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Extended roles Document Transcript

  • 1. RESEARCH ARTICLEExtended Roles of Non‐physician Health Professionalsand Innovative Models of Care within Europe: Resultsfrom a Web‐based SurveyTanja Stamm PhD, MSc, MBA1* & Jackie Hill PhD, MPhil (Dist), RN, FRCN21 Department of Internal Medicine III, Division of Rheumatology, Medical University of Vienna, Vienna, Austria, and FH Campus Wien,Department of Health, Division of Occupational Therapy, University of Applied Sciences, Vienna, Austria2 Academic and Clinical Unit for Musculoskeletal Nursing (ACUMeN), Academic Section of Musculoskeletal Disease, Leeds Institute ofMolecular Medicine, Leeds, UKAbstractBackground and objective. Due to the increasing prevalence of rheumatic diseases, extended roles of non‐physicianhealth professionals and innovative models of care may be important options in rheumatology in the future. Extendedroles have been pioneered in the UK, Canada, USA and Australia and been found to be effective and safe. However,few data are available about mainland Europe, so the aim of this study was to explore the current status of the extendedroles undertaken by health professionals within Europe, and the corresponding models of care used.Methods. Non‐physician health professionals from various European countries were asked to complete a web‐based survey using convenience and snowball sampling techniques. Data analysis involved calculating descriptivestatistics and frequencies based on the countries where the participants currently worked.Results. Of the 479 health professionals who filled in the survey, 430 (92%) indicated that they were performingextended roles. Considerable differences between the 27 participating countries existed, in terms of which extendedroles and which innovative models of care were being used. Barriers to performing extended roles were cited as theattitude of rheumatologists in all but eight countries, while attitudes of patients were less common barriers. Lack ofknowledge, education and educational opportunities were also experienced in several countries.Conclusion. The present study produced the first data on extended roles for non‐physician health professionalsand corresponding innovative models of care in rheumatology within Europe. We recommend increasingeducational opportunities, as well as developing strategies to limit the barriers experienced. Copyright © 2011 JohnWiley & Sons, Ltd.KeywordsExtended roles; occupational therapy; physical therapy; nursing; social work; psychology; rheumatology health professionals*CorrespondenceTanja Stamm, Department of Internal Medicine III, Division of Rheumatology, Medical University of Vienna, Währinger Gürtel 18‐20, 1090Vienna, Austria.Email: tanja.stamm@meduniwien.ac.atPublished online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/msc.201Introduction osteoarthritis (OA) affects 60–70% of the populationThe prevalence of rheumatic diseases increases with age above the age of 65 years (Dahaghin et al., 2005a, b;and with the increasing longevity of the population Kraus, 1997). At the present time, almost 80% of the(World Health Organization, 2004). For example, population can expect to live through most of theirMusculoskelet. Care (2011) © 2011 John Wiley & Sons, Ltd.
  • 2. Extended Roles of Health Professionals in Europe Stamm and Hillseventh decade of life, so the impact of OA is likely to extended roles and to develop recommendations/increase even further in future (Kraus, 1997). Rheumatic guidelines for European HPs wishing to undertakediseases affect not only body functions and structures, extended roles based on the survey results.but also activities and the societal participation of theindividual (Stamm et al., 2009). Given the ever‐increasing Methodsnumber of people affected by rheumatic diseases, as wellas their various needs, innovative models of care, such as Designimplementing extended roles for multidisciplinary, non‐ A 10‐minute, anonymous survey with a web‐based ques-physician health professionals (HPs), may be an tionnaire was conducted. The survey was available for oneimportant option in future rheumatology care. Extended month (April 2010), with an extension period of 15 days.roles can be defined as tasks which have not beencommonly undertaken by HPs, or a certain group of HPs, Participantsto date and which require at least additional training oreducation in addition to basic professional training. Sampling followed convenience and snowball sampling Extended roles for HPs in rheumatology at present techniques. HPs from different disciplines, includinginclude consultant roles (defined as expert practice, nurses, occupational therapists, physiotherapists, psy-leadership, education and research) (Humphreys et al., chologists and social workers, working in rheumatology,2007), advanced clinical tasks specifically undertaken by from as many countries as possible, were