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RESEARCH ARTICLE
Better arthritis care: What training do community‐based health
professionals need to improve their care of people with
arthritis? A Delphi study
J. Erwin
1
|K. Edwards
1
|A. Woolf
1
|S. Whitcombe
2
|S. Kilty
3
1
Bone & Joint Research Group, Royal
Cornwall Hospitals NHS Trust, Truro, UK
2
School Healthcare Studies, Cardiff University,
Cardiff, UK
3
Arthritis Care, Truro, UK
Correspondence
Dr Jo Erwin, Bone & Joint Research Office,
Knowledge Spa, Royal Cornwall Hospitals NS
Trust, Truro, Cornwall, TR1 3HD, UK.
Email: josephine.erwin@nhs.net
Funding information
Education Project Grant from Arthritis
Research UK, Grant/Award Number: 20536
Abstract
Objective: The aim of the present study was to identify the competencies that non‐specialist
community‐based nurses and allied health professionals (AHPs) need to enable them to assess,
care for and manage arthritis appropriately.
Methods: A Delphi survey with an expert panel of 43 rheumatology specialists and expert
patients was used to identify the competencies needed by community‐based nurses and AHPs
to enable them to improve their care of people with arthritis. The process was informed by
feedback from focus groups with arthritis patients, community‐based nurses and AHPs.
Results: The core competencies in arthritis care needed by non‐specialist community‐based
nurses and AHPs were identified. The key goals identified were to increase the understanding
of arthritis and its impact on patients’lives, and to increase the ability to help patients to self‐
manage their condition and access support. Competencies included an understanding of the
pathology underlying inflammatory and non‐inflammatory arthritis, the ability to distinguish
between the two and the ability to recognize early warning signs, with an emphasis on osteoar-
thritis (OA), rheumatoid arthritis, gout and septic arthritis. Essential competencies included the
ability to engage in shared decision making, goal setting and signposting, to provide patients with
education and information and to make appropriate referrals.
Conclusions: Health professionals working in the community commonly encounter arthritis
as a presenting problem or as a co‐morbidity. The quality of care provided to people with
inflammatory arthritis and OA in the community is currently variable. The present study identified
the core competencies that all community‐based nurses and AHPs should have in relation to OA
and inflammatory arthritis.
KEYWORDS
allied health professionals, arthritis, community–based, competencies, musculoskeletal, nurses
1|INTRODUCTION
Arthritis is a common condition that causes pain and inflammation in a
joint, affecting people of all ages, including children. Osteoarthritis
(OA) is the most common form of arthritis and a leading cause of dis-
ability (Arthritis Research, 2014; Cross et al., 2014). Inflammatory
arthritis (IA) affects approximately 2% of the UK female population
(Arthritis Research, 2014). Health professionals (HPs) working in the
community commonly encounter arthritis as a presenting problem or
as co‐morbidity. However, arthritis management in primary care does
not always meet guidelines (Goodwin, Curry, Naylor, Ross, & Duldig,
2010), and insufficient knowledge of rheumatoid arthritis (RA) and
OA can lead to a lack of ability to educate and inform patients (Scott
et al., 2008). The National Audit Office (2009) recommended that
awareness of RA be improved in primary care. A report by the King's
Fund (Goodwin et al., 2010) concluded that the quality of care pro-
vided in the community for people with OA and RA is highly variable,
often suboptimal and could be significantly improved. It emphasized
the need for a better understanding of the condition among primary
care professionals and called for a more proactive approach to care
DOI: 10.1002/msc.1202
Musculoskeletal Care. 2017;1–12. Copyright © 2017 John Wiley & Sons, Ltd.wileyonlinelibrary.com/journal/msc 1
management, with high‐quality care for people with arthritis shared
across care settings and multi‐professional teams.
Community‐based nurses, occupational therapists (OTs), physio-
therapists, podiatrists and pharmacists routinely encounter patients
with arthritis in their clinical practice. Their roles in relation to the care
of arthritis and other musculoskeletal (MSK) conditions have been
clearly outlined in the MSK Services Framework (Department of
Health, 2006); however, there is little evidence on the competencies
that these professionals need in order fulfil these roles (Lillie, Ryan, &
Adams, 2013; Mann, 2012). A study of nursing and allied health pro-
fessional (AHP) undergraduates showed a lack of adequate training
to meet this need (Almeida et al., 2006). A study of practice nurses
showed that confidence, knowledge and the ability to manage MSK
conditions was low (Fletcher, Oliver, Cook, & Albrow, 2012). In podia-
try and pharmacy, studies have looked at the provision of services
(Redmond, Waxman, & Helliwell, 2006), good practice in training and
education (Podiatry Rheumatic Care Association, 2008) and the effec-
tiveness of interventions for arthritis (Marra et al., 2012; Osterhaus
et al., 2002) but there is little on the competencies that these profes-
sionals need for the care of those with arthritis.
This study sought to establish the competencies needed by non‐
specialist community‐based nurses and AHPs to enable them to assess,
care for and manage arthritis appropriately.
2|METHODS
The study used a Delphi survey, and focus groups and interviews with
patients, community‐based nurses and AHPs. It used a phenomenolog-
ical approach to the focus groups and interviews. This approach facili-
tated the gaining of insights into people's perceptions, perspectives
and understanding of receiving and providing arthritis‐related
FIGURE 1 Study process. AHP, allied health professional; GP, general practitioner; HP, health professional; MSK, musculoskeletal; OT,
occupational therapist; OA, osteoarthritis; PA, psoriatic arthritis; RA, rheumatoid arthritis [Colour figure can be viewed at wileyonlinelibrary.com]
2ERWIN ET AL.
healthcare. The data were collected between June and November
2014. Figure 1 shows an outline of the study process.
2.1 |Recruitment
2.1.1 |Delphi participants
An expert panel of rheumatology specialists and expert patients was
established. Panel members were recruited through research and pro-
fessional networks, patient organizations and professional organiza-
tions for HPs with a rheumatology specialism. These included the
British Society for Rheumatology, rheumatology specialist/interest
groups from the Royal College of Nursing, the College of Occupational
Therapists, the Chartered Society of Physiotherapists, the College of
Podiatry and the Royal Pharmaceutical Society. A total of 43 members
were recruited to the expert panel; the number from each profession is
shown in Figure 1.
