Rheumatoid arthritis (RA) is a systemic autoimmune disease characterized by an involvement of sensorimotor and psychological factors, which can impact on the sufferer's quality of life. Education and health promotion activities from a multidisciplinary approach including nursing could help in symptom management. This review aims to analyze and evaluate health promotion interventions from a nursing perspective in patients with RA. A scoping review method was employed to identify relevant peer-reviewed articles published between 2019 and 2024 across PubMed and Web of Science databases. The Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist was followed. The specific search strategy was: (rheumatoid arthritis) AND (health promotion OR health education OR promotion OR education OR therapeutic education OR health care OR health management) AND (nursing intervention AND nursing). Six articles met the inclusion criteria, showing that nursing interventions include educational sessions (for patients or family caregivers), interviews, daily phone calls, written information and professional counseling. They implied an improvement in disease activity (even in biochemical parameters), medical adherence or readiness, self-efficacy, quality of life, and psychological wellbeing. Besides, a reduction in pain intensity was described. This review demonstrates that nursing interventions within multidisciplinary teams, as well as comprehensive and individualized care, significantly improve sensorimotor and psychological variables, which contribute to managing chronic pain in patients with RA.
La artritis reumatoide (AR) es una enfermedad autoinmune sistémica caracterizada por la afectación de factores sensoriomotores y psicológicos, que pueden repercutir en la calidad de vida de los pacientes. Las actividades de promoción y educación para la salud desde un enfoque multidisciplinario, que incluyan a la enfermería, podrían contribuir al manejo de los síntomas. Esta revisión tiene como objetivo analizar y evaluar las intervenciones de promoción de la salud desde la perspectiva de la enfermería en pacientes con AR. Se empleó una revisión exploratoria para identificar artículos relevantes revisados por pares, publicados entre 2019 y 2024 en las bases de datos PubMed y Web of Science. Se siguió la lista de verificación PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews). La estrategia de búsqueda específica fue: (artritis reumatoide) Y (promoción de la salud O educación para la salud O promoción O educación O educación terapéutica O atención médica O gestión de la salud) Y (intervención de enfermería Y enfermería). Seis artículos cumplieron con los criterios de inclusión, mostrando que las intervenciones de enfermería incluyeron sesiones educativas (para pacientes o cuidadores familiares), entrevistas, llamadas telefónicas diarias, información escrita y asesoramiento profesional. Estas intervenciones implicaron una mejora en la actividad de la enfermedad (incluso en parámetros bioquímicos), la adherencia o disposición al tratamiento médico, la autoeficacia, la calidad de vida y el bienestar psicológico. Además, se describió una reducción en la intensidad del dolor. Esta revisión demuestra que las intervenciones de enfermería en equipos multidisciplinarios, así como su atención integral e individualizada, mejoran significativamente las variables sensoriomotoras y psicológicas, lo que contribuye al manejo del dolor crónico en pacientes con artritis reumatoide.
Rheumatological diseases are a large and varied group of disorders that mostly affect the joints, although they can also impact almost any organ in the body. These conditions are usually linked to problems with the immune system, inflammation, infections, or the gradual breakdown of muscles, joints, and bones. They often last a long time and get worse over time. They are commonly painful, limiting what patient can do, and in the worst cases, they can cause serious disability.1
Overall, rheumatological diseases are a major global health problem, accounting for 6% of the total global burden of disease.2 According to the study on the prevalence of rheumatic diseases in Spain conducted by the Spanish Society of Rheumatology (called EPISER study), it is estimated that in Spain more than 300,000 people suffer from rheumatoid arthritis (RA), and around 20,000 new cases are diagnosed each year.3 This data are very relevant considering that it is the most disabling rheumatic pathology according to the Spanish Society of Rheumatology.2,3
RA is a systemic autoimmune disease of an inflammatory nature that affects the joints, with the synovial membrane being the most involved structure.4,5 Its course is progressive and insidious, and its most important features are chronicity and irreversible joint damage.3,6
The disease can irreversibly modify the structure and function of the joint causing degenerative changes and limiting mobility.7,8 Seventy percent of patients show at least one poor prognostic factor, such as the presence of rheumatoid factor and anti-citrullinated protein antibodies in the blood.9
In terms of incidence, it is a disorder more common in women than in men, the ratio being 3:1, with an age of onset between 40 and 60 years, although it can appear at any age.2 The prevalence of RA is estimated to be between 0.3% and 1.2% of the world population, with variations in frequency depending on countries and ethnicities, being in Spain between 0.3% and 1.6% of the population over 20 years of age.2,3 On the other hand, the incidence ranges between 0.2 and 0.4 cases per 1000 inhabitants worldwide.
