have a broad knowledge and understanding on how to give advice on the use of drug treatment in RMDs • Responses to medication should be reviewed regularly with the patient, taking into account patients’ fears, beliefs and concerns • For joint injections, HPRs should understand the (evidence-based) role of joint injections in the management of RMDs • HPRs are expected to have knowledge about common surgical interventions in musculoskeletal conditions like OA and IA QL Indicates a LoE based onstudies that used qualitative methods. SoR: Strength of Recommendation, LoA: Level of Agreement

11. Recommendation 5. LoEQLIb, SoR B, LoAMean (SD) 9.53 (0.90) • HPRs should provide advice on non-pharmacological interventions, treat or refer as appropriate, based on the evidence, expected benefits, limitations and risks for people with RMDs. • Planning and implementation of non-pharmacological treatment should be done in collaboration with the individual and the multidisciplinary team • Furthermore, HPRs should alleviate patients’ concerns about treatment and should understand that some people with RMDs (e.g. with mental health issues, multi-morbidity, fatigue or frailty) might need additional support during rehabilitation and that their trajectory of recovery or increased independence may be slower than for others QL Indicates a LoE based onstudies that used qualitative methods. SoR: Strength of Recommendation, LoA: Level of Agreement

12. Recommendation 6. LoEQLIb, SoR A, LoAMean (SD) 9.42 (1.02) • HPRs should assess the educational needs of people with RMDs and their carers to provide tailored education using appropriate modes of delivery, relevant resources and evaluate their effectiveness. • HPRs should be able to assess the educational needs for each patient, designing a personalized approach based on the patient’s individual. • HPRs should be able to signpost to sources of education and information • The importance of the promotion of a healthy lifestyle, in particular physical activity was underlined in multiple papers QL Indicates a LoE based onstudies that used qualitative methods. SoR: Strength of Recommendation, LoA: Level of Agreement

13. Recommendation 7. LoEQLIb, SoR A, LoAMean (SD) 9.79 (0.71) • HPRs should take responsibility for their continuous learning and ongoing professional development to remain up-to-date with the clinical guidelines and/or recommendations on the management of RMDs. • HPRs should continuously undertake professional development and remain up-to-date with the best available evidence • Enable and participate (leading or contributing, as appropriate) in research to advance the development of knowledge on RMDs and practice QL Indicates a LoE based onstudies that used qualitative methods. SoR: Strength of Recommendation, LoA: Level of Agreement

14. Recommendation 8. LoEQLIIa, SoR B, LoAMean (SD) 9.42 (1.07) • HPRs should support people with RMDs in goal setting and shared decision making about their care (e.g. identify, prioritize, address their needs and preferences and explain in lay terms). • To support people with RMDs in goal setting and shared decision making (SDM) • Empowering people with RMDs in decision making might improve adherence to treatment and enhance quality of life QL Indicates a LoE based onstudies that used qualitative methods. SoR: Strength of Recommendation, LoA: Level of Agreement

15. Recommendation 9. LoEQLIb, SoR A, LoAMean (SD) 9.74 (0.81) • HPRs should support people with RMDs in self-management of their condition. This encompasses selecting and applying the appropriate behavioural approaches and techniques to optimize their health and well-being (e.g. engagement in physical activity, pain and fatigue management). • To support people with RMDs in self-management of their condition • This support encompasses selecting and applying the appropriate behavioral approaches and techniques • Different techniques can be used, like motivational interviewing, cognitive or behavioral approaches or other technique QL Indicates a LoE based onstudies that used qualitative methods. SoR: Strength of Recommendation, LoA: Level of Agreement

16. Recommendation 10. LoEQLIb, SoR A, LoAMean (SD) 9.74 (0.73) • HPRs should be able to select and apply outcome measures for people with RMDs, as appropriate, to evaluate the effectiveness of their interventions. • Select and apply outcome measures to evaluate the effectiveness of their interventions • The literature on nurses’ competences concluded that nurses should be able to regularly revise the treatment plan, and conduct follow-up visits accordingly to monitor patients through a systematic clinical evaluation including measurements and metrological parameters or questionnaires, and, consult referrers when necessary QL Indicates a LoE based onstudies that used qualitative methods. SoR: Strength of Recommendation, LoA: Level of Agreement

17. Assessing the methodological quality of the studies • The methodological quality of studies addressing multiple professions of HPRs was as follows • Qualitative studies • A modified version of the 12 criteria reported by Harden et al. • Each item was scored as not present (0) or present (1) • The sum of the 12 item scores constituted the final methodological quality score • Stratified as low, medium or high quality • Systematic literature reviews • AMSTAR (A MeaSurement Tool to Assess systematic Reviews) criteria were used • Stratified as critically low, low, moderate or high quality • Quantitative studies or for studies using mixed methods • Mixed Methods Appraisal Tool (MMAT) score • The final score was expressed as a percentage • Opinion paper not assessed. Harden A et al. BMJ 2009 Shea BJ et al. BMC Med Res Method 2017 Pluye P et al. Int J Nurs Stud. 2009

18. Slide 16: Summary Level of Evidence • Most of the studies retrieved were of qualitative methodology • The LoE for qualitative papers was categorized using a modified version of the hierarchy of evidence-for-practice in qualitative research described by Daly et al* • Level I: generalizable studies • Level II: conceptual studies • Level III: descriptive studies • Level IV: single case studies. • Modifications: • Subcategories (a and b) added at each level to allow for more accurate reflection of grading of the evidence. * Daly et al. J of Clin Epidem, 2007

19. Summary Table Level of Evidence - Overarching principles

20. Summary Table Level of Evidence - Recommendations

21. Summary of Recommendations in bullet point format OVERARCHING PRINCIPLES • Communication skills and a biopsychosocial approach • Person-centred care and patient advocacy • Evidence-based approach, ethical conduct and reflective practice

22. Summary of Recommendations in bullet point format

23. Summary of recommendations in lay format I Three overarching principles were developed, focusing on the following: A. The need for effective communication skills to address both biological and psychological aspects of disease B. The need for a patient-centred approach to care and patient advocacy C. The use of appropriate scientific evidence in the management of patients and good ethical standards.

24. Summary of recommendations in lay format II Ten recommendations were developed, focusing on the following aspects for the Generic Core Competences of HPR: • Basic knowledge of common RMDs • Structured assessment to best support individuals with RMDs and their families • Effective communication • Knowledge on common drug and surgical therapies in RMDs • Knowledge on appropriate non-drug interventions • Patient and carer education on RMDs • Continuous learning and professional development • Emphasis on shared decision making • Emphasis on self-management • Outcome measures and value of intervention

25. Acknowledgements We thank J.W. Schoones, Walaeus Library, Leiden University Medical Center, the Netherlands, for his assistance with the literature search in the electronic databases. Dr H. Lempp, medical sociologist from King’s College London, London, UK, for her expert advice in the methodological quality assessment of qualitative research studies and considerations around hierarchical level of evidence. and all TF members: L.M. Edelaar (Fellow) E. Nikiphorou (co-methodologist) G.E. Fragoulis(EMEUNET fellow), A. Iagnocco (convenor), C. Haines (educationalist), M. Bakkers (PARE representative), L. Barbosa (TF member), N. Cikes (UEMS representative), M. Ndosi (TF member), J. Primdahl (TF member), Y. Prior (TF member), P. Pchelnikova (PARE representative), V. Ritschl, V.S. Schäfer (EMEUNET fellow), H. Smucrova (TF member), I. Storrønning (TF member), M. Testa (TF member), D. Wiek (PARE representative), T.P.M. Vliet Vlieland(convenor)