locating the evidence base for musculoskeletal nursing: an overview of the rheumatology nursing...

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International Journal of Nursing Studies 43 (2006) 507–518

www.elsevier.com/locate/ijnurstu

Locating the evidence base for musculoskeletal nursing:An overview of the rheumatology nursing literature

Claire Hale�, Jackie Hill

Academic and Clinical Unit for Musculoskeletal Nursing, School of Healthcare, University of Leeds, Baines Wing, P.O. Box 214,

Leeds LS2 9 UT, UK

Received 4 February 2004; received in revised form 17 May 2005; accepted 28 June 2005

Abstract

The main aim of this study was to locate and classify publications, particularly research publications, produced by

nurses working and/or researching in the area of rheumatology in order to develop a research strategy for a newly

established academic and clinical nursing unit. Database searches were undertaken to identify journal articles. Theses,

dissertations, research reports, conference abstracts and books were also included in the study. The publications once

located were entered into a Reference Manager electronic database and the facilities of this package were used to

analyse and classify the data. The findings of the study demonstrated that over the past 40 years nurses have been

steadily increasing the publication output in this area and in the last 10 years there has been a substantial increase in all

publications, but particularly research and investigative articles. However there is a lack of clinical research in this area

and this needs to be addressed in future as nurses develop more advanced roles in this speciality. The main limitations

was the difficulty in accurately identifying nursing publications because of inadequate details of authorship.

r 2005 Published by Elsevier Ltd.

Keywords: Musculoskeletal; Rheumatology; Literature overview; Nursing; Reference manager

What is already known about the topic?

�
Musculo skeletal diseases, of which rheumatological
disorders are a major group, are a major cause of

disability throughout the world.

�
There are an increasing number rheumatology
specialist nurses working in acute hospitals and in

the communities managing the care of patients.

�
A large amount of medical research is carried out in
the field of rheumatology.

e front matter r 2005 Published by Elsevier Ltd.

urstu.2005.06.006

ing author.

ess: [email protected] (C. Hale).

What this paper adds?

�
We now know that rheumatology nurses through-
out the world have been actively publishing in a

wide range of nursing and other journals for many

years.

�
We now know that in the last few years articles
descri-

bing of research and investigative studies have

increased.

�
We now know that when nurses do publish
in medical journals their contribution is often

invisible to outsiders because of lack of professional

attribution.

www.elsevier.com/locate/ijnurstu

ARTICLE IN PRESSC. Hale, J. Hill / International Journal of Nursing Studies 43 (2006) 507–518508

1. Background to the study

1.1. Musculoskeletal disease and the development of

rheumatology nursing as a speciality

Musculo-skeletal disorders are a major cause of

morbidity throughout the world with a substantial

influence on health and quality of life (The Bone and

Joint Decade, 2005). The malfunctions of the muscu-

loskeletal system, which often result in inflammations of

the joints—or arthritis, are a principal focus of

rheumatology. In the UK, more than seven million

people have long-term health problems due to a

rheumatic disease–one of the main causes of musculos-

keletal disorders (Arthritis Research Campaign, 2002).

These diseases can cause intense pain, restricted move-

ment, psychosocial dysfunction and in some cases

disfigurement. There are more than 200 different types

of arthritis and related conditions including (Arthur,

1998):

(a)
joint failure (osteoarthritis);
(b)
inflammatory joint diseases such as rheumatoid
arthritis;

(c)
spondyloarthropathies such as ankylosing spondyli-
tis and psoriatic arthritis;

(d)
crystal deposition diseases such as gout;
(e)
metabolic bone diseases such as osteoporosis;
(f)
connective tissue diseases such as systemic lupus
erythematosus and scleroderma;

(g)
non-articular conditions such as back pain and soft
tissue disorders.

1In the UK NHS, ‘Trusts’ are health care organisations that

are responsible for the management and delivery of patient care

services. Their exact configuration depends of the size of the

communities they serve, so for example in large conurbations

there are likely to be separate acute and community ‘Trusts’.

Whereas in less populated areas one ‘Trust’ may manage both

acute and community services.

Although nurses have always cared for patients with

rheumatic disease, the recognition of Rheumatology

nursing as a distinct nursing speciality dates from the

early1980s in the UK and in the USA (American Nurses

Association, 1983). In the UK, the inaugural meeting of

the Royal College of Nursing (RCN) Rheumatology

Nursing Forum was held in Manchester in 1981 and this

group, recognising that nurses had an important role to

play in the care of patients with rheumatic conditions,

lobbied the organisations responsible for post basic

nursing education in the UK to establish a course in

rheumatology nursing.