The main symptoms are due to changes in the connective tissue of the synovial membrane that result in chronic pain, stiffness, tenderness, warmth and swelling of the joints, which can hinder movement and, in some cases, lead to physical disability.5,10 The presence of pain can lead to significant physical limitations, negatively influencing a person's functional capacity, quality of life and activity.5,11–13 In addition, there are psychological variables that seem to be related to pain, such as anxiety, depression and anger, as several studies suggest that these types of disorders are more frequent in the RA population than in the rest of the population.11,14
Current treatment options for RA highlight the importance of having tools driven to control all manifestations of the disease, including inflammation, structural sequelae and comorbidities, with the goal of achieving sustained remission or low disease activity.5,14 To this end, research studies have shown that various drugs can help control pain and inflammation, complemented by nursing interventions related to health promotion.5,14,15 For example, therapeutic education, defined as a structured educational process that uses techniques such as interactive group workshops, individualized counselling and personalized educational materials to empower patients in the comprehensive management of their condition. These interventions aim to encourage self-care, providing patients with strategies that promote self-care habits, which improve self-efficacy, treatment adherence and patient's quality of life.5,14,15
On the other hand, RA is a multifactorial disorder in which not only the sensorimotor sphere of the sufferer is affected, but also the quality of life, involving other spheres such as the affective-motivational and cognitive-evaluative spheres.11–13 This is why comprehensive treatment and multidisciplinary work is required, covering the pathology from different disciplines to achieve better management of the disease.
In this context, we found it necessary to analyze the role of nursing in the management of RA due to the need to provide comprehensive care to patients with RA, attending not only to the clinical manifestations of the disease itself, but also to the problems derived from it. Thus, this review looks for synthesizing the available updated scientific evidence on the effectiveness of nursing interventions in order to support decision-making.
Based on the above, the purpose of this scoping review was to analyze and evaluate health promotion interventions from nursing to patients with RA. The research questions on which this review was based were the following: (1) What type of health promotion interventions from nursing to patients with RA predominate currently, and in what clinical contexts have they been developed? (2) What effect do these interventions have?
MethodsDesignThis study is a scoping review that was carried out between November 2023 and February 2024 following PRISMA-ScR (Appendix A. Supplementary data) in combination with the PRISMA 2020 flow diagram.16,17 The objective of using PRISMA-ScR checklist is to improve transparency, quality, and the completeness of reporting in scoping reviews.16
Search strategy and data extractionA literature search was performed using the PubMed and Web of Science databases together with the TESAURO dictionary of DeCS/MeSH (Descriptors in Health Sciences/Medical Subjects Headings), and the search was reproduced on January 10, 2024. The Boolean operators used were ‘OR’ for joining terms and ‘AND’ to create a reproducible search strategy. The search formula used was: (RHEUMATOID ARTHRITIS) AND (HEALTH PROMOTION OR HEALTH EDUCATION OR PROMOTION OR EDUCATION OR THERAPEUTIC EDUCATION OR HEALTH CARE OR HEALTH MANAGEMENT) AND (NURSING INTERVENTION AND NURSING).
During the search, a date publication filter was considered, in which articles were selected from the area of health sciences published between 2019 and 2024, and a series of keywords: ‘Rheumatoid Arthritis’, ‘Health promotion’, ‘Health education’, ‘Education’, ‘Therapeutic education’, ‘Health care’, ‘Health management’, ‘Nursing intervention’, ‘Nursing’. The search process was carried out by 3 independent reviewers (XXX, XXX, and XXX) using the same methodology. Differences that arose during this phase were resolved by consensus. Articles were screened by hand searching, and authors were contacted by e-mail if the full text was not available.
In the first phase, 3 independent reviewers (XXX, XXX, and XXX) carried out an analysis of the data, assessing the relevance of the articles in relation to the study question, objectives, selection criteria and results. The analysis was performed based on the information in the title, abstract and keywords of each study. If there was no consensus or if the abstract did not contain sufficient information, the full text was reviewed. In the second phase, the full text was examined to assess whether the studies met all the inclusion criteria (see below). Differences between reviewers were resolved by discussion, and consensus was moderated by a fourth reviewer (XXX).
Data extracted from the selected articles were the followings: first author's surname, year of publication, study design, age and characteristics of the population sample, the corresponding inclusion and exclusion criteria, type of intervention performed, duration of monitoring, and main study outcomes (based on variables measured for assessing the progression of RA, and thus for analyzing the efficacy of interventions).
Subsequently, the extracted data were charted, organized and categorized according to the main variables of interest, such as pain intensity, disease activity, quality of life, self-efficacy, and psychological outcomes. A descriptive and narrative synthesis approach was then applied to map the existing evidence, allowing the identification of common patterns, intervention characteristics, and reported effects across studies.