2.1.2 |Focus group and interview participants
Four face‐to‐face focus groups were held, with a total of 16 women
and nine men with arthritis. These were held in Bristol, Exeter and
Cornwall. Participants were recruited to the focus groups through
posting on the National Rheumatology Arthritis Society and Arthritis
Research UK websites and Facebook pages, posters in general practice
(GP) surgeries, advertisements in local newspapers and through local
support groups. Two groups were attended by people with IA (com-
prising RA and psoriatic arthritis [PA]); one group had patients with
RA and OA. A fourth group had people with OA only. The age of par-
ticipants ranged from 28 to 84 years, with varying socioeconomic
backgrounds. The focus groups varied in size, the largest having eight
participants and the smallest having four. Each focus group lasted
approximately 1 h.
Focus groups were established for four of the professional groups
–nurses, physiotherapists, OTs and podiatrists. Owing to difficulties in
establishing a focus group for community pharmacists, individual inter-
views were held with these contributors. Participants were recruited
to the focus groups and interviews through professional networks,
professional organizations for nurses and AHPs, local pharmaceutical
committees and local practice forums. The interviews took between
45 min and 1 h. Telephone focus groups and telephone interviews
were held with 26 community‐based nurses and AHPs (Figure 1).
2.2 |Delphi survey
The Delphi technique has been used to build consensus on essential
skills and competencies needed by HPs for the management of a range
of conditions, including rheumatological conditions (Broomfield &
Humphris, 2001; Hewlett et al., 2008; Rohan, Ahern, & Walsh, 2009).
The aim of the present use of Delphi was to obtain a list of recommen-
dations for competencies that community‐based nurses and AHPs
should have to enable them to care effectively for patients with arthritis.
Guided by previous studies, relevant guidelines and standards of
care (Hewlett et al., 2008; National Institute for Health and Care Excel-
lence, 2008, 2013; Podiatry Rheumatic Care Association, 2008; Royal
College of General Practitioners, 2015; Stoffer et al., 2015; Woolf,
Walsh, & Akesson, 2004; Woolf & Akesson, 2008), the project team
developed a draft list of categories and topics to be considered for inclu-
sion in the training of community‐based nurses and AHPs (Table 1).
2.2.1 |Delphi round 1
Using an online survey, the expert panel was asked to consider nurses
and AHPs who work in the community and who DO NOT have a rheu-
matology specialism, to decide what they should know to enable them
to care effectively for the patients with arthritis that they encounter in
their clinical practice. The panel were offered the draft list of topics
(Table 1) as a starting point. The panel was asked to add any other cat-
egories or topics not listed that they thought were important or essen-
tial. It was asked to rate each topic for the importance of its inclusion
(‘not important’,‘moderately important’,‘important’or ‘essential’). They
were also asked to consider the degree of competency that commu-
nity‐based nurses and AHPs should have in each topic (‘knowledge’,
‘understanding’or ‘application’).
2.2.2 |Eliciting the views of patients and community‐
based nurses and AHPs
Patient focus groups
The focus groups participants were asked about their experiences of
receiving care for their arthritis from community‐based nurses and
AHPs, how this care might be improved and what they would want
nurse and AHPs who work in the community to know about arthritis.
They were also asked to comment on the draft list of competencies in
arthritis care for community‐based nurses and AHPs which the expert
TABLE 1 Draft list of categories and key topics for inclusion in
arthritis training for community‐based nurses and allied health
professionals
STRUCTURE & FUNCTION: Anatomy; physiology
PATHOLOGICAL FEATURES: Main pathological features
DIFFERENCES BETWEEN COMMON TYPES OF ARTHRITIS: Clinical
characteristics of OA, AS, juvenile idiopathic arthritis, PA, gout, SA and
other types of arthritis
WARNING SIGNS: Signs and symptoms of IA; red flags
INVESTIGATIONS: Investigations for inflammation; rheumatoid factor
test; urate test; other tests (not imaging); X‐rays for arthritis; CT scans
for arthritis; MRI scans for arthritis
IMPACT: Psychosocial; mental health; mobility & activities of daily living
MANAGEMENT & TREATMENT OPTIONS:
Use of analgesics, non‐steroidal anti‐inflammatory drugs, steroids, disease‐
modifying anti‐rheumatic drugs, anti‐TNF/biologics for arthritis;
Surgical interventions for people with arthritis;
Non‐surgical interventions (e.g. joint injections);
Self‐management; physical activity; specific exercises; joint protection;
weight management; how to advise patients on pain management
DISEASE MONITORING FOR ARTHRITIS: Monitoring
FOOTWEAR, AIDS & ORTHOSES: Footwear; adaptive equipment;
orthoses
MULTIDISCIPLINARY TEAM & REFERRALS: Multidisciplinary team;
referral pathways
PATIENT EDUCATION: Information sources for patients; promotion of
healthy lifestyles
AS, ankylosing spondylitis; CT, computed tomography; IA, inflammatory
arthritis; OA, osteoarthritis; PA, psoriatic arthritis; SA, septic arthritis;
TNF, tumour necrosis factor.
ERWIN ET AL.3
panel had produced in the first round of the Delphi survey. These find-
ings were fed back to the expert panel in round 2 of the Delphi.
Community health professional focus groups
The nurses and AHPs were asked about their experiences of delivering
care to people with arthritis, their views on the patients’expectations
and priorities (Table 2) and their views on the draft list of competencies
produced by the expert panel in the first round of the Delphi survey.
