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http://jnep.sciedupress.com Journal of Nursing Education and Practice 2021, Vol. 11, No. 4
ORIGINAL RESEARCH
Asia-Pacific initiative for rheumatology nurse
education: An impact survey in China
Susan Oliver∗1, Linda Bradbury2, Rong Mu3, Xiaobing Wang4, Daniel Furtner5
1Susan Oliver Associates, North Devon, United Kingdom
2Gold Coast University Hospital, Queensland, Australia
3Clinical Immunology Center, Department of Rheumatology and Immunology, People’s Hospital, Peking University Medical
Center, Beijing, China
4Rheumatology Department, First Affiliated Hospital of Wenzhou Medical University, Ouhai, Wenzhou, China
5Regional Medical Affairs, Janssen Asia-Pacific, Singapore, Singapore
Received: September 3, 2020 Accepted: November 29, 2020 Online Published: December 15, 2020
DOI: 10.5430/jnep.v11n4p8 URL: https://doi.org/10.5430/jnep.v11n4p8
ABSTRACT
Background/Objective:
Asia-Pacific Initiative for Rheumatology nurse Education (ASPIRE) is a faculty-led initiative established
to meet the educational needs of rheumatology nurses in Asia Pacific in recognition of the expanding role of nurses in daily
rheumatology clinical practice. The objective of this study is to measure the impact of ASPIRE workshop training on nurses’
levels of knowledge, confidence, attitudes and beliefs using a Before-after-control-impact (BACI) survey.
Methods:
A total of 210 nurses who completed both pre- and post-surveys were included in the BACI analysis. The intervention
group (n = 111) refers to nurses who attended the ASPIRE workshop training held during the China Chronic Disease Management
Forum in Baotou, Inner Mongolia in September 2019 whereas the control group (n = 99) refers to Chinese nurses that have never
attended the ASPIRE training.
Results:
Overall level of knowledge significantly increased by 30% (5.63 pre- vs. 8.34 post-survey; p< .001), and overall level
of confidence significantly increased by 29% among nurses who attended ASPIRE training (5.83 pre- vs. 8.39 post-survey; p<
.001). Nurses in the control group demonstrated no significant increase in knowledge (6.18 pre- vs. 6.50 post-survey; p= .097) or
confidence (6.46 pre- vs. 6.71 post-survey; p= .169) over the same period.
Conclusions:
Nurses who attended the ASPIRE training workshop reported a significant increase in their levels of knowledge
and confidence compared with a control group of nurses who have never undergone ASPIRE training. Training rheumatology
nurses to acquire more in-depth knowledge and skills can help optimize their role in clinical practice to meet the greater demands
of disease monitoring and long-term management of rheumatology patients.
Key Words: Asia, Inflammatory joint disease, Nurse practitioners, Patient-centered care, Rheumatology, Spondylarthritis
1. INTRODUCTION
Diagnostic advances and better understanding of disease pro-
gression and therapeutic strategies have significantly evolved
in the management of rheumatic diseases.
[1, 2]
The additional
demands in the screening, assessment and management of
patients receiving biologic therapies have contributed to the
expanding role of the rheumatology nurse in daily clinical
practice.[3–6]
The World Health Organization (WHO) has highlighted the
importance of developing nurses and midwives to ensure
∗Correspondence:
Susan Oliver; Email: sue@susanoliver.com; Address: 7 Trafalgar Lawn, Barnstaple, North Devon, EX32 9BD, United Kingdom.
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accessible and acceptable quality of care internationally.
[7]
The WHO is working alongside ‘Nursing Now’, an initiative
launched in 2018, to improve global health by advancing
the role of the nurse with the aim of improving access to
care with cost-effective interventions for non-communicable
diseases.
[8, 9]
This highly pertinent initiative acknowledges
the demographic challenges for healthcare systems world-
wide and will require sufficient resources to ensure nurses
are well-trained to acquire the knowledge and competencies
needed to enhance their roles and improve patient care.[10]
At present, the most common responsibilities of rheumatol-
ogy nurses in Asia Pacific practices are: performing patient
education, adjusting medication doses and conducting physi-
cal examinations.
[4, 11]
In order to enhance a stronger patient-
centered approach and empower patients with rheumatic
conditions, nurses must play a greater role in educating,
assessing and monitoring patients with inflammatory joint
diseases (IJD).