Study selection criteriaAny type of intervention from the nursing service to promote health in patients with RA, either alone or in combination with other treatment techniques, was accepted. Participants selected for the studies should be adult men and women (over 18 years of age) with a diagnosis of RA under follow-up by a rheumatology service, in treatment with drugs or with criteria for initiation of drug treatment. There were no restrictions regarding the language of the studies or their publication status. Randomized controlled trials (RCTs), quasi-experimental studies and pilot studies were selected as primary studies from which useful information (i.e., characteristics and effects of nursing interventions) can be extracted. Exclusion criteria included articles selected as: review, systematic review, cross-sectional, observational study, meta-analysis; as well as those that did not address the pathology of interest as the main topic of the study or collect data before 2016.
Assessment of risk of biasThe risk of bias has been assessed in all the studies included in the review. The Jadad scale, developed and validated to assess the quality of randomized clinical trials (RCTs) on pain, based on three methodological characteristics (randomization, blinding and participant accountability), is used in clinical trials.18,19 The questionnaire score ranges from 0 to 5, so that the higher the score, the higher the methodological quality of the study.18,19
VariablesFor the sake of clarity in the interpretation of data extracted from the selected articles in this review, below there is a description of the variables and tools mostly used to define the outcomes of RA.
Pain intensity- -
Visual Analogue Scale (VAS): It is used to measure pain intensity before and after each treatment. The VAS is a 100-mm line with 2 endpoints representing the extreme states of “no pain” and “the maximal pain imaginable”. It showed a good retest reliability (r, 0.94; p<0.001) and a minimal detectable change of 15.0mm.20
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Rheumatoid Arthritis Impact of Disease (RAID): The RAID score is a patient-reported outcome instrument used to assess the impact of RA on patient's well-being at baseline and follow-up assessments. It consists of 7 items covering pain, functional disability, fatigue, sleep disturbances, physical and emotional well-being, and disease activity, rated on 0–10 numerical rating scales. This tool weights into a total score (range 0–10), where higher scores indicate greater disease impact. RAID has demonstrated high reliability and validity.21,22
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European Quality of Life 5-Dimension 3-Level (EQ-5D-3L): This tool is used to assess health-related quality of life at baseline and follow-up. It comprises five dimensions (mobility, self-care, usual activities, pain/discomfort, anxiety/depression), each of them with three severity levels, plus a 100-mm VAS for overall health, yielding a summary index via country-specific value sets. It demonstrates high reliability and construct validity.23
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Hannover Functional Questionnaire (FFbH): It is a self-administered questionnaire used to assess functional ability in activities of daily living among patients with RA and other rheumatic diseases. It consists of 18 items covering common motor tasks, each of which is rated on a three-point scale (i.e., can perform without difficulty, can perform with difficulty, cannot perform or can only perform with help). The responses are totaled and converted into a functional ability score ranging from 0 to 100%, where higher values indicate better function. The FFbH has demonstrated good reliability and construct validity in rheumatology populations.24
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Health Assessment Questionnaire (HAQ): HAQ is a self-assessment tool used to evaluate functional disability in patients with RA. It consists of 20 questions divided into eight categories (dressing/grooming, getting up, eating, walking, hygiene, reaching, grasping and other activities) covering physical function in activities of daily living. Each question rates on a four-point scale (0=no difficulty; 3=unable to perform), taking into account aids/devices and assistance from others. The average of the category scores is calculated on a scale of 0–3, where a higher score indicates greater disability. It demonstrates excellent reliability, responsiveness and predictive validity for long-term outcomes.25,26
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Arthritis Self-Efficacy Scale (ASES): This tool is a self-report instrument used to assess beliefs regarding self-efficacy in managing arthritis symptoms at both the start of the study and during follow-up. It consists of 20 items distributed across three subscales: pain (5 items), function (9 items), and other symptoms (6 items), each of which is scored on a 10-point numerical scale (1=very unsure to 10=very sure), resulting in subscale scores (0–10). An overall average score is obtained across the completed items, with higher scores indicating greater self-efficacy. It demonstrates strong internal consistency, test–retest reliability, and construct validity in populations with RA.27,28