This nursing speciality development occurred along-

side the development of rheumatology as a distinct

medical speciality. Key to this development was the new

drug treatments that were coming on to the market in

the late1970s and the subsequent increase in clinical

trials and other research studies. Treatment for rheu-

matic diseases moved from being entirely focussed on

rest, splints, physiotherapy and surgery, to a focus on

how drug therapies could help to alleviate and even

modify the course of the disease. The drug therapies

required careful monitoring and it was nurses who took

on this emerging new role and created opportunities to

develop it further (Bird et al., 1980, 1981; Bird, 1983;

Hill, 1985, 1986). Subsequently, the understaffing of

medical services and reduced junior doctors’ working

hours have led to Rheumatology Units in the UK

increasingly augmenting their multidisciplinary team

with senior nurses specially trained to take undertake

extended roles and manage patient groups (Mounce and

Ryan, 2001)

Rheumatic diseases are chronic conditions and the

nature of the diseases are that patients require different

types of nursing input at different times. Therefore the

nursing input to care can vary from the very essentials of

nursing such as help with the activities of daily living,

pain management, maintaining tissue viability and

patient education, to highly technical activities such as

intra articular injections and the management of

intravenous drug therapy. The complex needs of

patients with rheumatic diseases demand that nurses

need to have a mastery of a whole range of nursing

skills. Important among them is the ability to work as

partners with the patients and their families at different

stages of their illness, and to maintain the cohesiveness

of the partnership in the face of shortage of staff and

changes in the organisation of care delivery. The recent

policy changes affecting service delivery in the UK

National Health Service have resulted in a shift from

acute services to community services and in many

Trusts1 the majority of rheumatology patients are now

seen in the outpatients department and the community

(Grahame and West, 1996; Ryan, 1996). These changes

in the location of service delivery have led to develop-

ments in nursing roles and in particular, nurse led

clinics, in the UK and in other countries (Barry et al.,

1998; Gardiner et al., 1994; Hill, 1992, 1997; Hill and

Hale, 2004; Lloyd, 2003; McCabe et al., 2000; Miura,

1993; Moya et al., 1999; Ryan, 1995; Ryan and

Seymour, 1997; Temmink et al., 2001; Tijhuis et al.,

2002).

The research agenda in rheumatic disease is huge and

varied. For many years the Arthritis Research Cam-

paign (arc), in the UK has funded research projects and

research posts and in 2002–3 had a total research and

education expenditure of £18.360m (Arthritis Research

Campaign, 2003). Most of the money is devoted to

‘laboratory’ research in the hope of finding a cure.

Pharmaceutical companies also fund research into the

development and monitoring of new therapeutic agents.

ARTICLE IN PRESSC. Hale, J. Hill / International Journal of Nursing Studies 43 (2006) 507–518 509

However because rheumatic diseases are chronic,

research has also focussed on the social and psycholo-

gical aspects of the diseases and the perspectives of those

affected (Cornelissen et al., 1988; Hill et al., 1994c;

Brown and Williams, 1995; Dildy, 1996; Jakobsson and

Hallberg, 2002; Hill et al., 2003). Another major area for

research is the evaluation of the effectiveness of various

interventions particularly those introduced to alleviate

symptoms such as pain, fatigue, poor sleeping patterns

(Tack, 1991; Sinclair et al., 1998; Kim and Jo, 2001). An

important area in this category is that of patient

education and the evaluation of patient education

programmes (Hill et al., 1994b, 2003; Ehrlich-Jones et

al., 2001; Park, 2001; Olaleye, 2004; Hill, 2003a). As new

nurse-led services have been developed, research has

been undertaken to evaluate their effectiveness (Hill et

al., 1994a; Tijhuis et al., 2003; Hill, 2003b; Moya et al.,

1999).

In summary, the areas where rheumatology research

is undertaken can be summarised as:

(a)
cure;
(b)
drug therapies;
(c)
social and psychological aspects of the disease;
(d)
effectiveness of interventions to improve symptoms;
(e)
evaluations of new services.
Given the increasing centrality of nurses to the care of

patients with rheumatic diseases and the development of

a cadre of specialist nurses and nurse consultants with

advanced clinical and educational skills, it would be

reasonable to assume that nurses should be actively

contributing to the research agenda in this area.