invited tonurses, such as examining the musculoskeletal system, participate and contacted via regular and co‐optedassessing disease status, managing symptoms, recom- members of the European League Against Rheumatismmending changes to or prescribing drug treatment and (EULAR) Standing Committee for Health Professionalsmaking referrals to other HPs (Hill et al., 2009; Miles in Rheumatology, the EULAR member organizations,et al., 2006), administering intra‐articular injections individuals (if no member organization existed in a(Meadows and Sheehan, 2005) and managing patient certain country) and participants of the EULAR HPadvice lines (McCabe et al., 2009; Thwaites, 2004). Teach‐the‐Teachers courses. In addition, each healthFurther examples include triage recommendations for professional was asked to share the web link for thispatients with OA carried out by physiotherapists survey with colleagues and HPs from other countries(MacKay et al., 2009) and triage by occupational therapists known to work in rheumatology.of whether or not patients require hospital admission inemergency care settings (Cusick et al., 2009). Data gathering Several studies have found extended HPs roles to be The questionnaire was derived from the literature on theeffective and safe (Hill, 1986; Hill et al., 1994, 2009; extended roles of HPs (Hill et al., 2009; Humphreys et al.,MacKay et al., 2009; Ryan et al., 2006). The implemen- 2007). Pilot testing of the questionnaire was undertakentation of extended roles for HPs commonly occurs in to ensure the relevance of the questions for the differentparallel with the development of innovative models of care, countries. The questionnaire was translated from Englishsuch as internet‐based care, telephone helplines and triage into the following 11 languages: Czech, Estonian,models to decrease the number of patients on waiting lists. Finnish, French, German, Greek, Italian, Lithuanian, The literature demonstrates that extended roles for Polish, Portuguese and Spanish. These languages wereHPs and corresponding innovative models of care have chosen, as we expected fewer health professionals of thesebeen pioneered in the UK, Canada, USA and Australia nationalities to be familiar with English.(Cusick et al., 2009; Hill et al., 2009; Humphreys et al.,2007). However, there are no data on the current Data analysissituation in mainland Europe and no commonEuropean perspective concerning the situation of HPs Data were transferred electronically from the web‐performing extended roles. Therefore, the aims of this based questionnaire and corresponding databasestudy were to explore the current status of extended (http://www.surveymonkey.com) to a Microsoft Excelroles undertaken by HPs within Europe, to gain an spreadsheet. Data analysis involved calculating descrip-overview of the different models of care and clinical tive statistics and frequencies based on the countriesand research settings in which HPs undertake these where the participants currently worked. Musculoskelet. Care (2011) © 2011 John Wiley & Sons, Ltd.
  • 3. Stamm and Hill Extended Roles of Health Professionals in EuropeResults physiotherapists and 45 (9%) occupational thera- pists, these three groups comprised 92% of theParticipants cohort. The remaining 8% were psychologists,A total of 479 HPs from 27 countries participated in podiatrists, social workers and other professionals,the survey (Figure 1); their demographic data are such as clinical pharmacists, medical secretaries andshown in Table 1. Sixty‐one per cent of the all clinical study coordinators. No nutritionists com-participants were nurses and, with the 103 (22%) pleted the survey. Number of participants United Kingdom 120 Turkey 2 Switzerland 62 Sweden 8 Spain 27 Slovenia 6 Slovakia 5 Serbia 18 Romania 1 Portugal 28 Poland 5 Norway 40 Netherlands 9 Malta 3 Luxembourg 1 Lithuania 12 Latvia 1 Ireland 1 Greece 1 France 2 Finland 19 Estonia 29 Denmark 3 Czech Republic 41 Cyprus 4 Belgium 11 Austria 8 0 20 40 60 80 100 120 140Figure 1 Distribution of the survey participants by country. The bars indicate the total number of participants per country. Countries arelisted from bottom to top in alphabetical orderTable 1. Demographic data of the survey participants Total Age group (in years) Clinical experience (in years) Research experience (in years) 20–30 31–40 41–50 Over 0–1 2–10 11–20 More 0–1 2–10 11–20 More 50 than 20 than 20Nurse 294(61%) 34 66 104 90 13 116 106 49 108 133 27 5Occupational therapist 45 (9%) 7 10 13 15 2 21 11 11 27 10 4 2Psychologist 13 (3%) 5 6 2 – 4 4 5 – 7 4 2 –Podiatrist 6 (1%) 2 2 1 1 – 5 – 1 4 2 – –Physiotherapist 103 (22%) 15 30 35 23 2 36 30 34 62 26 2 3Social worker 5 (1%) – 1 – 4 1 1 3 – 3 1 1 –Other 13 (3%) 3 4 2 3 3 4 4 2 4 8 – 1Total 479 63 115 155 136 25 187 159 97 215 184 36 11 (13%) (24%) (32%) (28%) (5%) (39%) (33%) (20%) (45%) (38%) (8%) (2%)Musculoskelet. Care (2011) © 2011 John Wiley & Sons, Ltd.