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Disease activity score in 28 joints (DAS28): DAS28 is a composite index used to quantify the activity of RA. Specifically, the aim of this tool is to quantify the severity of joint inflammation and monitor the response to treatment. It evaluates 28 specific joints for tenderness (TJC28) and swelling (SJC28), incorporates erythrocyte sedimentation rate (ESR, mm/h) or C-reactive protein (CRP, mg/L), and includes patient global health assessment via a 100-mm visual analog scale (VAS). The score (range 0–10) is computed using the validated formula DAS28=0.56×√TJC28+0.28×√SJC28+0.70×ln (ESR)+0.014×VAS, categorizing activity as remission (<2.6), low (2.6–3.2), moderate (3.2–5.1), or high (>5.1), with high reliability (r=0.89) and sensitivity to change.29
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Clinical Disease Activity Index (CDAI): It is a purely clinical composite index used to assess the activity of RA. It is calculated as the simple sum of four components: the count of painful joints across 28 joints, the number of swollen joints out of 28, the patient's global assessment of disease activity (VAS 0–10cm) and the clinician's global assessment of disease activity (VAS 0–10cm), giving a total score of 0–76, where higher values indicate greater disease activity. Standard cut-off points define remission (≤2.8), low disease activity (>2.8–10), moderate (>10–22) and high (>22) disease activity, and the index has demonstrated high reliability and a strong correlation with the DAS28.30,31
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Medication Adherence Report Scale (MARS): This tool is a self-report instrument used to assess medication adherence at baseline and follow-up visits in RA patients. It comprises 5 items on a 5-point Likert scale (1=never to 5=always) evaluating intentional and unintentional non-adherence behaviors (forgetting doses, altering timing, stopping due to side effects or perceived lack of need), yielding a total score (range 5–25) where higher scores indicate better adherence. In RA patients, the modified MARS demonstrated good reliability, validity, and ease of administration.32
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Beliefs about Medicines Questionnaire (BMQ): It is a self-assessment tool used to evaluate patients’ beliefs about medication. It consists of two scales: BMQ-General (8 items assessing negative beliefs about medicines in general: Overuse and Harm subscales) and BMQ-Specific (10 items assessing beliefs about prescribed medication: Need and Concerns subscales). Each scored on a 5-point Likert scale (1–5) for total and subscale scores, where higher scores on “Need” compared to “Concerns” predict better adherence. The BMQ demonstrates good test–retest reliability and construct validity in the Spanish population.33
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Hospital Anxiety and Depression Scale (HADS): This tool assess the anxiety and depression states. The scale has 2 subscales of 7 items each that measure anxiety and depression. The HADS presented an internal consistency (Cronbach's alpha) at 0.80–0.93 for the anxiety, and 0.81–0.90 for the depression subscales.34
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Self-rating Anxiety Scale (SAS) and Self-rating Depression Scale (SDS): They are self-report instruments used to assess subjective severity of anxiety and depression symptoms. The SAS consists of 20 items covering somatic, cognitive, and affective anxiety symptoms rated on a 4-point Likert scale (1=none to 4=most severe), with raw total score 20–80 converted to 25–100 (≥60=significant anxiety). The SDS includes 20 depression symptom items with identical scaling and conversion (≥60=significant depression). Both scales demonstrate good internal consistency, test–retest reliability, and concurrent validity with clinical rating scales in general and clinical populations.35,36
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Taiwanese Depression Questionnaire (TDQ): It is a culturally designed self-report instrument for the Taiwanese population, used to detect depressive symptoms. It consists of 18 items assessing affective symptoms (depression, crying, pessimism), somatic symptoms (insomnia, fatigue, loss of appetite), and cognitive symptoms (poor concentration, memory problems) on a 4-point Likert scale (0=never to 3=always) over the past week, with a total score range of 0–54 (cut-off ≥19 for depression screening). It demonstrates excellent internal consistency and concurrent validity in the Taiwanese population.37
The research selection process is shown in the form of a flow chart in Fig. 1. Initially, 407 articles were found, of which 315 were left after eliminating duplicates. Following this process, 55 full-text review articles were selected for further evaluation. Finally, 6 articles met the inclusion criteria. Publication dates ranged from 2020 to 2022. Of the excluded articles, 44 did not address the pathology of interest in terms of nursing management, while 4 did not address the pathology of interest itself: one Delphi study, and three study protocols for a controlled trial or a pilot study.
Characteristics of the included studies
Table 1 reflects the main characteristics of the articles selected for the scoping review and Table 2 indicates the assessment of risk of bias for each of the selected articles using the Jadad scale. This included 4 controlled clinical trials,38–41 1 quasi-experimental study42 and 1 pilot study,43 with a total of 758 patients.
Characteristics of the included studies.