The opinions of the participants in the health professional focus groups
were fed back to the expert panel in round 2 of the survey.
2.2.3 |Delphi round 2
In round 2 of the Delphi survey, the expert panel was presented with
the categories and topics from round 1, plus the additional comments
made by members of the expert panel and the comments from the
focus groups. The panel was asked to rate the topics again, bearing
in mind the views of other members of the panel and the feedback
from the patient and community‐based HPs’focus groups. Those that
were rated as essential or important were taken forward into round 3.
2.2.4 |Delphi round 3
In round 3, the expert panel was presented with the ratings of topics
from round 2 and the comments made by members of the panel. The
panel was asked to rate the topics again.
2.2.5 |Health education stakeholder interviews
Telephone interviews were conducted with 4 key personnel responsi-
ble for making decisions on the training offered to community based
health professionals. The interviewee asked for views on possible bar-
riers and facilitators to providing arthritis training to community based
nurses and AHPs. The interviewees were a senior lecturer in district
nursing, and from community health care organisations, a professional
lead, a training manager and a clinical training lead. The interviews
were conducted by a researcher (JE), three by telephone and one
face‐to‐face; the interviews were recorded and transcribed for later
analysis.
2.3 |Data analysis
There is no agreement in the literature on Delphi studies as to what
constitutes consensus (Keeney, Hasson, & McKenna, 2006). The deci-
sion was made that consensus for inclusion was on the basis of
whether 80% of the panel members rated the topics as important or
essential. In Delphi rounds 2 and 3, the expert panel was given the per-
centage agreement and measure of the central tendency (mode). Only
those topics that were rated as important or essential by 80% of the
panel were carried through from round 2 to round 3 of the Delphi.
The final topics and competencies were those that were rated as
essential by 80% of the expert panel. These are listed inTable 3; please
note that, in contrast to the ratings of other professions, the compe-
tency “To have knowledge of common surgical operations available
for individuals with IA and OA”was not rated as essential by 80% of
community pharmacists.
The data from both the individual interviews and the focus groups
were transcribed verbatim. The data were analysed by a researcher
(J.E.) using thematic analysis. Initial codes were generated, and themes
identified, reviewed and defined. Five of the transcripts were also
coded by another researcher (K.E.). Final themes were refined through
discussions between J.E. and K.E. The final codes and themes were
reviewed by A.W.
3|RESULTS
3.1 |Patient focus groups
As an outcome of the focus group, a list of patient priorities was pro-
duced (Table 2) which was shared with the expert panel. The partici-
pants’views are described in more detail in Erwin et al (in press).
3.2 |Community health professional focus groups
3.2.1 |Experience in caring for people with arthritis
Nurses and AHPs reported that they dealt mainly with OA patients and
sometimes patients with RA or gout. Other types of IA were encoun-
tered much less frequently. When caring for people with OA, their
focus is on symptom control, pain management and functional ability.
Across the professions, it was felt that, in contrast to those with IA,
there is a lack of management advice for people with OA; they often
do not get access to the full range of management options from their
TABLE 2 Knowledge and skills that community‐based nurses and
allied health professionals need to care for people with arthritis –
Patient priorities
To understand and be able to distinguish between inflammatory arthritis
and OA
To be able to take a holistic approach
To take OA seriously and understand its impact
To be able to advise on the management of OA
To understand the unpredictability of IA
To understand flares
To understand and be able to give basic advice on pacing
To be able to adjust their normal professional practice for people with
arthritis (e.g. how to hold and manoeuvre limbs comfortably)
To understand the psychological adjustment needed when diagnosed
with IA
To understand the psychosocial impact of arthritis, including impact on
friends and family
To understand the impact of arthritis on mental health (e.g. depression)
To understand the kinds of drug treatments that people with IA receive
and the implications of taking immunosuppressive drugs
To understand the pain associated with arthritis
To be able to advise on pain management
To be able to signpost people to sources of help (e.g. self‐management
programmes, expert patient programmes, support groups, advice lines)
To be able to signpost people to good, reliable sources of education and
information
To be able to make multidisciplinary referrals and to communicate
effectively between referral points
To understand that patients who have had a diagnosis for a long time
know best about their own disease
To have good communication skills
IA, inflammatory arthritis; OA, osteoarthritis.
4ERWIN ET AL.
GP and may return to their GP multiple times in an effort to cope with
their condition:
Because of the demographic, we'll be seeing a lot of
people with OA changes. We are not skilled in
understanding or working with the mental health effects
of LTCs [long term conditions] like OA or rheumatoid
[arthritis]. Being time limited, it's very difficult to be as
holistic as you can because what you're trying to do [is]
to offload a deformed foot or to make sure there is no
excessive loading of an area, and you are working on
those sorts of things; then, you're not seeing the whole
patient or treating some of the psychological
implications of an LTC like that –we just don't have
time to do everything. (Podiatrist)
I find a lot of people with OA don't get much access from
their GP for the full conservative management of OA. I
think it's mainly a time issue with their appointments.