However, the quantity of research actually undertaken

by nurses is generally considered by colleagues working

in this area, to be small. The large (mainly medical but

increasingly multidisciplinary) rheumatology confer-

ences such as the American College of Rheumatology

(ACR)/American Health Professionals in Rheumatol-

ogy (AHPR), the European League for Arthritis and

Rheumatism (EULAR) and the British Society for

Rheumatology (BSR)/British Health Professionals in

Rheumatology (BHPR) appear to have relatively few

original research papers by nurses. In the UK, the RCN

Rheumatology Nursing Forum Conference, the main

UK venue where rheumatology nurses meet and discuss

their practice, devotes little time to the research activity.

At the RCN Research Society Annual Conference there

are few research presentations concerning rheumatol-

ogy.

Therefore it seems that for the most part, the nurses

who are actively engaged in research activity are those

who are working on drug trials. While this kind of

activity can be a useful way of developing research skills,

usually the nurses are employed as data collectors and

research study managers and are rarely given the

opportunity to contribute to papers or apply for

funding. More importantly their names are sel-

dom included as authors on a paper and even if

they are, their professional background may not be

mentioned.

1.2. An academic unit for musculoskeletal nursing

The stimulus for carrying out the work described in

this paper came from the establishment in 2003, of the

Academic Unit for Musculoskeletal Nursing (ACU-

MeN) a tripartite endeavour between the School of

Healthcare, the Academic Unit of Musculoskeletal

Medicine, both of the University of Leeds and the

Leeds Teaching Hospital NHS Trust, and the need to

develop a research strategy for this new Unit. It was

decided therefore, to identify publications in the area of

rheumatology nursing to ascertain how nurses were

contributing to the development and dissemination of

knowledge and to identify the gaps which the research

strategy could address. A previous publication (Hill and

Hale, 2004) has looked more broadly at the evidence for

some of the clinical and psychological interventions

carried out by nurses working in this area.

1.3. Why is it important to focus on nursing publications?

The care of patients with rheumatological conditions

relies heavily upon good teamwork between healthcare

professionals: nurses, doctors, physiotherapists, occupa-

tional therapists, podiatrists and dieticians. Nurses are

the largest group of these health professionals and they

are increasingly taking on more advanced roles and

increasing their autonomy. As such, they need to be

involved in developing the evidence for their own

practice, formulating and answering their own questions

and disseminating their findings to other nurses. When

trying to develop a programme of future work it is

important to know what has been carried out previously

and where expertise is located.

1.4. Aims of the study

The aims of this study were to:

1.
To outline the nature of the work of the rheumatol-
ogy nurse and identify the parameters of the knowl-

edge base.

2.
Locate and classify the publications produced by
nurses working in this area.

3.
Identify the area where nurses have carried out
research in rheumatology.

4.
Identify the areas where rheumatology nurses need to
direct their future research activity.


1.5. The work of the rheumatology nurse

The development of the role of the rheumatology

nurse has been outlined above. However, as a frame-

work for this study, a model for the role of the nurse was

derived from the RCN document ‘Standards for

effective practice and audit in rheumatology nursing

(Royal College of Nursing, 2001). This document

provides an indication of the knowledge base that

practitioners need to obtain and develop in order to care

for patients with rheumatological diseases.

1.6. A model for the role of the nurse

The above-mentioned RCN document states that

assessment and subsequent care of rheumatology

patients should focus on three main areas:

(a)
Disease knowledge and management—including in
particular pain, stiffness, fatigue, joint protection,

pacing and planning, sleep, exercise, medication,

complementary therapies.

(b)
Self-care abilities—including hygiene and dressing,
skin care, nutrition, elimination and fluid intake,

psychological state, body image, sexuality, mobility.

(c)
Social and environmental factors—including the
family and social support, occupation, housing,

finance and benefits, transport, leisure.

Therefore, when searching for publications by nurses

caring for patients with rheumatological diseases, it

would be reasonable to expect that some of these areas

would be covered because this would indicate that

nurses were disseminating their knowledge and con-

tributing to the development of the evidence base in this

area.

1.7. Identifying publications

For the purpose of this study, a publication was

considered to be one of the following:

(a)
a journal article;
(b)
a book;
(c)
an abstract for a conference presentation or poster;
(d)
an unpublished research study report;
(e)
a thesis or dissertation.
2. Method

The methods used to access the publications were:

1.
A literature search of the following electronic
databases: Medline; Cinahl; Embase.

2.
A search of conference abstracts from conferences
where research active nurses were known to have

contributed and whose abstracts were easily avail-

able.