| Study | Objective | Study design | Sample | Inclusion/exclusion criteria | Variables | Intervention | Follow-up | Results |
|---|---|---|---|---|---|---|---|---|
| Beauvais et al. (2022) | Evaluating the effect of nurse-led education on safety skills for patients treated with biological disease-modifying antirheumatic drugs (DMARDs). | Randomized clinical trial. | Intervention group (n=64):- Women: 40- Men: 24- Average age: 48.6Control group (n=63):- Women: 44- Men: 19- Average age: 45.4Country: France. | Inclusion criteria:- Men and women aged 18–75 with a diagnosis of RA or spondyloarthritis (SpA) who meet criteria to initiate their first treatment with biological DMARDs.Exclusion criteria:- Conditions that could alter treatment comprehension or adherence- Cognitive impairment- Previous education on biological DMARDs | Primary variable:- Patient safety problem-solving skills (BioSecure)Secondary variables:- Disease activity, coping, and psychological well-being (NRS)- Impact of rheumatoid arthritis (RAID)- Arthritis helplessness index (IAH)- Beliefs about medications questionnaire (BMQ) | Intervention group (n=64): Received 3 sessions spaced 3 months apart, conducted by educational nurses.Control group (n=63): Completed 2 sessions spaced 6 months apart, with no educational nurse involvement. | 6-Month follow-up | The intervention group exhibited improved skills regarding infections, increased willingness to get vaccinated, and behaviors related to medication adherence. |
| Lahiri et al. (2022) | Evaluating a multidisciplinary intervention on the quality of life in patients with RA. | Randomized clinical trial. | Multidisciplinary care group (n=64):- Women: 52- Men: 12- Average age: 56.5Routine care group (n=67):- Women: 61- Men: 6- Average age: 56.6Patients: Chinese, Indian, Malay, Others. | Inclusion criteria:- Men and women over 21 years old with a diagnosis of RA who are being followed by the rheumatology service.Exclusion criteria:- Pregnant patients- Subjects unable to provide informed consent- Subjects who have previously received a multidisciplinary intervention | Primary variable:- Quality of life (EQ-5D-3L)Secondary variables:- Pain intensity (VAS)- Patient global assessment of improvement (PGA)- Disease activity score in 28 joints (DAS28)- Modified health assessment (MHAQ)- Patient acceptance of symptoms (PASS)- Degree of self-efficacy (RASE)- Medication adherence scale (MARS)- Evaluation of specific disease knowledge (DSK) | Multidisciplinary care group (n=64): Conducted an initial interview with all health professionals, followed by 2 routine follow-up sessions.Routine care group (n=67): Completed all 3 sessions through routine care without involvement from various health professionals. | 6-Month follow-up | A single visit of stable patients with low disease activity to a multidisciplinary group did not achieve the minimal detectable change in EQ-5D-3L. However, it did lead to small but statistically-significant improvements in EQ-5D-3L, disease activity (DAS28), pain intensity, and self-efficacy. |
| Hoeper et al. (2021) | Comparing the treatment outcomes after 1 year in patients with ACPA/RF*-positive RA under rheumatologist-led care (RLC) or nurse-led care (NLC). | Randomized clinical trial. | NLC or intervention group (n=111):- Women: 80- Men: 31- Average age: 58.81RLC group (n=113):- Women: 86- Men: 27- Average age: 58.10Country: Germany. | Inclusion criteria:- Men and women over 18 years old with a diagnosis of ACPA/RF-positive RA.Exclusion criteria:- Severe comorbidities- Inability to provide informed consent- Anticipated unavailability throughout the study | Primary variable:- Patient-reported disease activity assessment (DAS28-CRP)Secondary variables:- Rheumatoid Arthritis Disease Activity Index (RADAI)- Functionality in performing daily activities (FFbH)- Health-related quality of life (Impact of RA Index)- Depression and anxiety (HADS) | NLC group (n=111): Completed 5 sessions, 2 with the responsible rheumatologist and 3 with the rheumatology specialist nurse.RLC group (n=113): Completed 4 routine sessions with their responsible rheumatologist. | 12-Month follow-up | This study supported the non-inferiority of nursing care in the management and follow-up of patients with RA with high disease activity and poor prognostic factors, in addition to rheumatologist care. |
| Li et al. (2021) | Exploring the influence of education for family caregivers of patients with rheumatoid arthritis and the factors influenced by this education. | Randomized clinical trial. | Intervention group (n=80):- Women: 55- Men: 25- Average age: 60.6Control group (n=78):- Women: 59- Men: 19- Average age: 57.7Country: China. | Inclusion criteria:- Have a family caregiver and have lived with them for at least 5 years- Not received training on rheumatoid arthritis- Not received stable systemic therapy for 1 year | Disease variables:- Tender joint count (TJC28)- Swollen joint count (SJC28)- Pain on visual analog scale (VAS)- Patient global assessment of disease activity (PtGA) on VAS- Clinical Disease Activity Index (CDAI)- Simplified Disease Activity Index (SDAI)Psychosocial variables:- Health Assessment Questionnaire (HAQ)- Self-Rating Depression Scale (SDS)- Self-rating Anxiety Scale (SAS) | Intervention group (n=80): 6 individual educational sessions and 6 group educational sessions for family caregivers, along with written information.Control group (n=78): No educational sessions conducted. | 6-Month follow-up | Nurse education for family caregivers reduces inflammation levels, alleviates disease activity, and addresses mood disorders. |
| Tuna et al. (2021) | Determining the effects of Orem's self-care nursing model provided to geriatric patients with RA on symptoms, activities of daily living, and pain. | Pilot study. | Intervention group (n=11):- Women: 10- Men: 1- Average age: 67.27Control group (n=11):- Women: 8- Men: 3- Average age: 67.0Country: Turkey. | Inclusion criteria:- Having one hand affected by RA and difficulties with activities of daily living- Over 65 years old- Using only prescribed medications- Diagnosed at least a year ago- Absence of psychiatric illness or mental impairment- Absence of cancerExclusion criteria:- Hand pain due to other rheumatic diseases- Raynaud's disease or other circulatory disorders- Patients who have undergone hand surgery | Main variables:- Pain (VAS)- Functional status and quality of life in patients with rheumatic diseases (HAQ)- Functional assessment for hands with RA (DHI) | Intervention group (n=11): Daily phone calls and interviews every 4 weeks with the nurse, in addition to standard follow-up by a rheumatologist.Control group (n=11): Standard follow-up by a rheumatologist. | 8 weeks of follow-up | The nursing care provided according to Orem's Model is effective in reducing pain, improving hand functions, and performing daily activities. |
| Lu et al. (2020) | Examining the effectiveness of nurse-led programs in the treatment of patients with chronic and potentially life-threatening illnesses. | Quasi-experimental non-randomized study. | Intervention group (n=50):- Women: 38- Men: 12Control group (n=46):- Women: 41- Men: 5Country: Taiwan. | Inclusion criteria:- Age ≥20 years- No cognitive impairment- Diagnosis of RA | Main variables:- Self-efficacy level (ASES)- Depression (TDQ)- Disease activity (DAS28)Secondary variables:- BMI- C-reactive protein (CRP)- Pain (VAS)- Use of medication | Experimental group (n=50): Standard care plus professional counseling, educational sessions, and follow-up phone sessions.Control group (n=46): Standard care. | 6 months of follow-up. | The implementation of nurse-led programs reduced disease activity levels. |
Assessment of the selected articles according to the Jadad scale.