The GP usually just prescribes some sort of pain relief. A
lot of our clients have been back to their GP multiple
times and [are] having to cope with their condition. The
main challenges facing these [OA] patients is that they
don't know how to manage their condition; their pain is
not very well managed with medication and they just
feel that they don't have many other options. (Private
practice physiotherapist)
3.2.2 |Views on patients’priorities
All community‐based HPs felt that the patients’priorities and expecta-
tions (Table 2) were reasonable and realistic:
I think the patients’views are very realistic and that's
probably where I am, unless I have a particular patient
with a problem, and then I'll go a bit more in‐depth. I
hope I would be able pretty much to fulfil those
patients’needs. Looking at where I am now and being
able to gen up quite quickly. (Nurse)
Good communication and being handled respectfully and
gently were seen as basic good practice that all patients should
expect:
We might know what we are doing but we don't
communicate that much to them [patients]. We don't
ask them enough questions about the problem. We
make too many assumptions about what it probably is,
rather than letting them tell us; and then at the end,
having made all these wise decisions, we don't actually
tell them what we've been thinking. We say, do this, do
that, and don't tell them why. If you do that, at the end
of it they feel, yes, I understand that and they feel
happier. That kind of communication makes all the
difference. (Podiatrist)
The need for a holistic approach was acknowledged but was
sometimes difficult to achieve in practice:
Working under the pressure, just go in and do the job and
often don't have time me to look at the wider picture, and
some of the things on the patients' list are reflecting the
wider picture. (OT)
TABLE 3 Core competencies in arthritis care for community‐based
nurses and allied health professionals
Core knowledge to support the diagnosis and management of OA and IA
To have core knowledge of MSK anatomy and relevant structure and
function to support diagnosis and management of OA and IA
Common pathological processes to support diagnosis and
management of OA and IA
Main characteristics of OA and common forms of IA
Assessment skills
To have a holistic approach to the patient
To be familiar with diagnostic tests for arthritis and with the
monitoring of disease
Application of assessment skills to arthritis
Ability to distinguish between IA and non‐inflammatory arthritis
Ability to identify and characterize OA
Ability to identify and characterize RA
Ability to identify and characterise SA
Ability to identify, characterize and manage gout
Understand and characterize the signs and symptoms of AS
Knowledge of MSK red flags
Knowledge of MSK red flags and referral
Understanding of the impact of OA and IA on the individual, family and
friends
Impact on participation and relationships
Impact on mental health
Impact on physical health
Principles of management
To understand the principles and theoretical basis of self‐management
in the care of people with OA and IA
To understand the principles of pain management in the care of those
with OA and IA. To include understanding pain management
strategies that use pharmacological and non‐pharmacological
approaches and that can be applied in any context, including work
To have knowledge of simple analgesics and NSAIDs, and how to give
advice on their use
To have knowledge of the use of corticosteroids for OA and IA
To have knowledge of DMARDs and their use for IA
To have knowledge of common surgical operations available for
individuals with OA and IA
a
To have knowledge of other non‐surgical interventions
Multidisciplinary teams and referrals
To know the roles of the members of the multidisciplinary team and
local referral pathways
Footwear, adaptive equipment and appliances
To know the issues around foot health and footwear for people with
OA and IA
To have knowledge of adaptive equipment and appliances for people
with OA or IA
Patient education
Signpost and advise patients
AS, ankylosing spondylitis; DMARD, disease‐modifying anti‐rheumatic drug;
IA, inflammatory arthritis; MSK, musculoskeletal; NSAID, non‐steroidal
anti‐inflammatory drug; OA, osteoarthritis; RA, rheumatoid arthritis.
a
Competency not ranked as essential by community pharmacists.
ERWIN ET AL.5
I think that one thing that might be underestimated by
practitioners is the mental health aspect of having, you
know …like with any chronic, debilitating disease, I
don't think it's something that's often brought [up] –I
don't think patients are –they've put there about being
treated holistically and I think that's a really good point
because I don't think we do treat them holistically, and I
don't think we often take into account the amount of
pressure they're under really, and how the pain does
impact them and impact on their mental health. (Nurse)
Some elements were seen as beyond the remit of certain profes-
sional groups. For example, podiatrists were unwilling to become
involved in pharmacological management and would refer patients
to their GP for that (although they acknowledged that this might
change in the future, with changes in prescribing rights for
podiatrists).
3.2.3 |Views on the expert panel's draft list of
competencies
There was a view expressed by some community‐based nurses and
AHPs that the draft list of competencies put forward by the expert
panel in round 1 of the Delphi was too detailed for generalists and
was more consistent with acute rather than community‐based care:
This is what an expert needs to know, this is not what I
need to know as a community therapist. (OT)
Now, the pressure is for OTs to be more generic –they
want patients to be kept at home, not in hospital, and I
don't know whether that de‐skills us, and I think unless
you're in a specialist role, you won't be asked to be this
specialist in arthritis. Need to have a baseline and to
know the experts in your area. (OT)
I think the one from the rheumatology panel, a bit like
generalists always find... I have the same sort of list,
whether it be the pressure ulcer focus or alcohol focus.
It's always going to have this huge list attached to it
and, like I say, I'd never be able to absorb or maintain
the expertise in that area unless you have a patient
that's very active and you're dealing with that
knowledge all the time. (Nurse)
The list is too long. Just need to pick out a few things that
would have an impact, so, obviously, knowing about the
diseases, knowing about the medication and how it
works, when to refer, the side effects, drug interactions
–these are the key things. (Community pharmacist)
It was highlighted that arthritis is just one of the many conditions
for which that they are expected to have a working understanding, and
that the emphasis should be on competencies that are essential.
3.2.4 |Anatomy, physiology and pathology
The need for a basic knowledge of anatomy and physiology was
acknowledged across the professions. Physiotherapists felt they
needed an extensive understanding of anatomy and physiology in
order for them to be able to manage arthritis and problems such as
referred pain. They suggested that the training should include more
on tendinopathy and degenerative changes in tendons. OTs felt that
knowledge of anatomy, physiology and pathology was important, in
order to be able to provide appropriate self‐management advice to
patients. Highlighting the immunological aspect of the disease was
seen as very important:
I think, certainly, the thought about [the] immune system
and how it affects the whole body, that, you know, you
could become quite sort of joint focused and then,
obviously, sort of seeing how people are exhausted and
fatigued and that sort of thing does remind you that
we're not just dealing with a problem of pain here, we're
dealing with other areas. (Nurse)
3.2.5 |Knowledge of IA other than RA
The general view across the AHPs was that, in addition to OA and RA,
they should know that other types of common IA, such as PA, exist but
that they should not be expected to carry details about them in their
heads. An exception to this was gout, which is seen relatively fre-
quently in primary care and the community. Many patients self‐
manage this condition successfully but with some, particularly elderly
patients with co‐morbidities who cannot take anti‐inflammatory drugs,
gout can be very difficult to manage, so more training on gout would be
helpful.