[12, 13]
Nurses in Asia Pacific report that they
carry out some of these tasks as an integral aspect of their
ward work. However, there are limitations to this ‘add on’
approach as competing ward demands can compromise the
scope and depth of the education offered.
Patients with chronic IJD should have access to a team that
includes specialist nursing support. Specialist nurses focus
on providing a tailored educational approach that enables the
patient to better understand their disease and make informed
decisions about their treatment choices. Initially, if these
aims are to be achieved, more nurses within Asia Pacific
need to have access to adequate training and frameworks for
practice that will advance their training towards specialist
training.
Recommendations for the roles of rheumatology nurses have
been developed and updated by the European League Against
Rheumatism (EULAR)
[14, 15]
and highlight the need for ade-
quately trained nurses to deliver patient education and conti-
nuity of care. These recommendations have also been sup-
ported by recommendations for core competencies for health
professionals.[16]
Nurse-led care (NLC) was shown to be efficacious and cost-
effective compared with general practitioner (GP)-led usual
care in gout
[17]
and was comparable to rheumatologist-led
care (RLC) in rheumatoid arthritis (RA).
[3]
In chronic in-
flammatory arthritis (CIA), NLC was shown to incur less
cost and resources with no difference in clinical outcome
compared to RLC.
[18]
Similarly, osteoarthritis patients who
were allocated to clinical nurse specialist care were better
informed, more satisfied with their care and importantly had
similar clinical outcomes compared to that of junior hospital
doctor clinics.[19]
Several exploratory studies highlighted the wide variation in
the training and education of rheumatology nurses
[21, 22]
with
one study reporting that nurses relied heavily on informal
knowledge sources such as interactions with physicians and
experiential knowledge.
[20]
Improved training standards, ac-
cess to educational resources and formal education have been
suggested to improve levels of knowledge and confidence
in the areas of patient education on therapeutic options and
also to optimize the role of rheumatology nurses in clini-
cal practice.
[20–24]
Academic/professional conferences and
events were reportedly the most preferred method for nurse
practitioners to receive and share educational information.
[23]
Nurses are a key healthcare resource and constitute a large
proportion of the workforce, yet demonstrating the value of
advanced nursing roles is complex and may be a barrier to
many authorities’ reticence in investing in specialist nurse
developments in chronic disease management.
[25]
It was with
this in mind that the ASia-Pacific Initiative Rheumatology
nurse Education (ASPIRE) was seen as a first step in devel-
oping structured education for rheumatology nurses and was
established as a response to the expanding role of nurses in
daily rheumatology clinical practice. Therefore, it is hoped
that ultimately professional regulatory bodies work with hos-
pital authorities within Asia Pacific to create a rheumatology
nursing curriculum to assist nurses in acquiring a foundation
of knowledge and skill set that extend beyond that of their
initial education and training. The goal is to drive change
and generate enthusiasm, while also supporting education ini-
tiatives organized by the hospital authorities which may lag
behind new training needs or lack resources to offer sufficient
training.
The ASPIRE initiative was spearheaded by the founding
working group comprised of leading rheumatologists (Pro-
fessor Kazuhiko Yamamoto from Japan, Professor Lai-Shan
Tam from Hong Kong) and rheumatology nurse specialists
(Susan Oliver from United Kingdom, Mie Fusama, from
Japan, Chunyang Zhang from China, Gladys Kwok from
Hong Kong) across the Asia Pacific region. To explore is-
sues and service needs, an informal small-scale educational
needs survey was deployed among nurses across several
countries in Asia Pacific to inform and prioritize topics to
be included in the core training modules.
[26]
Following the
review of findings and reconvening of the working group,
three core training modules were developed. These mod-
ules focused on RA disease management, specifically: (1)
patient assessment, (2) treatment and self-management ed-
ucation, (3) disease monitoring and follow-up care. The
modules were reviewed and endorsed by Asia Pacific League
Against Rheumatism (APLAR) and can be tailored to meet
specific educational needs of nurses with different levels of
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rheumatology nursing experience. The modules are avail-
able on the APLAR website as an open access resource
(http://www.aplar.org/education_page/aspire/).