| Item 1 | Item 2 | Item 3 | Item 4 | Item 5 | Item 6 | Item 7 | Total | |
|---|---|---|---|---|---|---|---|---|
| Beauvais et al. (2022) | Yes | Yes | Yes | No | Yes | Yes | Yes | 4 |
| Lahiri et al. (2022) | Yes | Yes | Yes | No | Yes | Yes | Yes | 4 |
| Hoeper et al. (2021) | Yes | Yes | Yes | No | No | No | Yes | 2 |
| Li et al. (2021) | Yes | Yes | Yes | Yes | No | No | No | 2 |
| Tuna et al. (2021) | Yes | Yes | Yes | No | No | No | No | 1 |
| Lu, et al. (2020) | No | Yes | No | No | No | No | No | 0 |
Item 1: Is the study described as randomized? Item 2: Is the method used to generate the randomization sequence described, and is it adequate? Item 3: Is the method used to generate the randomization sequence adequate? Item 4: Is the study described as double-blind? Item 5: Is the method of masking described, and is it adequate? Item 6: Is the method of masking adequate? Item 7: Are there descriptions of losses to follow-up and dropouts?
Overall, nursing interventions described in the selected articles included educational sessions (for patients or family caregivers), interviews, daily phone calls, written information and professional counseling. In most of the included studies, there was a control group that either followed usual care or routine follow-up by a rheumatologist without including any educational sessions. Regarding the intervention groups, it should be noted that the nursing service intervened mainly through educational sessions.
Characteristics of the study samplesConsidering the population included in the studies, all of them were adults, with a diagnosis of RA of at least one year, under follow-up by the rheumatology service, and on treatment with disease-modifying anti-rheumatic drugs (DMARDs).
The articles were aimed at people of both sexes with a diagnosis of RA. One article included people aged 20 years and older,42 one article included people aged 21 years and older,38 while another article indicated only people aged ≥65 years with at least one hand affected by RA43. The remaining articles targeted people of adult age (≥18 years)40 by indicating a cut-off age, such as 75 years,39 or a specific condition, such as having a primary caregiver.41
Changes in the outcomes analyzed after interventionsThe results of the papers selected for this review were evaluated in terms of the analyzed variables, along with their evolution after relevant interventions. The outcomes studied were the followings.