3.2.6 |Facilitating early diagnosis
It was agreed that front‐line nurses and AHPs could have a potentially
important role in recognizing the signs of arthritis and facilitating early
diagnosis. Training in how to distinguish between signs indicating OA
and those indicating IA, particularly in older patients, who sometimes
have a number of co‐morbidities, was welcomed. Community pharma-
cists highlighted their accessibility. However, in general, they did not
feel confident in being able to distinguish between signs indicating
OA and those indicating IA:
It's pretty tricky to distinguish between OA and
inflammatory arthritis just by talking to a patient. I
wouldn't like to say that's what you've got. I might want
to refer them to their GP if they have symptoms that
might indicate OA. (Community pharmacist)
Physiotherapists felt that it was important to be able to pick up on
warning signs:
I think you need to be able to pick up on warning signs of
people who are at poor prognostic risk of developing
disability from their arthritis. You need yellow and blue
flags. I understand why the focus is on inflammatory
[arthritis] but these markers we will pick up early.
6ERWIN ET AL.
Behavioural changes in the early stages can optimize
function and minimize disability in this patient group.
That way, we can prevent de‐conditioning. (National
Health Service [NHS] physiotherapist)
3.2.7 |Tests
All professional groups agreed that it was appropriate to expect them
to have some knowledge of why tests are done but they did not think
that they should be expected to be able to interpret diagnostic tests.
Nurses emphasized that, while they might be able to take the blood
sample and explain why a test was performed, its interpretation was
the role of the GP or specialist. However, some felt that they should
know the indicators of poorly controlled IA, to enable them to signpost
people appropriately:
I think you need to know what the tests mean and what
particular factors in the tests you're looking for. Need to
know tests so you know what you require from GP.
(NHS physiotherapist)
I wouldn't expect to know about a urate test but would
expect to know what investigations that patient has
had. Or if the patient asked me: “What is an ultrasound
test? Do I have to go dressed or undressed?”I could
answer that in simple terms. (OT)
Occasionally, a patient may come with the results of their
blood test and ask us to decipher them but, quite frankly,
we can't do that. We know the ranges for certain
conditions but we wouldn't know what to tell the
patient. If they have something seriously wrong, it's not
our job to explain it to the patient. We ask the patient
to go back to the person who ran the test. (Community
pharmacist)
To be honest, if I had …in my situation if I had
somebody who had something that looked like RA, I
would tell them, just go to your GP and tell him I think
I may have RA. And they'd take it from there. I don't
actually know what a urate test is, for example. I don't
know all the investigations they would do for
inflammation. If they had inflammation, swelling and
[the] possibility of RA, I would just say, go to the
doctor. (Private podiatrist)
3.2.8 |Impacts of arthritis
All the professional groups felt that they should have knowledge and
understanding of the psychological, social and physical impact of
arthritis. It was felt that working in a community setting gave greater
opportunities to identify the impacts. The psychological aspect of
arthritis was raised as a particular area of training need, and members
of all the professional groups highlighted the need for more training
to understand the mental health impacts of OA and IA. Some of the
physiotherapists recommended adding the impact on work to the
training, and, in particular, fitness for work assessments for the early
detection of yellow flags and work issues.
Podiatrists spoke about the challenges of dealing holistically with
arthritis and their own perceived lack of skill in understanding or
working with the mental health effects of long‐term conditions like
OA or RA. Nurses and podiatrists commented that, owing to time lim-
itations, they were forced to focus on specific physical problems,
rather than addressing some of the psychological implications of a
long‐term condition such as arthritis. The OTs also felt that, although
their training in physical and mental health prepared them to under-
stand and address psychological and psychosocial issues, they were
often working under pressure and so did not have time to look at
the wider picture:
As to looking at the psychosocial impact of inflammatory
arthritis or OA, some OTs would explore it, some
wouldn't, but it fits in with the role of OT. In a
community setting, we are in a good place –spending
time in people's home, we can pick up their signals
more. It takes a while for the patient to adjust and
realize the impact on their life. (OT)
It was felt that, across the AHPs, there was a lack of apprecia-
tion of the how pain affects patients’mental health. Community
pharmacists felt that this aspect was currently missing from their
training, which tended to concentrate on the conditions and their
treatments. They said that they were used to dealing with depres-
sion but were less attuned to the other less obvious impacts of
arthritis.
3.2.9 |Medicines for arthritis
Nurses, OTs and physiotherapists highlighted immunosuppressive
drugs and the drugs given to people with IA as areas for further train-
ing. OTs felt that they needed to know more about how these drugs
affect daily function. All of the professional groups agreed that training
on simple analgesics and non‐steroidal anti‐inflammatory drugs should
be included. For discussions around the use of live vaccines, they
expected to refer the patient to a rheumatology specialist nurse. Com-
munity nurses and physiotherapists felt that it was reasonable to
expect them to understand the use of injections and their role in man-
agement, and to be able to discuss with patients their expectations of
the effects of these. For drugs used for IA disease control, community‐
based health professionals said that they often relied on the patient's
knowledge and experience, and would recommend that patients seek
guidance from their rheumatology nurse. There were mixed views on
how aware nurses and AHPs should be of the effectiveness of medica-
tions such as disease‐modifying anti‐rheumatic drugs (DMARDs) and
anti‐TNFs, and of the major changes in the pharmacological manage-
ment of RA:
I'm not sure how much we need to know about DMARDs
etc. In GP practice, [we] can consult letters from the
consultant. In private practice, this isn't so easy to do
but patients often know a lot about their own
medication. Don't see many people with IA, so don't feel
[I have] to know all the issues around DMARDs –if [I]
ERWIN ET AL.7
had patients with IA who were on these drugs, [I] would
go and look them up. (Private physiotherapist)
Understanding drug treatment and immunosuppressive
drugs? [I] just need to touch on this –[I] don't need to
know too much about this as an OT. (OT)
Nurses and physiotherapists alike pointed out that, as patients
with IA were relatively rare, rather than trying to hold detailed informa-
tion in their head, they would research National Institute for Health
and Care Excellence guidelines and other sources of information when
they had a patient with the condition. An area of concern expressed by
nurses in regard to treating people with arthritis was the contraindica-
tions of medicines. This was identified as an area for further training.