  • 4. Table 2. Extended roles performed by health professionals within Europe. If one participant in a certain country marked a specific task, this is marked with a ■ in the table in the column relating to this country If you are performing extended roles in the rheumatology setting in which you are currently working, please indicate these by ticking the Czech Extended Roles of Health Professionals in Europe boxes below. Austria Belgium Cyprus Republic Denmark Estonia Finland France Greece Ireland Latvia Lithuania Luxembourg Malta Netherlands Norway Poland Portugal Romania Serbia Slovakia Slovenia Spain Sweden Switzerland Turkey UK Work as a consultant/ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ advanced practitioner Manage your own caseload ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ independently Triage ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Assess disease status and ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ activity Examine the musculoskeletal ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ system Formulate and carry out a ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ plan of disease management Manage disease symptoms ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Recommend changes of drug ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ treatment Prescribe medications by ■ ■ ■ ■ ■ ■ ■ protocols Prescribe medications ■ ■ ■ ■ independently Give intra‐articular injections ■ ■ ■ ■ ■ ■ Making referrals to other ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ health professionals Make referrals to physicians, e.g. ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ orthopaedic surgeon Admit patients to hospital ■ ■ ■ ■ ■ ■ ■ ■ ■ wardsMusculoskelet. Care (2011) © 2011 John Wiley & Sons, Ltd. Stamm and Hill
  • 5. Discharge patients from your ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ care Recommendations for further ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ and other treatment options Address psychological ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Stamm and Hill problems Address social problems ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Order investigations such as ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ X‐rays and blood tests Assess the patients’ knowledge ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ of their disease Lead/teach patient education ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ courses Design patient education ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ materials Manage patient telephone ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■Musculoskelet. Care (2011) © 2011 John Wiley & Sons, Ltd. advice lines Supervise health professionals ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ from different disciplines, including physicians and medical students Teach health professionals from ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ different disciplines, including physicians and medical students Manage clinical trials ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Work as a research assistant ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Lead clinical trials/research ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Undertake independent ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ research Assessment other than typical ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ for your profession If one participant in a certain country marked a specific task, this is marked with a ■ in the table in the column relating to this country. Extended Roles of Health Professionals in Europe
  • 6. Table 3. Innovative models of care and research settings in which the survey participants worked If you do work in an extended role, please specify the model of care in which you are currently performing the extended roles you identified in Czech the previous question. Austria Belgium Cyprus Republic Denmark Estonia Finland France Greece Ireland Latvia Lithuania Luxembourg Malta Netherlands Norway Poland Portugal Romania Serbia Slovakia Slovenia Spain Sweden Switzerland Turkey UK Traditional medical setting ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ (physician prescribes) Multi/interdisciplinary rheumatology/ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Extended Roles of Health Professionals in Europe rehabilitation team, with physician being the team leader Multi/interdisciplinary rheumatology/ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ rehabilitation team, with non‐physicians as the team leader Academic/research setting, with the ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ physician as the team leader Academic/research setting with different ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ professionals, with non‐physicians as the team leader Community/primary care setting, with the ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ physician as the team leader Community/primary care setting, with ■ ■ ■ ■ ■ ■ non‐physicians as the team leader Telephone helpline ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Internet‐based helpline ■ ■ ■ ■ ■ Internet‐based care ■ ■ ■ Clinic led by nurse or other health ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ professional Private practice ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ If one participant in a certain country marked a specific task, this is marked with a ■ in the table in the column relating to this country.Musculoskelet. Care (2011) © 2011 John Wiley & Sons, Ltd. Stamm and Hill