Following the success of the initial modules, the Original
Working Group members reconvened in 2019 with an ex-
panded team of three rheumatologists (Professor Matthew
Brown from Australia, Professor Yi Liu from China, Pro-
fessor Hideko Nakahara from Japan) and two experienced
rheumatology nurses (Linda Bradbury from Australia, Ying
Wang from China). The working group reviewed the feed-
back and evaluation, then went on to identify the need for
two further modules for the ASPIRE program: (1) Axial
Spondyloarthritis (axSpA) including Ankylosing Spondyli-
tis (AS) and (2) A framework for patient-centered nursing
consultations. These were developed by the members of
the working group and have been reviewed and endorsed by
APLAR at the education committee meeting in November
2019.
Survey data collected following ASPIRE training workshops
in the past have shown very positive levels of satisfaction and
self-reported level of improvement from nurses who have at-
tended the training. However, the impact of ASPIRE has not
been previously measured. Therefore, a Before-after-control-
impact (BACI) survey was conducted in conjunction with an
ASPIRE training workshop. Participants had the opportunity
to learn from accomplished rheumatology nurses on axSpA
and the framework for patient-centered nursing consultations.
Workshops involved presentations by experienced rheumatol-
ogists and rheumatology nurses and were supplemented with
patient case study, interactive small-group discussions and a
hands-on assessment and evaluation session with patient vol-
unteers. The impact survey explored improvements in knowl-
edge and confidence of ASPIRE-trained nurses compared
with a control group of nurses who have never undergone
ASPIRE training.
2. METHODS
The outcome survey was undertaken as a market research
activity and adhered to all applicable standards. All partici-
pants gave consent to participate and privacy was guaranteed.
Consent forms were reviewed and approved by the spon-
sor’s regional and local legal and privacy teams in Singapore
and China, respectively (Supplementary Materials 1-4). An
Australian-based company (Blue Planet Research and Con-
sulting) together with a local panel partner in China (Rakuten
Insight), both specializing in market research, conducted the
pre- and post-surveys abiding fully by the Australian Mar-
ket & Social Research Society (AMSRS) Code of Conduct
and Principles and the ICC/ESOMAR International Code on
Market, Opinion and Social Research and Data Analytics.
A dedicated ASPIRE China Steering Committee met in
May 2019 at the Chinese Rheumatology Association (CRA)
annual meeting in Qingdao to review and advise on the
survey questionnaire. The survey was designed to measure
the impact of the program on nurses’ knowledge, confidence,
and attitude and beliefs. Eleven individual dimensions of
knowledge of the axSpA module in particular were mea-
sured:
1) Disease in general
2a) Pharmacological treatment options
2b) Non-pharmacological treatment options
3a) Comorbidities
3b) Extra-articular manifestations
4) Practical disease assessment
5a) Risks, benefits and outcomes of disease
5b) Pharmacological therapeutic information
5c) Self-management techniques (behavioral, motivational,
social)
5d) About extra-articular manifestations
5e) About exercise and physical therapy.
Similarly, 11 individual dimensions of confidence were mea-
sured:
6) Disease assessment
7a) Recognizing and managing comorbidities
7b) Recognizing and managing extra-articular manifestations
8a) Educating patients about risks, benefits, and outcomes of
disease
8b) Educating patients about therapeutic information
8c) Educating patients about self-management techniques
8d) Educating patients about extra-articular manifestations
8e) Educating patients about comorbidities
8f) Educating patients about exercise and physical therapy
9a) Educating patients about pharmacological treatments
9b) Educating patients about non-pharmacological treat-
ments.
Nurses rated their level of knowledge and confidence using a
visual analog scale (VAS) ranging from 1 (extremely low) to
10 (extremely high).
Attitude is defined as a settled way of thinking and beliefs
are things that a person holds personally to be true.
[27]
To
measure nurses’ attitude and beliefs, they were asked to rate
how strongly they agree or disagree with eight statements on
the nurse consultation framework module on a scale from 1
to 5 with 1 being ‘strongly disagree’ and 5 being ‘strongly
agree’.
1) I aspire to implement the nurse consultation framework.
2) Rheumatology nurse training has the potential to add value
to clinical practice.
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3) I believe it is important to involve patients in management
of their rheumatological conditions.
4) I believe it is important to involve carers in the treatment
journey for the management of rheumatological conditions.
5) I believe it is important to educate patients with rheumato-
logical conditions about their disease in general.
6) I believe it is important that nurses should have a role
in educating patients with rheumatological conditions about
pharmacological treatment.
7) I believe it is important that nurses should have a role
in educating patients with rheumatological conditions about
non-pharmacological treatments.
8) I believe that I am equipped with knowledge to perform
my role as a nurse caring for patients with rheumatological
conditions.