3.
Contacting programme managers of known post-
graduate courses in rheumatology nursing in the UK.

4.
Chance—whereby a relevant publication came to the
attention of the authors.

2.1. Search terms for the electronic databases

The terms used for searching all the above electronic

databases were:

�
rheumatology and nursing;
�
rheumatology and nurse;
�
rheumatoid and nursing;
�
rheumatoid and nurse;
�
rheumat $ and nurs$.
2.2. Identification of publications from the electronic

search

The electronic database search of Medline, Cinahl and

Embase from 1966 to December 2003 generated

1300+publications which were primarily articles and

theses. These publications were published in a range of

languages but all had either English abstracts or titles.

The references were downloaded directly from the

databases into the bibliographic database Reference

Manager-Version 10 (Institute for Scientific Informa-

tion, 2003) and then checked for duplicates. Any

duplicates were discarded. These publications were then

reviewed to identify those which had nurses as authors.

However at times it was not always clear, to which

professional group(s) the author(s) belonged. Therefore

when selecting relevant articles for inclusion, using the

above-mentioned criteria, the following assumptions

were made:

(a)
If an article was published in a nursing journal, it
was more likely to have written by a nurse.

(b)
If the author(s) address was a nursing department
then at least one author was likely to be a nurse.

Publications concerning the effectiveness of drug

regimes were discarded even though they might have

included nurses as authors. This latter decision was made

because the aim of the study was to see how far nurses

were contributing to the dissemination and generation of

knowledge and therefore it was important to find

publications which had either been written entirely by

nurses or to which a nurse was one of the contributing

authors. In most drug studies nurses are employed as data

ARTICLE IN PRESS

Table 1

Summary of the type and number of publications included in

the database

Books and book chapters 6

Journal articles 444

Theses 18

Conference papers and posters 19

Reports 1

Total 488

C. Hale, J. Hill / International Journal of Nursing Studies 43 (2006) 507–518 511

collectors or study managers and their contribution to the

generation and design of the study is limited.

The authors of the remaining articles were reviewed

by J.H. (a rheumatology nurse specialist) for recognition

of names and verification (or not) of nursing authorship.

There were approximately 58 articles where nursing

authorship was uncertain. This was because although

the journal in which the article was printed was not

specific to nurses, the title of the article was suggestive of

nursing involvement. Attempts were made to verify

authorship by searching web pages of organisations and

while this was successful in three cases, in others no

information was found. It was also a very time

consuming process. All 58 ‘dubious’ articles were left

in the database and included in the analysis.

2.3. Conference papers

Conference abstracts from the conferences listed

below were searched because it was known that

rheumatology nurses had presented papers or posters

and the abstracts books were readily available. In the

case of the ACR/AHPR conference the abstract book

was published as an appendix to the journal Arthritis

and Rheumatism and available in the university library.

Other abstract books were available from colleagues

who had attended the conference.

2.4. Conferences selected

(ACR/AHPR) 1998–2003;

Workshop of European Nurse Researchers (WENR)

2000 and 2002;

RCN Research Conference 2000–2004;

European League for Arthritis and Rheumatism

(EULAR) 2002 and 2003;

BHR/BHPR 2002 and 2003.

While the assumption could be made that those who

presented papers or posters at the RCN and WENR

conferences would almost certainly be nurses, it was more

difficult to identify papers and posters presented by nurses

at the ACR/AHPR, EULAR and BHPR conferences,

because the qualifications and the workplace of the

authors were not always provided. It was decided therefore

only to include abstracts from these latter conferences, if

there was some definite indication that a nurse was

involved, e.g. nursing qualifications were provided; work

place was an academic nursing department; the presenter

was known to the authors. This meant that the identifica-

tion of relevant publications from conference abstracts was

somewhat serendipitous and some relevant publications

may have been missed. The selected publications were

entered manually into the Reference Manager biblio-

graphic database and authors were checked for duplicates.

Furthermore, if the topic of a conference presentation was

subsequently published as an article which was located via

the electronic database search, then the conference

publication was removed from the Reference Manager

database to avoid inflating the results.

2.5. Books

There are only a small number of books specifically

about rheumatology nursing and these are mainly

published in English. Those known to the authors were

included in the study along with any that were found in

the electronic database search.

2.6. Reports, theses and dissertations

Some theses titles were identified by electronic database

searches. Programme managers of two Masters courses for

rheumatology nurses in the UK were invited to send details

of completed student dissertations and one did so. If, when

the reports and theses were entered into the database, it was

noticed that a journal publication had been produced from

this work then the thesis reference was deleted.

Only a small number of publications were obtained

from searching for books, reports and theses, the bulk of

the publications came from journal articles. Table 1

summarises the number and type of publication included

in the database.

The total number of publications included in the

Reference Manager database was 488 and comprised

journal articles, books, theses and conference abstracts.