Pain intensityAccording to Lahiri et al. in 2022, after an intervention within multidisciplinary groups including a clinical nurse specialist in rheumatology, pain in RA patients evolves from 2.9 to 2.1 according to Visual Analogue Scale (VAS), indicating an improvement of 0.8 points.38 Similarly, Tuna et al. in 2021, using the same scale, showed a difference in score of 2.74 points after an individualized care plan, with 5.45 points obtained before the intervention and 2.71 points obtained after 8 weeks of intervention.43 On the other hand, the study by Hoeper et al. in 2021 shows the non-inferiority of the care offered by nursing compared to the care offered by rheumatologists. Thus, after a 12-month intervention, pain measured according to the Rheumatoid Arthritis Impact of Disease (RAID) scale decreases from 6 to 3 points, in the same way that fatigue decreases from 5 to 3 points.40
Quality of lifeLahiri et al. showed that the quality of life measured by the European QOL-5-Dimension-3-Level (EQ-5D-3L) index increased by 0.07 points after a multidisciplinary intervention, a clinically relevant change when compared with the control group.38
Functionality and disabilityHoeper et al. evaluated functionality in activities of daily living by means of the ‘Funktionsfragebogen Hannover’ (FFbH) index, observing a change from 75 to 83.3 after nursing intervention in the management of the pathology, along with patient education and medication administration. However, differences between the intervention and control groups were not significant, so nursing care was not shown to be superior to the usual care provided by the rheumatologist alone, in this variable.40
On the other hand, Li et al. in 2021 obtained no difference in the Health Assessment Questionnaire (HAQ) scale to assess the degree of perceived physical disability after the intervention.41 Meanwhile, Tuna et al. obtained a difference of 0.31 points from a score of 1.85 to 1.54 after nurses monitored patients based on the self-care model.43 In addition, for functional hand assessment, a difference of 12.63 points was obtained, with 72.91 being the first score obtained and 60.28 the final one after the intervention.43
Self-efficacyTo evaluate the degree of self-efficacy, Lu et al. used the Arthritis Self-Efficacy Scale (ASES) before and after the educational intervention.42 Differences between the two measurements were significant (p<0.01) between groups (control vs. intervention), with an improvement of 369.27 points in the group that had received nursing intervention, while the control group worsened by 19.41 points.42
Disease activityDisease activity is usually assessed by using the disease activity score in 28 joints (DAS28). Lahiri et al. obtained a reduction of 0.43 in the DAS28 mean score after the intervention (from 3.13 to 2.7), thus demonstrating a significant improvement in the course of the disease.38 In the same line, Beauvais et al. obtained a decrease from 4.1 to 2.2 after a patient education intervention on safety skills showing significant improvement.39 On the other hand, Hoeper et al. showed a significant disease activity decrease from 4.51 to 2.64 in the nurse-led care group, and this change was maintained for 12 months.40
Disease activity is not only measured by the joints affected, but also by the biochemical factors that are altered in the disease. In this respect, the study by Li et al. tackled disease activity by measuring parameters such as C-reactive protein (CRP) and tumor necrosis factor (TNF)-ɑ, which tended to decrease during the caregiver education intervention.41 Thus, this study showed that primary caregiver education can also promote inflammation containment and reduce inflammation markers. In addition, they also used the DAS28 score to assess disease activity, which decreased from 4.94 to 3.4 points after the intervention. Consistently, the Clinical Disease Activity Index (CDAI) decreased from 19.97 to 4.51 points.41
This same scale (DAS28) was used in Lu et al. to assess the influence of a health education intervention based on pathology education and management, and it was observed that after 6 months of intervention, the score obtained was not clinically significant, but the intervention group improved by 1.21 points while the control group improved by only 0.36 points.42
Medication adherenceLahiri et al. reported an increase from 22.6 to 23.3 in the Medication Adherence Report Scale (MARS), after the intervention of a multidisciplinary group including a rheumatology nurse specialist.38
In addition, Beauvais et al. measured the same variable, but according to the Beliefs about Medicines Questionnaire (BMQ) scale, which went from 4.1 to 2.6 after patient education on safety skills.39 This study used the BioSecure questionnaire which included questions related to vaccination readiness, infection risk and medication adherence behaviors. The post-study showed a significant improvement in vaccination readiness and maintenance of drug treatment in periods of disease remission.39
Psychological wellbeingPsychological well-being considers numerous psychological variables such as anxiety and depression, among many others. In this line, the study by Hoeper et al. included the Hospital Anxiety and Depression Scale (HADS) to assess the evolution of anxiety and depression in patients, after being followed up by nurses and receiving education about their pathology and treatment. After 12 months of intervention, depression decreased from 4 to 3 points, while anxiety remained at 6 points.40
In turn, Li et al. found that the Self-rating Anxiety Scale (SAS) at the beginning of their study indicated 54.43 and evolved to 31.71 after 6 months, while the Self-rating Depression Scale (SDS) went from 57.31 to 31.81 in the intervention group.41 These differences were significantly lower than those observed in the control group (p<0.001). Thus, they suggested that family caregiver nursing education contributes to mental health and reduces mood indicators, with a more significant effect on older patients.
Finally, the study by Lu et al. demonstrated a significant difference in depressive symptoms in patients who underwent the health education-based nursing intervention with respect to pathology.42 These symptoms were measured according to the Taiwanese Depression Questionnaire (TDQ) scale, whose final scores showed statistically significant differences (p=0.01) between groups, favoring the intervention group. The group that had received the nursing intervention went from 12.71 initial points to 3.15 points at the end, while the control group went from 6.48 to 4.06 points.42
DiscussionThis review demonstrates that nursing interventions within a multidisciplinary team, as well as comprehensive and individualized care, significantly reduce pain intensity in patients with RA. This type of intervention also showed improvements in patients’ quality of life and self-efficacy, as well as their education about pathology and knowledge about treatment and possible adverse effects. In the same line, nursing interventions also favored safety behaviors and medication adherence. This last variable is closely linked to disease activity, which also showed improvements after the monitoring of the pathology by nurses. The levels of anxiety and depression shown by patients throughout the process also reflected the patient's satisfaction with the care received. Nursing care, as well as therapeutic education, showed statistically significant differences in the group of patients who received these interventions.