The final version of the survey questionnaire was reviewed
and approved by the Steering Committee before deploy-
ment (Supplementary Materials 5 & 6). The ASPIRE work-
shop was held during the Chinese Chronic Disease Manage-
ment Forum in September 2019 in Baotou, Inner Mongolia.
Nurses treating patients with chronic inflammatory disease,
(RA) and/or (AS) were invited to participate. All nurses who
wanted to attend the ASPIRE workshop in Baotou were asked
to complete a pre-meeting survey as part of their registration
process. The quantitative baseline survey was deployed dig-
itally in simplified Chinese. During the registration period,
a random group of rheumatology nurses across China were
also recruited to complete the same quantitative baseline
survey. The control group had never attended an ASPIRE
training and were not attending the ASPIRE training work-
shop at the Baotou meeting.
At the time of research design, 100 nurses were expected
to attend the training and included in the initial intervention
group. A control group consisting of 120 nurses was rec-
ommended for pre-survey, with up to 30% of control group
nurses predicted to not go on to complete the post-survey.
Two weeks after the ASPIRE workshop in Baotou, partici-
pants in both the intervention and control groups were asked
to complete a post-meeting quantitative impact evaluation
survey (Supplementary Materials 5 & 6), which was also
deployed digitally in simplified Chinese.
Only nurses who completed both the pre- and post-meeting
surveys (samples were matched by name, phone number
and/or unique QR survey link) were included in the final
sample for data analysis (n = 111 intervention group and n
= 99 control group). Interaction effect for the entire dataset
was tested and accounted for to ensure measurement and sig-
nificance of impact reflected true comparison pre- and post-
ASPIRE training between control and intervention group
nurses. Significance was assessed by paired t-test controlling
for years of experience, working in in-patient or out-patient
clinics, place of work (public vs. private hospital) and fre-
quency allowed to care for rheumatology patients (often,
occasionally, not at all). Changes in overall levels of knowl-
edge and confidence were respectively analyzed using mixed
model repeated measures analysis of variance (ANOVA)
with adjustment for group sample differences. All analysis
was performed using the Ime4 R package and InnerTest R
package.[28, 29]
3. RES ULTS
The ASPIRE training was attended by 134 nurses from 22
different provinces and 75 different hospitals across China.
One hundred eleven of these nurses completed both the pre-
and post-meeting surveys and formed the intervention group.
One hundred twenty nurses from across China who had never
attended an ASPIRE training were recruited for the control
group. Ninety-nine of these nurses completed both the pre-
and post-meeting surveys.
3.1 Nurse characteristics
Characteristics of the nurses participating in this study are re-
ported in Table 1. About half of the nurses in both the control
and intervention groups had 5-10 years of experience caring
for patients with rheumatological conditions. However, 33%
of intervention group nurses had 10+ years of experience
compared to only 10% of control group nurses.
3.2 Current role of nurses
On a typical workday, more than 80% of nurses in both
groups assess patient information needs, administer medica-
tion and perform routine assessments. Nurses in the interven-
tion group care for rheumatology patients more often than
nurses in the control group (94% versus 72%, respectively).
Similarly, more nurses in the intervention group provide pa-
tient education compared to nurses in the control group (95%
versus 73%, respectively). However, only 40% of nurses in
the intervention group offer information to the patients on the
risks and benefits of treatment, extra-articular manifestations,
comorbidities, and outcomes of AS disease to patients 70%
or more of the time (vs. 60% of control group nurses).
3.3 Impact measurement: Knowledge
Figure 1 demonstrates the overall level of knowledge about
ankylosing spondylitis in nurses in the control group and
intervention group. There was a significant 30% increase in
overall level of knowledge among nurses who attended the
ASPIRE training in September 2019 (average VAS: 5.63 pre-
vs. 8.34 post-survey; p< .001). Control group nurses who
did not attend ASPIRE training demonstrated no significant
increase in overall knowledge over the same period (average
VAS: 6.18 pre- vs. 6.50 post-survey; p= .097).