  • 7. Stamm and Hill Table 4. Barriers experienced by health professionals that keep them from performing extended roles in a certain country Whether or not you work in extended roles, are there any barriers that keep you or your colleagues from performing Czech extended roles in your centre? Austria Belgium Cyprus Republic Denmark Estonia Finland France Greece Ireland Latvia Lithuania Luxembourg Malta Netherlands Norway Poland Portugal Romania Serbia Slovakia Slovenia Spain Sweden Switzerland Turkey UKMusculoskelet. Care (2011) © 2011 John Wiley & Sons, Ltd. Lack of knowledge ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Lack of education ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Lack of educational opportunities ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Legal constraints ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Attitude of rheumatologists ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Attitude of colleagues or other ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ health professionals Attitude of patients ■ ■ ■ ■ ■ ■ ■ ■ ■ Lack of support from colleagues ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Lack of information during basic ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ training Lack of role models ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Lack of time ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Lack of funding ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ No need for extended roles ■ ■ ■ ■ ■ If one participant in a certain country marked a specific task, this is marked with a ■ in the table in the column relating to this country. Extended Roles of Health Professionals in Europe
  • 8. Extended Roles of Health Professionals in Europe Stamm and HillStatus of performance of extended roles Advantages of performing extended rolesin Europe An open question inviting participants to cite theIn the survey, 430 (90%) HPs said that they were potential advantages of performing extended roles wascurrently performing extended roles. The performance answered by 272 (57%) participants. Their responsesof extended roles in the 27 responding countries is included three main areas: (i) advantages for thedescribed in Table 2. The only country in which all patient (e.g. the provision of more holistic care,extended roles described in the survey were performed seamless care, a multidisciplinary perspective in care,by HPs was the UK. The tasks ‘design patienteducation materials’ (all countries, but two), ‘assess easier and timely access to care); (ii) advantages for thedisease status and activity’ and ‘lead/teach patient healthcare system/institution (e.g. more cost‐effectiveeducation courses’ (all countries, but three) were those care due to shorter access time and fewer professionalsmost frequently marked as being performed by HPs in involved); and (iii) advantages for the professionalsall responding countries. who performed extended roles (e.g. more challenging Educational courses were the most important workload, increased self‐confidence, self‐developmentadditional training requested to fulfil the extended and knowledge, as well as career progression).roles (42% of all participants), followed by informaltraining in the workplace (32%) and formal training in Discussionthe workplace (28%). Seventy‐three (15%) participants This was the first survey of its kind, focusing on thewith a Masters degree and 13 (3%) with a PhD degree extended roles of HPs and corresponding innovativethought that their degree was necessary for performing models of care in rheumatology within Europe. Theextended roles. data collected have enabled a comparison to be made between different countries. Ninety per cent of HPsModels of care were performing extended roles, with the threeInnovative models of care and research settings (e.g. commonest activities including design patient educa-with non‐physicians as leaders, and telephone‐ or tion materials, assess disease status and activity, andinternet‐based care) were used in all countries lead/teach patient education courses. No HPs from(Table 3), except for Greece, Ireland, Latvia, Romania Germany completed the survey and all those whoand Turkey. completed the survey from Italy were physicians (these datasets were deleted). In order to establish equalBarriers experienced by HPs to keep them opportunities for patients with rheumatic diseasesfrom performing extended roles within Europe, such as access to care and treatment, we suggest that innovative models of care, togetherAn overview of the barriers experienced by HPs in with extended roles for HPs, should be introduced andregard to performing extended roles is shown in promoted in all European countries.Table 4. A considerable number of HPs (249; 53%) Several HPs in our survey indicated that they neededindicated that they had experienced barriers. In Estonia additional training to perform extended roles. Educa-and Switzerland, all of the barriers described in the tional courses were the most often sought additionalquestionnaire had been experienced. Legal constraints training. It is therefore essential to introduce educa-had been experienced in all but seven countries and tional courses, such as the EULAR Teach‐the‐Teachersmost often been experienced in Austria (by 63% of the course, to HPs in countries where extended roles andparticipants), Switzerland (55%) and Portugal (43%), innovative models of care are rarely used. In addition,compared with just 9% of participants in the UK. enabling HPs to achieve higher qualifications may Interestingly, the attitudes of rheumatologists had influence whether they engage in extended roles andbeen experienced as barriers to performing extended the introduction of innovative models of care.roles in all but eight countries, while the attitudes of HPs throughout Europe experienced barriers topatients were cited as being a barrier in nine countries. performing extended roles, so the use of innovativeLack of knowledge, education and educational oppor- models of care may be limited. The main barrierstunities were also perceived as barriers in several recorded included legal constraints, the attitudes ofcountries. rheumatologists and patients, knowledge and educational Musculoskelet. Care (2011) © 2011 John Wiley & Sons, Ltd.