Nurse-directed care adopts a holistic approach that considers the physical, psychological and social needs of patients. Components of nurse-directed care include assessing disease activity, monitoring the effects of therapy, educating the patient on the pathology and its management, as well as raising awareness of possible complications and providing psychological support, which necessitates integration within multidisciplinary teams.44
In this line, the European League Against Rheumatism (EULAR) published eight evidence- and expert opinion-based recommendations for RA patients education, trying to offer a core framework across Europe.45 Among them, to provide patient education as an integral part of standard care, and throughout the course of the disease, also recognizing the role of rheumatologic nurses.
In order to implement the whole framework, it is necessary to study the cost-effectiveness of nursing care for RA patients by looking at changes in measurable variables such as pain intensity, disease activity, level of function or depressive symptoms, as this review does. Interventions for the management of these variables have been mainly: treatment through a multidisciplinary team including a rheumatology nurse specialist, as well as patient and caregiver education in nurse-led sessions on pharmacological treatment management and self-care.
Follow-up and monitoring are additional important points to discuss. Typically, pathology control and monitoring sessions are performed periodically in medical consultations every 3 months, although this will depend on disease activity.46 However, recent studies have shown that with protocols and in patients with stable disease activity, monitoring could be performed by rheumatology nurses.46 Thus, a systematic review by Sousa et al. corroborated that nursing follow-up shows positive effects on quality of life, pain, physical function, self-efficacy and overall satisfaction. Although benefits were observed, results did not reach significant differences in the control of disease activity (DAS28) after 1-year follow-up when comparing nursing consultations with rheumatology consultations (or even unplanned shared consultations). Overall, this study supports that nursing care, in collaboration with rheumatologists, is effective in the follow-up of people with RA, indicating that nurses should be trained in specialized rheumatology skills.46
Regarding the effectiveness of nursing intervention, the published literature presents mixed results. On one hand, the TITRATE (Treatment Intensities and Targets in Rheumatoid Arthritis ThErapy) program had very positive results when applying a multidisciplinary care setting, that included specialist nurses, for the management of RA.47 On the other hand, some studies have found no difference between nurse-led care and the standard care.48,49 An example is the review made by Lempp et al. in 2020, in which nurses helped patients in a variety of settings and the clinical outcomes they achieved were similar to those of specialist rheumatologist.49
To sum up, although literature seems to show a non-inferiority effect (not statistically significant difference) of nursing vs. rheumatologist follow-up, it is likely that patients would benefit more under a comprehensive multidisciplinary umbrella, along with their pharmacological treatment.
LimitationsAs a scoping review, this study is subject to inherent methodological limitations. First, the specific inclusion criteria and diversity of study designs may introduce heterogeneity, limiting the ability to draw definitive conclusions about intervention efficacy. Second, variations in healthcare systems, nursing roles, and levels of specialization across different countries may affect the generalizability of the findings. Third, the lack of standardized outcome measures and intervention protocols further constrains the ability to compare results across studies.
ConclusionThe interventions carried out by nurses for the management of chronic RA pain have been based on the participation of these professionals in multidisciplinary teams that allow them to provide the patient with comprehensive quality care. It is important to mention that most of the interventions performed by nursing professionals are educational sessions, which provide the patient with information that allows them to understand their pathology. Besides, patients’ education contributes to highlighting the importance of the recommendations offered by health professionals, about healthy habits, pharmacological treatment and possible comorbidities. Overall, the aim is to make patients aware and knowledgeable about their pathology, placing them in an active position of control over the disease, which can have a significant impact on variables such as disease activity, adherence to treatment, functionality, self-efficacy, quality of life and psychological well-being.
Authors’ contributionsMónica Grande-Alonso: Conceptualization, Methodology, Investigation, Writing – review & editing. Emma Aranda-Polo: Methodology, Formal analysis, Investigation, Writing – original draft, Writing – review & editing. Carlos Forner-Álvarez: Investigation, Writing – original draft, Writing – review & editing. Alba Sebastián-Martín: Validation, Investigation, Writing – original draft, Writing – review & editing. Rafael Moreno-Gómez-Toledano: Conceptualization, Methodology, Investigation, Writing – review & editing. All authors contributed to the final analyses and conclusions, critically revised the manuscript for intellectual content and approved the final version of the manuscript, including the order in which the author names appear.
Ethics considerationsThis is a bibliographic review. Patient data, biological samples or experimental animal data are not included in this study.
Inform consentIt does not apply; the article is a bibliographic review.
Declaration of generative AI and AI-assisted technologies in the writing processAuthors declare that AI has not been used.
FundingThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflict of interestThe authors declare no conflict of interest.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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