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Table 1. Characteristics of the nurses participating in the impact survey
Total (n = 210) Control Intervention
(n = 99) (n = 111)
Years caring for patients with
rheumatological conditions
(B1)
0 to 2 years 17% 5%
2+ to 5 years 25% 13%
5+ to 10 years 47% 50%
10+ to 15 years 9% 23%
15+ years 1% 10%
Highest level of formal education
(B2)
Nurse diploma 22% 5%
Nurse degree 73% 82%
Post graduate degree 2% 11%
Other 3% 2%
In v.s. out-patient clinics
(B3)
Rheumatology in-patient ward 40% 84%
Rheumatology out-patient clinic 2% 5%
Rheumatology in-patient and out-patient clinic 39% 10%
Other 18% 1%
Public v.s. private practices
(B4)
Public clinic 16% 3%
Public community hospital 24% 5%
Public teaching hospital (associated with a University) 49% 87%
Private clinic 1% 0%
Private community centre 0% 0%
Private teaching hospital (associated with a University) 3% 1%
Mix of public and private practices 4% 0%
Other 2% 5%
How many rheumatology trainings
attended
(B8)
None 19% 8%
1 to 3 44% 40%
4 to 7 29% 22%
8+ 7% 31%
How many ankylosing spondylitis
trainings attended
(B9)
None 32% 29%
1 to 3 49% 45%
4 to 7 15% 17%
8+ 3% 9%
Figure 1. Estimated overall knowledge impact measure between control and intervention group pre- and post-ASPIRE
training. Changes in overall level of knowledge (based on 11 individual knowledge domains) in the control and intervention
groups respectively before and after ASPIRE training workshop was conducted. *Self-rated on a 10-point scale,
**Analyzed using mixed model repeated measures ANOVA with adjustment for group sample differences
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The changes in pre- and post-ASPIRE training scores are
reported in Table 2. Significant improvements were observed
across all 11 individual knowledge dimensions measured
from pre- to post-ASPIRE training in the intervention group.
Control group nurses showed no significant change in 10 out
of the 11 knowledge dimensions measured, with the excep-
tion being practical AS disease assessment, where control
group nurses showed significant improvement between pre-
and post-survey. However, the increase in this measure in
the intervention group was still significantly greater than the
increase in the control group.
Table 2. Level of knowledge and confidence dimensions assessed in the impact survey
Areas assessed pre- & post-ASPIRE training Control group Intervention group
Estimate of impact from mixed
model repeated measures
ANOVA**
(The increase in each measure
in the intervention group
compared to the control group)
Pre Post P Pre Post P Impact
estimate P 95% CI
LEVEL OF KNOWLEDGE 6.18 6.50 .097 5.63 8.34 < .001* 3.02* < .001 2.43-3.61
1. Disease in general 6.32 6.41 .689 5.68 8.16 < .001* 2.68* < .001 2.04-3.31
2a. Pharmacological treatment options 6.05 6.34 .237 5.80 8.25 < .001* 2.48* < .001 1.84-3.12
2b. Non-pharmacological treatment options 6.06 6.41 .123 6.02 8.45 < .001* 2.40* < .001 1.78-3.01
3a. Comorbidities 5.99 6.39 .086 5.05 8.00 < .001* 2.85* < .001 2.20-3.50
3b. Extra-articular manifestations 6.25 6.56 .154 5.25 8.44 < .001* 3.37* < .001 2.67-4.07
4. Practical disease assessment 6.05 6.52 .043* 5.37 8.61 < .001* 3.34* < .001 2.55-4.12
5a. Risks, benefits and outcomes of disease 6.22 6.56 .102 5.59 8.16 < .001* 2.82* < .001 2.16-3.47
5b Pharmacological therapeutic information 5.94 6.35 .058 5.88 8.36 < .001* 2.55* < .001 1.89-3.22
5c. Self-management techniques (behavioral,
motivational, social) 6.43 6.56 .606 5.84 8.43 < .001*
2.47* < .001 1.86-3.08
5d. About extra-articular manifestations 6.23 6.62 .113 5.38 8.38 <0.001* 3.29* < .001 2.56-4.02
5e. About exercise and physical therapy 6.44 6.83 .082 6.02 8.53 < .001* 2.83* < .001 2.19-3.48
LEVEL OF CONFIDENCE 6.46 6.71 .169 5.83 8.39 < .001* 2.90* < .001 2.32-3.48
6. Disease assessment 6.42 6.59 .489 5.44 8.51 < .001* 3.36* < .001 2.63-4.08
7a. Recognizing and managing comorbidities 6.20 6.6 .065 5.48 8.19 < .001* 2.75* < .001 2.07-3.42
7b. Recognizing and managing extra-articular
manifestations 6.30 6.36 .796 5.34 8.37 < .001*
3.59* < .001 2.85-4.32
8a. Educating patients about risks, benefits, and
outcomes of disease 6.41 6.76 .090 5.95 8.36 < .001*
2.84*,† < .001 2.19-3.49
8b. Educating patients about therapeutic
information 6.49 6.85 .105 6.00 8.41 < .001*