Community pharmacists felt that they had an important role in giving
evidence‐based advice on over‐the‐counter and complementary
medicines in the treatment of OA, and could help in the management
of OA through evidence‐based use of medicines. They also stated that
they needed to be fully aware of and able to help with aids to
overcome the manual dexterity problems that could affect compliance
in patients with arthritis.
3.2.10 |Providing advice on self‐management
The importance of supporting patients over a period of time and seeing
them regularly in order to support changes in behaviour, lifestyle and
habits was emphasized. This was seen as a natural role for HPs working
in the community. Knowing how to provide basic self‐management
advice for people with arthritis, and particularly for those with OA, was
seen as a key area of training. It was also emphasized that community‐
based HPs need to give consistent messages, to avoid confusing patients:
Key is self‐management with an emphasis on exercise,
behavioural change and motivational support. It's
important that [we] can think about goal setting for
patients, not just with their physio exercise, but with life
in general. It's important to support patients over a
period of time, seeing them regularly, in order to support
changes in behaviour, lifestyle and habits. This is
absolutely fundamental. (NHS physiotherapist)
I think we would benefit from more training in self‐
management. When I talk to patients, I talk about how
arthritis affects them, and the medication and how it
affects them. Health professionals need to make sure
that patients understand what they are taking, why
they take them and how it affects their body. Need to
encourage patients to ask questions. Need to be aware
of side effects and aware of their own condition, so not
just nodding their head and saying “Yes”. Help patients
to own their condition and how it affects them because
it affects everyone differently. (Podiatrist)
3.2.11 |Pain management
Nurses commented that when dealing with complex cases with a num-
ber of co‐morbidities, managing pain may fall to the bottom of the
priority list. They stated that this may be particularly true of chronic
pain because it is always there but the emphasis should be on dealing
with emergencies and high‐level care. Podiatrists also pointed out that,
while they recognized the importance of pain management and the
emphasis given to it by patients, in current podiatry services risk (e.g.
the risk of losing a limb), rather than pain, is the determinant for treat-
ment. This may mean that podiatrists miss the opportunity to do more
prevention work. Nurses highlighted the need for further training in
managing pain within the restrictions of co‐morbidities, polypharmacy
and contraindications. OTs also mentioned the need to learn more
about managing chronic pain and understanding its effects. Commu-
nity pharmacists recognized that, for people with OA, they were an
important source of help and advice on what patients could do to help
themselves, and pain control. They also felt that they had an important
role in giving advice to patients on appropriate dosing schedules for
pain relief.
3.2.12 |Handling patients appropriately
The appropriate handling of patients was recognized as important and
something that patients should expect:
For colleagues who are handling the patients, especially
when they are handling the types of arthritis, to be
aware that even a gentle touch can cause pain.
Everybody's arthritis effects them in different ways, also
depends on what medication they are on. It's just a case
of really listening to patients. The consultant may have
the clinical experience but the patient lives with it every
day –they know how it affects their body and what
works. (Podiatrist)
3.2.13 |Communication between the multidisciplinary
team (MDT) and referrals
All agreed that signposting, onward referral and where to find support
were all important parts of their toolkit for every patient, regardless of
condition. It was agreed that community‐based HPs need to have a
baseline level of knowledge of the role of experts in their area, and
the pathways and criteria for referral. They agreed that the communi-
cation loop between professionals can be fairly poor and that this
should be a matter to be highlighted for discussion in any training.
Podiatrists felt that they needed more training on the clinical fea-
tures in patients with RA or other forms of IA that would require refer-
ral back to the GP or rheumatologist. For example, if a patient is having
flares repeatedly, should s/he be referred back to the GP? Pharmacists
in particular said that they felt isolated from other members of the
MDT and needed more understanding of the roles of the various
AHPs. They felt further distanced because they were not able to make
referrals and could only suggest that patients sought help from other
members of the MDT. Changes in the organization of health services
have led to changes in referral pathways and in communication between
various health organizations. The health professionals agreed that the
communication loop between professionals can be poor and that this
should be a matter to be highlighted for discussion in any training:
8ERWIN ET AL.
GPs often refer patients to OTs without fully knowing
what OTs do! (OT)
I feel we have little to do with other parts of the umbrella
looking after patients, and for podiatry I feel we are quite
isolated. We have patients come in through the door,
[and] we have a short space of time with them. We try
to address these problems the best we can. (Podiatrist)
3.2.14 |Accessing information and providing key
messages
Nurses, pharmacists and physiotherapists commented on the impor-
tant role they had in signposting patients to appropriate sources of
help and advice in the community. All professions felt that they needed
to know more about how to access information on wider support for
patients such as education, support groups, exercise classes, social
care, mental health support and advice lines. It was felt that this is par-
ticularly an issue for those in private practice, who may be somewhat
“out of the loop”:
Yes, I think we need to be able to access information more
easily –for instance, I didn't even know about the expert
patient programme available here until today! (Private
physiotherapist)
Participants highlighted the need for further sources of informa-
tion for people with OA. It was pointed out that some of the current
phrases used to describe OA, such as “wear and tear”are not helpful
and that more training in how to provide key messages to people with
OA would be appropriate:
The lady with RA I was caring for was very knowledgeable
and was teaching me –what was good for her [and] what
was bad for her ... fatigue management, everything. I
think it's different with OA, which patients are less
informed about and [is] seen as a lesser condition in
some ways. (Nurse)
Some participants commented on how changes to the organization
of the NHS –for example, the loss of primary care trusts (PCTs) –had
made obtaining information on sources of support for patients more
challenging, and that training in how to find resources would be
helpful:
We definitely need more on that because since the PCTs
went and CCGs [clinical commissioning groups] have
taken over, everything is very sketchy. It's difficult to
know what's going on. If patients come in and they are
in a lot of distress, we try to find sources of support for
them. I think the problem is that things are there but we
just don't know about them. (Community pharmacist)
Luckily, now most of the pharmacies have the internet, and
the bigger businesses have a list of organizations –you can
show them [patients] which websites are good for them.