  • 9. Stamm and Hill Extended Roles of Health Professionals in Europeopportunities. The German‐speaking region of Europe, Dahaghin S, Bierma‐Zeinstra SM, Reijman M, Pols HA,particularly Austria, is an area where legal constraints Hazes JM, Koes BW (2005b). Prevalence and determi-might prevent HPs from performing extended roles and nants of one month hand pain and hand relatedthis could have been the reason why innovative models of disability in the elderly (Rotterdam study). Annals of the Rheumatic Diseases 64: 99–104.care were also hardly used there. Hill J (1986). Patient evaluation of a rheumatology The potential use of innovative models of care may nursing clinic. Nursing Times 82: 42–3.depend on the professional and educational status of Hill J, Bird HA, Harmer R, Wright V, Lawton C (1994). Annon‐physician HPs in a certain country. Innovative evaluation of the effectiveness, safety and acceptability of amodels of care include multi/interdisciplinary teams in nurse practitioner in a rheumatology outpatient clinic.which all participating HPs have an equal professional British Journal of Rheumatology 33: 283–8.status, so that either a physician or a non‐physician can Hill J, Lewis M, Bird H (2009). Do OA patients gainbe the team leader, compared with traditional settings, additional benefit from care from a clinical nursein which always physicians were/are the team leaders. specialist? A randomized clinical trial. Rheumatology The results from this survey could be applied in several 48: 658–64.ways – for example, for lobbying for extended roles Humphreys A, Johnson S, Richardson J, Stenhouse E,in those countries in which this does not currently Watkins M (2007). A systematic review and meta‐ synthesis: Evaluating the effectiveness of nurse, midwife/occur, using the inter‐country comparisons. Comparing allied health professional consultants. Journal of ClinicalEuropean with US data might be an interesting future Nursing 16: 1792–808.challenge for defining extended roles and models of care Kraus VB (1997). Pathogenesis and treatment of osteoar-in terms of the different social and healthcare systems. thritis. The Medical Clinics of North America 81: 85–112.Starting a common world‐wide discussion on the MacKay C, Davis AM, Mahomed N, Badley EM (2009).extended roles of non‐physician HPs may enable HPs Expanding roles in orthopaedic care: A comparison ofto extend their current roles in countries where this is not physiotherapist and orthopaedic surgeon recommenda-yet common practice. Further, educational needs could tions for triage. Journal of Evaluation in Clinicalbe identified in several countries, as well as barriers which Practice 15: 178–83.could be addressed within international organizations McCabe C, McDowell J, Cushnaghan J, Butts S, Hewlett Ssuch as EULAR. (2009). Rheumatology telephone helplines: An activity analysis. Rheumatology 39: 1390–5. Meadows A, Sheehan NJ (2005). Prescribing and injecting:Acknowledgements The expanding role of the rheumatology nurse.We would like to thank all participants of the survey, the Musculoskeletal Care 3: 176–8.translators Elzbieta Bobiatynska, Walter Grassi, Jana Miles K, Seitio O, McGilvray M (2006). Nurse prescribingKorandova, Katti Korve, Marja‐Leena Kukkurainen, in low‐resource settings: Professional considerations.Maria Matheou, Serge Perrot, Ruta Sargautyte, Pereira International Nursing Review 53: 290–6.de Silva and Jenny de la Torre, who translated the survey Ryan S, Hassell AB, Lewis M, Farrell A (2006). Impact of a rheumatology expert nurse on the wellbeing of patientsinto the different languages, and the EULAR secretariat attending a drug monitoring clinic. Journal of Advanced(Anja Schönbächler and Caroline Pasche) for their help Nursing 53: 277–86.and support in the present project, and EULAR for partly Stamm T, Van der Giesen F, Thorstensson C, Steen E,funding this project. Birrell F, Bauernfeind B, Marshall N, Prodinger B, Machold K, Smolen J, Kloppenburg M (2009). PatientREFERENCES perspective of hand osteoarthritis in relation to concepts covered by instruments measuring function-Cusick A, Johnson L, Bissett M (2009). Occupational ing: A qualitative European multicentre study. Annals therapy in emergency departments: Australian practice. of the Rheumatic Diseases 68: 1453–60. Journal of Evaluation in Clinical Practice 15: 257–65. Thwaites C (2004). Rheumatology telephone advice lines.Dahaghin S, Bierma‐Zeinstra SM, Ginai AZ, Pols HA, Musculoskeletal Care 2: 120–6. Hazes JM, Koes BW (2005a). Prevalence and pattern of World Health Organization (2004). The World Health radiographic hand osteoarthritis and association with Report 2004. Available at http://www.who.int/whr/ pain and disability (the Rotterdam study). Annals of the 2004/en/ (Accessed 20 August 2010). Rheumatic Diseases 64: 682–7.Musculoskelet. Care (2011) © 2011 John Wiley & Sons, Ltd.