2.63*,§ < .001 1.96-3.30
8c. Educating patients about self-management
techniques 6.73 6.87 .517 6.00 8.44 < .001*
2.89* < .001 2.23-3.56
8d. Educating patients about extra-articular
manifestations 6.39 6.61 .334 5.42 8.27 < .001*
3.15* < .001 2.43-3.87
8e. Educating patients about comorbidities 6.19 6.65 .026* 5.52 8.21 < .001* 2.23* < .001 1.63-2.83
8f. Educating patients about exercise and
physical therapy 6.71 7.00 .198 6.40 8.50 < .001*
2.28* < .001 1.63-2.94
9a. Educating patients about pharmacological
treatments 6.61 6.71 .689 6.28 8.50 < .001*
2.12* < .001 1.49-2.74
9b. Educating patients about
non-pharmacological treatments 6.62 6.86 .274 6.24 8.51 < .001*
2.03* < .001 1.43-2.63
*P < .05, significant results; **Assessed using the Ime4 R package and Inner Test R package controlling for years of experience, working in-patient or out-patient clinics,
where worked (public vs. private hospital) , and allowed to care for rheumatology patients (often, occasionally, not at all); †Significant interaction of effect with patient care and
in-patient/out-patient experience; §Significant interaction effect with experience and in-patient/out-patient experience.
3.4 Impact measurement: Confidence
Figure 2 reflects the overall level of confidence about anky-
losing spondylitis among nurses in the control group and
intervention group respectively. Overall level of confidence
significantly increased by 29% among nurses who attended
the ASPIRE training in September 2019 (average VAS: 5.83
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pre- vs. 8.39 post-survey; p< .001). Control groups nurses
who did not attend ASPIRE demonstrated no significant in-
crease in overall confidence over the same period (average
VAS: 6.46 pre- vs. 6.71 post-survey; p= .169).
Figure 2. Estimated overall confidence impact measure between control and intervention group pre- and post-ASPIRE
training. Changes in overall level of confidence (based on 11 individual confidence domains) in the control and intervention
groups respectively before and after ASPIRE training workshop was conducted. *Self-rated on a 10-point scale,
**Analyzed using mixed model repeated measures ANOVA with adjustment for group sample differences
Pre- and post-ASPIRE scores for level of confidence are re-
ported in Table 2. Significant improvements were observed
across all 11 individual confidence dimensions measured
from pre- to post-ASPIRE training in the intervention group.
Control group nurses showed no significant change in 10 out
of the 11 confidence dimensions measured, with the excep-
tion being educating AS patients about AS comorbidities,
where control group nurses showed significant improvement
between pre- and post-survey. However, the increase in
this measure in the intervention group was still significantly
greater than the increase in the control group.
3.5 Impact measurement: Nurses’ attitudes and beliefs
The proportion of nurses that strongly agree they are
equipped with knowledge to perform their role as a nurse
caring for patients with rheumatological conditions increased
from 70% pre-ASPIRE to 82% post-ASPIRE among inter-
vention group nurses (Supplementary Materials 5 & 6; Ques-
tion 10). By comparison fewer control group nurses strongly
agreed and their belief decreased from 53% to 49% over the
same period.
As confidence and knowledge increased in nurses who at-
tended the ASPIRE training, so did their belief that they
should have a role in educating patients. The proportion of
nurses that strongly agreed that they should have a role in
educating patients with rheumatological conditions about
pharmacological treatment increased from 76% pre-ASPIRE
to 87% post-ASPIRE among the intervention group nurses
(Supplementary Materials 5 & 6; Question 10). By compar-
ison, fewer control group nurses strongly agreed, and their
belief decreased from 59% to 53% over the same period.
The perception of nurses’ opportunity to spend time to edu-
cate rheumatological patients increased significantly for the
intervention group nurses pre- and post-ASPIRE but did not
change significantly for control group nurses over the same
time period, as represented in Figure 3.
3.6 Subgroup analysis: Years of experience
Overall, the nurses who attended the ASPIRE training were
more experienced than the nurses in the control group.