Not everyone is internet savvy but if you can open it up
and show them, then that gives them a little bit of
support. We have leaflets but often they are well out of
date. You can even give them a contact number for the
organizations. We try to use these expert groups because
people need more than 5 or 10 minutes sometimes to get
to grips with things. (Community pharmacist)
3.3 |Expert panel
The core competencies that all community‐based nurses and AHPs
should have, as agreed by the expert panel, are shown in Table 3.
3.4 |How training should be delivered
The Expert Panel, community health professionals and training profes-
sionals had a number of suggestions about the delivery of training. It
was recognised that health professionals can suffer from an overload
of information and it was emphasised that training need not be too
in‐depth but should concentrate on what the health professional needs
to know to support and care for their patient. Having the involvement
of patients was suggested in order to give health professionals a better
understanding of the impact arthritis has on patient lives and to enable
trainees to see clinical characteristics and examples of altered
anatomy.
The training professionals felt that interactive workshops were
most effective ‐a short sharp burst of information followed by some
interaction and discussion. Health professionals emphasised the
importance of the training being carefully pitched and relevant to prac-
tice. They suggested a variety of training options including mandatory
one day training, tool kits and information packs and websites with
access to information, evidence based good practice and recommenda-
tions. A number of health professionals emphasised the value of train-
ing together with members of the multi‐disciplinary team, bringing
together knowledge and different approaches and allowing for a
deeper understanding of professional roles.
The use of different levels of training was suggested by some
members of the Expert Panel, the training professionals and by nurses,
occupational therapists and podiatrists in the focus groups. It was sug-
gested that it may be effective to train a person in the team who has a
special interest to a higher level and that s/he can act as link person
and a source of advice for colleagues using a similar model to infection
control nurses.
There were mixed views on e‐learning among the health profes-
sionals. Some thought it useful for its accessibility and flexibility others
missed the opportunity for interactivity. How the on‐line training is
presented is seen as very important ‐it must be lively and engaging
with a variety of presentations including aural and videos. It needs
to be relevant to practice (using case studies where possible), succinct
but with good links to trusted outside sources to further information.
Training professionals emphasised the need to embed and
contextualise e‐learning by giving health professionals the opportunity
to meet and discuss their e‐learning after taking the course. Webinars
were also mentioned as a mode of delivery that has increasing poten-
tial as it offers the advantages of access of e‐learning together with
some level of interaction. Participants suggested on‐line training
together with a local or regional clinical workshop preferably with par-
ticipants from the MTD with joint and profession specific sessions.
ERWIN ET AL.9
Such training would present an opportunity to find out more about the
MTD so health professionals (and in turn patients) have realistic expec-
tations. The training would need to be delivered by an expert in the
field who understands the MTD roles and the differing ways in which
they in turn interact with patients.
Barriers and facilitators for training
The barriers to training cited by community based health and training
professionals can be considered at 3 levels‐the organisation, the team
and the individual. Focus group participants and interviewees pointed
out that in general the barriers and facilitators for arthritis training
are not arthritis specific but reflect issues around training in general
for community based health professionals. Access to training varies
across the country and across professions. Access to rheumatology
specialists for advice and in‐house training also varies widely.
Organisation
For training to be run it needs to have top level sign up. Barriers may
include the cost of providing the training, the cost of time release for
staff to attend the training, competing national and local priorities and
the importance of the training in comparison to other areas. Decisions
on what training community based clinicians should receive should be
based on best practice and available evidence however community
health organisations differ considerably in the degree to which the
process of choosing training is formalised. Moreover the frequency
of organisational change in recent years presents challenges to devel-
oping and maintaining a well recorded programme of CPD and pro-
fessional practice. When choosing priorities a choice may have to
be made between arthritis, (common and non‐fatal) and a condition
which is common and fatal. Arthritis is not national priority and is
not part of the Commissioning for Quality and Innovation (CQUIN)
payment framework. However given the relationship between arthri-
tis and frailty, which is a national priority and the link between arthri-
tis and falls, arthritis can be argued to be a key learning priority for
most clinical groups. The interviewees felt that with the current pres-
sures in terms of service delivery that it would be hard to make arthri-
tis a priority and that it would be more realistic to include arthritis
training in existing training programmes such as medicines
management.
Team
For many community teams there is too much work and not enough
staff. There is little capacity to release people to attend training as pro-
viding clinical care is the first priority. When there are particular pres-
sures on the service training may be seen as a luxury instead of a core
activity to maintain and improve quality standards. There is a consider-
able amount of mandatory training that needs to be covered across a
wide range of subjects and the impact on the team of taking a person
out for training may be a barrier. There may be positive and negative
drivers for teams to seek training in arthritis for example a rise in
patient complaints or a team leader with a particular interest in the
condition.
Individual
Individuals have to undertake a wide range of statutory and mandatory
training. Barriers to additional training may be due to pressure of work
and low morale leading to a lack energy or inclination. The geographi-
cal area where one works is also a factor‐in a big city it may be easy to
reach the training location but in more rural areas it may involve trav-
elling long distances. The pressures on the individual associated with
organisational change such as increased workload and changes in work
practice are also seen as significant barriers to training uptake.
