Top Tips for Nurses

Top tips written by Sandra Robinson, Senior Nurse Researcher (Rheumatology), and Dr David Walker, Consultant Rheumatologist, at Northumbria Healthcare NHS Foundation Trust, and kindly reviewed by Alison Kent, Speciality Manager/Nurse Lead - Rheumatology, at Salisbury NHS Foundation Trust.

Sandra writes:

These “Top Tips” are the result of a culmination of work conducted around how nurses educate patients who are starting methotrexate. A national survey was carried out to determine how nurses are trained to perform this role and to investigate how long it takes for them to become confident (Robinson et al 2017). Semi-structured interviews were conducted with six nurses from two different rheumatology services to determine their perspective on how they perform this service (Robinson et al 2018) and finally, ten nurse/patient consultations were video-recorded and meticulously analysed to identify verbal and non-verbal communication between nurse and patient. The studies showed that the content of the consultation was reasonably standard, as the Versus Arthritis booklet on methotrexate was widely used to guide the process. However, it was clear that many nurses are not trained to perform consultations, embracing techniques which would help them to ensure that patients understood the information and it is tailored to suit that individual. There is a clear need to standardise nurse training to take on these roles and these top tips are the first step to address this.

To make comments on the top tips, please use the survey monkey link https://www.surveymonkey.co.uk/r/MTXTopTips.

Robinson, S., Hassell, A., Ryan, S., Adams, N., & Walker, D. (2017). A national survey of nurse training: confidence and competence in educating patients commencing methotrexate therapy. Musculoskeletal Care, 15(3), 281-292.

Robinson, S. M., Ryan, S., Adams, N., Hassell, A., & Walker, D. (2018). An exploration of the experiences of rheumatology nurses counselling patients on methotrexate therapy. Musculoskeletal Care, 16(4), 463-470.

1. Provide written information to the patient before their appointment

   
   By giving someone written information before their appointment, you can spend your interview time addressing what the patient wants to talk about.

2. Set the baseline

   
   Personalise your approach to the individual patient. Find out what they already know about their drug treatment and what they want to learn.

3. Chunk and check

   
   Present a ‘chunk’ or section of information. Then, check the patient understands. For example, you could ask an open question, such as "What have you understood about what I have told you?"

4. Avoid information overload

   
   Remember that the patient has written information and additional opportunities to learn about their drug treatment. That means you should not worry if you miss something in your discussion. However, you should make sure the patient gets the minimum information that they need for their own safety. See ‘Minimum information’ below.

5. Let the patient talk

   
   Don’t dominate the conversation and don’t interrupt. Legitimise the patient’s point of view.

6. Listen and watch

   
   Make sure that, while you’re listening, you pay attention to both verbal and physical cues: Is your patient giving you a signal they want to discuss a topic?
   If you use hand gestures when you talk, make sure they illustrate what you’re saying.
   Are you sure that your patient understands?
   Be aware that nodding is often defensive, not a sign of agreement.
   A patient who appears agitated or who interrupts may not understand what you’ve told them.

7. Summarise with the patient what you have discussed

   
   Together, with the patient, summarise your conversation.

8. Ask questions

   
   You may want to ask, “What questions do you have?” and “How confident do you feel on a scale of one to ten?”

9. Give written information

   
   This should include information about the service, monitoring and any methods to get in touch in between appointments, such as a helpline.

Minimum information

You should always give a patient the following minimum information around their drug treatment. This is for their safety.

• What to take and how to take e.g. tell the patient the number of tablets they should take and the frequency of the dose.
• How long methotrextate takes to work.
• Monitoring requirements- you may need to explain to the patient that if they do not get monitoring, they cannot take the drug.
• Whether changes the patient experiences could be related to the drug- consult the drug’s information leaflet.
• Potentially serious issues- for methotrexate, these include infections, fever, shortness of breath and pregnancy.
• The helpline number to call if the patient needs assistance.

You can also download and keep these Top Tips as a PDF (199 KB).