Eighty-three percent of nurses in the intervention group had
> 5 years of experience compared to 57% of nurses in the
control group. However, the benefits of the ASPIRE program
were significant regardless of how many years of experience
the nurses had. Subgroup analysis showed that the impact of
the ASPIRE training on levels of knowledge and confidence
was only slightly higher for those nurses with < 5 years of
experience compared to those with > 5 years of experience.
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Figure 3. Perception of nurses’ opportunity to spend time educating rheumatological patients pre- and post-ASPIRE
training
4. DISCUSSION
Nurses who attended an ASPIRE training workshop reported
a significant increase in their levels of knowledge and con-
fidence compared with a control group of nurses who have
never undergone any ASPIRE training. Nurses at the Baotou
ASPIRE training were generally well-educated, worked in
teaching hospitals, and attended more rheumatology train-
ings compared with a control group of nurses who have never
undergone ASPIRE training. The impact of the program was
only slightly higher in those with < 5 years of experience
than those with > 5 years of experience. It is likely that those
with > 5 years of experience were the group most likely to be
expected to extend their practice and the combined benefit of
the axSpA module and the nurse consultation framework had
more significance for the more experienced nurses. Nurses
who participated in the ASPIRE training may have been
highly motivated to develop their expertise. In addition, ap-
proximately 30% of these nurses had previously attended
other ASPIRE programs. It was also noted that there was
endorsement for nurse development by the hospital authority
and the consultants at the Baotou hospital which may have
influenced the motivation of the nurses. In addition, not
all nurses who attended ASPIRE have necessarily received
specialized rheumatology trainings previously or worked
in Chinese rheumatology clinics or rheumatology hospital
departments.
ASPIRE fills a gap regarding specialized, rheumatology
nurse education with international experts that otherwise
has been limited in China to date. The need to provide
nurses with access to best-practice knowledge and training
in rheumatology has been recognized globally. The Execu-
tive Committee of the Association of Rheumatology Health
Professionals (ARHP), a division of the American College
of Rheumatology (ACR), recognized the need for innova-
tive solutions to meet the needs of patients with rheumatic
diseases.
[30]
They identified nurse practitioners (NPs) and
physician assistants (PAs) as groups of health professionals
who could help address the workforce shortage. Informed
by needs assessment data and stakeholders, they developed a
curriculum outline endorsed by the ACR Board of Directors
for use by community-based and academic rheumatology
practices who desire to add NPs and PAs to their practice
setting. The ACR/ARHP rheumatology curriculum outline
can be utilized to train NPs and PAs and create more effi-
cient integration of NPs and PAs into rheumatology practice.
Equally, EULAR had also identified educational and training
initiatives for all health professionals together with recom-
mendations for core competencies and for the role of nurses
managing Chronic IJD.
[13, 17]
In addition to these initiatives,
the Royal College of Nursing in the UK has recently prepared
a competency and role development framework specifically
directed at rheumatology nurse specialists.[31]
Confidence comes with experience, knowledge, and training,
and may take many months to develop.
[20]
Nurse special-
ists already have a wide remit and play an invaluable part
in the delivery of modern rheumatology services. Advanc-
ing nursing practice could improve patient care and enhance
nursing career pathways in rheumatology.
[32]
Career progres-
sion and job satisfaction will be an increasingly important
recruitment factor for the future of nursing workforces. So,
if nurses are to sustain their newly acquired knowledge and
skills, they must have opportunities to reinforce their roles
in clinical practice. This is a challenge and has to be recog-
nized as a transition from novice to expert and is a continuum
that may initially require some time to consolidate learning
and develop confidence further before practicing indepen-
dently.
[33, 34]
Nurses have a professional responsibility to
continue their education and training, whilst also ensuring
that the care they deliver is adequately measured using out-
come measures appropriate to the evidence base in their
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specialty and the nursing model of care.[24]
Training packages, such as the ASPIRE program, may be
helpful by filling a critical gap enabling greater management
of patients by optimizing the role of the nurse. The hope is
that ASPIRE nurses will not only educate patients, but also
cascade their expertise to other nurses as ASPIRE train-the-
trainers. This will also serve as additional motivation for
these nurses to learn and increase their knowledge and confi-
dence. Although ASPIRE provides a first step in influencing
nurses within the field of rheumatology, sustained value can
only be achieved if the nurses return to clinical practice and
are supported by the management team and consultant col-
leagues to build upon their knowledge and can demonstrate
their competencies in routine clinical practice.