Organisational changes such as the loss of PCTs have also created dif-
ficulties in individuals finding out what training is available. Physiother-
apists and podiatrists who work in private practice found cost an
important consideration, not just in terms of the actual cost of the
course itself but also the cost of lost income and travel. Community
pharmacists tended to have more access to free or low cost training
through their local forums but this was provided in the evenings or
weekends and so formed an additional commitment over and above
their normal working day. For single handed private practitioners
accessing training caused particular difficulties.
4|DISCUSSION
To ensure that people with arthritis receive the care they need, and con-
sistent self‐management and lifestyle messages, it is important that all
of the healthcare providers with whom they may have contact are famil-
iar with arthritis, and its impact, diagnosis and management. Drawing on
the views of rheumatology specialists, community‐based HPs and those
living with arthritis, core competencies in arthritis care for community‐
based nurses and AHPs were identified. It was agreed that HPs need
to increase their understanding of arthritis and its impact on patients’
lives and to increase their ability to help patients to self‐manage their
condition and access all the means of support available to them. Compe-
tencies needed include a basic understanding of the pathology underly-
ing IA and non‐inflammatory arthritis, and the ability to distinguish
between the two and to recognize early warning signs, giving promi-
nence to the more commonly encountered conditions such as OA, RA
and gout and the less common but potentially fatal septic arthritis.
The provision of holistic care with the support of self‐management
is a core component of the community‐based management of long‐
term conditions (Goodwin et al., 2010). The successful support of
self‐management is dependent on the HP being able to understand
the impact of arthritis on the patient, their family and their friends,
so that they can work with the patient to find the best ways for that
individual to manage their condition and to identify those issues that
may motivate them to make behavioural changes. Community‐based
nurses and AHPs often see patients and their carers in their own envi-
ronment and therefore have a valuable opportunity to build a full pic-
ture of their patients’lives and how best to support them. Essential
competencies relating to this role are the ability to engage in shared
decision making, goal setting and signposting, and to provide patients
with education and information so they can learn more about their
condition and how they might manage it.
Patients diagnosed with IA are mainly treated in secondary care
and have little ongoing care from community professionals. However,
10 ERWIN ET AL.
community nurses and AHPs can play an important role in early diag-
nosis, which is crucial to the long‐term health and well‐being of those
with IA. These HPs are in the position to be the first line in identifying
the signs and symptoms of inflammatory arthropathies and emergen-
cies such as septic arthritis. An awareness of the common forms of
arthritis as a diagnostic possibility and the ability to distinguish
between OA and IA would greatly enhance early referral and diagnosis.
This is particularly important for nurses and AHPs in the community
who work with older people as their symptoms may be overlooked
or wrongly ascribed to other conditions.
A core competency agreed by all participants is that community
nurses and AHPs should have knowledge of the roles of the various
professions, what they may have to offer to those with OA and IA,
how to refer to them and what resources there are for their patients
in the wider community. Having consistency in the messages given
by different professionals is vital if patients are to be supported effec-
tively to take a more active role in the management of their own con-
dition. Good networks with rheumatology specialists were seen as
essential; however, the ease with which community‐based nurses
and AHPs could access advice from these specialists appeared to differ
widely by profession and by organization.
In relation to delivery of training preference was indicated for
web‐based learning together with multi‐disciplinary clinical workshops
using case studies and perhaps involving expert patients. This training
may be offered at different levels of complexity and may be presented
in a modular form to fulfill the specific needs of health professionals
working in different roles. The study identified generic barriers to
training such as cost and time. However arthritis faces a greater barrier
because it, despite being a common, debilitating, long term condition,
is not a national priority and must compete with national priorities in
a time of significant financial restraints and pressures on the work-
force. An emphasis on the relationship of arthritis to national priorities
such as fragility and the development of training modules that can be
integrated into other programmes may offer a way to increase training
opportunities.
The strengths of the present study were the wide range of rheu-
matology specialist and community‐based HPs consulted and the
inclusion of patients’views. A weakness was that AHPs were not
equally represented on the expert panel; there was an under‐represen-
tation of community pharmacists and an over‐representation of podia-
trists. Another weakness was that although patients and community‐
based HPs gave their feedback on the first round of the Delphi and
the comments of the experts, they were not invited to discuss the final
version of the competencies which were agreed on by the expert
panel. Their contribution would have helped to confirm that the views
of the experts and the community‐based HPs were aligned.
As people with long‐term conditions are being treated increasingly
in the community, new ways of delivering services are being developed
and the roles of community‐based nurses and AHPs are changing. For
example, the wider adoption of musculoskeletal interface services has
seen an extension of roles, particularly for physiotherapists
(Hussenbux, Morrissey, Joseph, & McClellan, 2015). The roles of a
“community‐based nurse”or a “community‐based occupational thera-
pist”vary widely and the skills and knowledge they need depend on
what is clinically relevant to their practice. A wider consultation within
professions is needed to identify what can and should be included in
profession‐specific training. The accessibility of community pharma-
cists provides the potential for an increased role in meeting the needs
of patients with arthritis. Whether community pharmacists would wel-
come this, and the services that they think they are best suited to
deliver, is an area which warrants further investigation.
ACKNOWLEDGMENTS
The authors would like to thank the participants for giving up for their
time for the study. They would also like to thank the other members of
the study team: Dr Karen Mattick, Professor of Medical Education,
University of Exeter Medical School, and Professor Sarah Hewlett,
Professor of Rheumatology Nursing at the University West of England.
This work was supported by an Education Project Grant from Arthritis
Research UK [grant number 20536].
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How to cite this article: Erwin J, Woolf A, Edwards K,
Whitcombe S, Kilty S. Better arthritis care: What training do
community‐based health professionals need to improve their
care of people with arthritis? A Delphi study. Musculoskeletal
Care. 2017;1–15. https://doi.org/10.1002/msc.1202
12 ERWIN ET AL.
