In July 2011 AJN, the Hospital for Special Surgery, and the National Association of Orthopaedic Nurses (NAON) collaborated to host a two-day symposium: the State of the Science in the Prevention and Management of Osteoarthritis. More than 40 experts in nursing, medicine, physical therapy, complementary modalities, and public health discussed how people living with osteoarthritis (OA) can be better served.
One session on the second day brought together a panel of three nurses, all of them skilled clinicians serving OA patients in diverse settings. They were asked by moderator Diana J. Mason, PhD, RN, FAAN, to address several specific questions about nursing's role in OA management.
* What are the issues for nurses working with patients with OA in various settings?
* What knowledge and skills do these nurses need?
* What are the factors influencing their ability to educate and support adults with OA?
* What tools are you using?
Miki Patterson, PhD, NP, ONP-C, a pediatric NP, is a past-president of NAON and teaches orthopedic nursing at the University of Massachusetts Lowell. She said that when treating adults with OA it's important to bear in mind that the condition very often has its origins in childhood illness or trauma.
She said that OA can develop within 10 years of pediatric orthopedic conditions such as developmental dysplasia of the hip (DDH). “We see these patients back for hip replacements very early on, in their twenties,” she said. But childhood hip exams can help detect DDH at an earlier stage of the disease, she said, allowing treatment to help the femoral head and acetabulum form more normally. Avascular necrosis of the femoral head (caused by insufficient blood supply to the bone), slipped capital femoral epiphysis (a displacement of the growing bone), and Blount's disease (a bowing of the legs), in addition to injuries like a torn meniscus, can affect children or adolescents and place them at risk for developing OA, she said.
Nurses can take on several important roles, Patterson said, but the primary one is helping patients cope with chronic illness. “It affects their whole life from a very young age,” she said. And yet the health care system's separation of pediatrics from adult care might prevent nurses from having optimal involvement throughout a patient's life. “One of our biggest problems,” she said, “is we separate by age.”
Charla Johnson, MSN, RN, ONC, is the program coordinator of the orthopedics service at Our Lady of the Lake Regional Medical Center, Baton Rouge, Louisiana. In her 23 years in orthopedics, she said, she has seen a lot of change in acute care—for example, emergency and elective orthopedics patients are now treated on separate units. Now she works exclusively with joint replacement patients and has recognized the effects of obesity and aging on acute care.
“With a patient with joint arthroplasty, you don't want a bone doctor managing comorbidities,” Johnson said. She emphasized that the roles of nurses can be wide ranging with surgical patients: assessing for falls risk, ensuring safe patient handling, performing medication reconciliation, providing education, encouraging patients’ compliance with treatment, and others.
She said that nurses who aren't orthopedics specialists possess a good deal of knowledge applicable to this population—how to screen for renal and pulmonary risk in pain management, for example—but in turn they might lack some specialized information, such as when and why to use assistive devices.
Johnson spoke about a nurse at her facility who has rheumatoid arthritis and whose greatest concern is that some patients who have OA can't participate in physical therapy. Nurses need a better overall understanding of how OA affects the joints, that nurse said, in order to help patients manage their pain.
“Don't discount the pain,” that nurse told Johnson. “No, it won't kill the patient. But it robs them of quality of life.”
Doris Gould, MS, ANP-BC, GNP-BC, a nurse for 40 years and an NP for 16, works in adult and geriatric orthopedics at Worcester Medical Center in Worcester, Massachusetts. She sees a wide variety of degrees of severity: only about half of people with OA know they have the condition, she said, and her first contact with them is when they get reports from their primary care providers saying they have OA. And as an NP, she wears two hats, she said: the provider and the educator.
With a new patient, she goes over the X-ray, discusses self-management, and presents information on the medical options: cortisone and hylan injections, total joint replacement. But because a new patient can absorb only so much, she ultimately focuses on weight management and physical therapy and other forms of exercise. And she encourages the patient to be as actively involved in treatment as possible.
“This is a partnership,” she said. “I try not to make it sound like ‘You have to do this and that.’ That doesn't work. I let them direct their own care as much as they can. I'm there to help guide them through what we know.” She helps patients look into nonpharmacologic forms of pain management such as acupuncture, and if joint replacement becomes necessary, she helps them understand the risks and benefits.
“Knee patients are petrified after they speak to their friends,” she said. “They think it's such a painful surgery that they just don't want to go there.”
THE NURSE NAVIGATOR AND OA
During the question-and-answer portion of the discussion, Patience White, MD, vice president of the Public Health Department at the Arthritis Foundation, asked the panelists about the “navigator role” that has recently been discussed in the context of health care reform. Such a navigator can help patients through a complicated maze of procedures involving screening, diagnosis, treatment, and ongoing self-management, as well as face financial challenges.
“The best person to play that role is a nurse,” White said. “There's a lot of interest in transitions between pediatric and adult care and how youth with special health needs move into the adult world.” White also said that “health literacy” is an increasingly important issue for the millions of people with arthritis. For instance, many people have a visual or an auditory learning style that's not employed by many educational materials. How might a navigator help such patients?
Patterson agreed that a one-size-fits-all approach cannot work with OA education and management. OA is a chronic illness, and like diabetes it requires a long-range vision for management. “We should have OA educators” that are similar to diabetes educators, Patterson said. “Nursing has the ability to help decide how people learn.”
Johnson said that she volunteers in a clinic for the uninsured and underinsured and agreed with Patterson that special populations need specialized attention. “When dealing with those patients,” she said of the people at the clinic, “I don't need to hand them a pamphlet. They might not be able to read. There's a huge opportunity for nursing there, but we need more materials and more bodies.”
Gould said that in her practice, especially with older patients, written materials have a definite role. “They are not going to remember what I tell them,” she said. “A lot of people refuse to go to physical therapy; there's a copayment, or they don't have a ride. The only alternative I have is to give them a sheet of exercises and quickly go over them.”—Joy Jacobson