Assessing long-term knowledge gain is key for determining
whether education knowledge transfer is sustainable. Hands-
on learning techniques have shown to be important to long-
term knowledge retention.
[35]
Simulation-based education
of general medicine nursing staff that included a didactic
lecture followed by simulation scenarios demonstrated statis-
tically significant improvements in nursing confidence and
knowledge and were sustained over the three-month follow-
up period.
[36]
ASPIRE training workshops use a mixture of
didactic lectures and hands-on workshops.
The limitation of this work is that the results outlined in this
study are based upon a single event intervention in China
and were measured over a short period. The questionnaire
was developed specifically for ASPIRE and has not been
validated. Therefore, there is no test-retest reliability for the
questionnaire. Some questions in the survey related specif-
ically to patients with axSpA/ankylosing spondylitis while
others were more broadly related to rheumatology patients.
Rheumatological patients were not defined in the survey, and
therefore may have been interpreted differently by differ-
ent nurses. A confounding factor is that the control group,
may have perceived beliefs of knowledge/expertise which
remained unchallenged (Supplementary Materials 5 & 6;
Question 10). If they had attended the training event as
part of the intervention group, they may have been subject
to further scrutiny of their baseline perceived knowledge.
The control group achieved small benefits without attend-
ing ASPIRE training. It is unclear whether their perceived
beliefs in their pre- and post-survey match actual competen-
cies or whether their awareness encouraged them to review
their knowledge independently. Further studies are needed
to explore the long-term benefits of attending the ASPIRE
program in the intervention group, and also the perceived
knowledge, attitudes and beliefs in the context of patient care
for Chronic IJD.
There are many drivers that highlight the need to enhance
high-quality, cost-effective health care for those with chronic
diseases. An essential component of improving care can be
achieved by building a strong nursing workforce. Yet, if
recruitment and retention are to be improved, it is vital that
a greater focus be given to driving changes that will build
clinical career pathways for nurses. Specialist services for
people with rheumatological conditions is an exciting and de-
veloping field of practice with advances in treatment options
in both drugs and management approaches that demonstrate
greatly improved outcomes for patients. Training rheumatol-
ogy nurses to acquire more in-depth knowledge and skills can
help optimize their role in clinical practice to meet the greater
demands of disease monitoring and long-term management
of rheumatology patients. Basic education about rheumatic
diseases should begin in undergraduate nursing school and
be built upon through continuing education courses.
Nurses who attended the ASPIRE training workshop reported
significant increases in levels of knowledge and confidence
compared to the control group. Training was delivered by ad-
vanced nurse specialists who not only presented but acted as
role models and encouraged interactive discussions. The the-
oretical basis of advanced roles in nursing was supported by
interactive practical discussions and reinforced by hands-on
sessions, demonstrated by the nurse specialists with patients.
The long-term value of such training program relies upon
not only inspiring the nurses, but also their consultant and
managerial colleagues to build the next steps and achieve
organizational changes that may benefit patient care. How-
ever, the extent to which nurses can develop also relies upon
professional regulation within the Asia Pacific region that
will allow nurses to advance their roles in line with nurses in
Europe and the United States. It is hoped that such training
programs will be a catalyst for change while also enabling
units to implement greater involvement of their nurses. Pilot
studies should be developed to explore the value of advanced
roles in rheumatology within the Asia Pacific region. We
hope that this initial preliminary study encourages further,
and more in-depth studies, to explore in detail the issues of
enhancing nursing expertise within the field of rheumatology
nursing in Asia Pacific.
ACKNOWLEDGEMENTS
Asia-Pacific Initiative for Rheumatology Nurse Education
(ASPIRE) was funded by Janssen Asia Pacific, a division
of Johnson and Johnson Pte Ltd. Blue Planet Research and
Consulting (partnering with Rakuten Insight in China) con-
ducted the pre- and post-surveys, data collation and analytics.
Medical writing support, in accordance with GPP guidelines,
was provided by Mediwrite Asia Inc Pte Ltd and included
16 ISSN 1925-4040 E-ISSN 1925-4059
http://jnep.sciedupress.com Journal of Nursing Education and Practice 2021, Vol. 11, No. 4
proofreading and editing services.
CON FLI CT S OF INTEREST DISCLOSURE
Susan Oliver has received consultancy fees from Janssen and
expenses related to travel while delivering these modules.
Daniel Furtner is an employee of Johnson & Johnson Pte.
Ltd. and may own stock/options.
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