The electronic database search of Medline, Cinahl and

Embase produced approximately 1300 publications

(mainly articles and theses) of which 444 were used,

the remainder being discarded because they did not meet

the inclusion criteria.

2.7. Classification of the publications

When selected publications are entered into the

Reference Manager database, either manually or by

automatic download from the electronic database, the

following details are recorded:

(a)
Type of publication (e.g. journal article, thesis)
(b)
Authors


(c)
Name of journal
(d)
Date of publication
(e)
Abstract (where available)
(f)
Country of origin
(g)
Language
(h)
Keywords
Once the search for publications was completed, the

abstracts and titles were scrutinised by CH and the

publications classified by a keyword according to the

focus of the publication and whether or not the article

was a research study. The most common classification

headings which emerged are given below and these

covered 467 of the 488 publications in the database.

(a)
Clinical: These were publications which primarily
provided clinical information to nurses, e.g. an

article about the difference in types of arthritis or

details of how to care for a patient with a particular

disease.

(b)
Patient Education: These were publications whose
focus was on education for patients.

(c)
Pain and stress: These were publications where the
focus was on pain and/or stress experienced by

patients with rheumatology disorders.

(d)

Table 2

Role of nurse: These publications focussed on the

role of the nurse when caring for patients with

rheumatology disorders.
Number of articles published in the different countries (e)
North America (US and Canada) 140

United Kingdom 135

Service development: These publications described

some new service development that had either been

introduced or was being evaluated.

Japan 34
(f)
France 19

Netherlands 17

User perspective: These publications had a focus on

the experience of the service user and included those

dealing with satisfaction and quality of life.

Germany 12
(g)
Other articles from Spain/Switzerland/Finland/Norway/Korea/

Denmark/Australia/New Zealand/Taiwan.

Research: Those publications which described a

research or evaluative study (this definition would

include audits) were given a keyword classification

of ‘research’ in addition to one of the above

keywords. No attempt was made at this stage to

make any judgement as to the quality of the study or

the type of method used to collect data.

0

20

40

60

80

100

120

140

research

non research

124362

66-70 71-75 76-80 81-85 86-90 91-95 96-00 2001-04

Fig. 1. Number and chronology of publications.

The features of Reference Manager allow for classi-

fication of articles by ‘terms’ such as publication year,

name of journal, keywords, author and also allow for

combination of some of these terms. Thus the analysis of

the publications was undertaken using these features.

2.8. Analysis of the publications

2.8.1. Country of origin

In total, a larger number of publications than

expected were obtained and these were published in a

range of countries. Table 2 shows the countries from

which publications emerged and the number of publica-

tions produced. Although the UK and North America

are leaders in the field, other countries are also

contributing to knowledge development and dissemina-

tion in rheumatology nursing by publishing in their own

language and also in English

2.8.2. Chronology of publications

Fig. 1 shows a histogram with the chronology and

number of the publications, starting from the year 1966.

The number of publications classified as ‘research’ are

shaded in red. This table demonstrates that the total

number of publications has grown over the years,

particularly from the mid-1980s. It is heartening to note

that in recent years there has been a substantial growth

in the number of ‘research’ publications and in the years

of the current decade (2001–4) ‘research’ publications

already make up just over half of all publications.

2.8.3. Main publication categories

Fig. 2 shows the findings of the classification of the

publications by the above-mentioned keywords. The

most common classification group was that of ‘clinical’.

These were articles written primarily for other nurses

and were descriptive clinical articles giving information

about the disease and disease processes. Publications

ARTICLE IN PRESS

0

20

40

60

80

100

120

140

160

180

200

Clinical Patient Stress & Role of Service UserEducation Pain Nurse Development Perspective

185

65 63 49 4164

Fig. 2. Main publication categories.

Table 3

Main countries contributing to the research literature (5 or

more articles)

United Kingdom 44

North America (US and Canada) 42

Netherlands 8

Finland 6

Korea 5

Total ‘research’ articles ¼ 124 (see Fig. 1).

0

5

10

15

20

25

30

35

12User Service dev Stress & Patient Clinical perspective evaluation pain education

32

26 23

20

3

Fig. 3. Categories of research publications (n ¼ 124).

C. Hale, J. Hill / International Journal of Nursing Studies 43 (2006) 507–518 513

about patient education, stress and pain and the role of

the nurse formed the next main group with slightly fewer

publication concerning service developments and the

user perspective, which included patient satisfaction and

quality of life.

2.8.4. Research publications

Fig. 1 illustrated how the number of ‘research

publications’ had started to increase substantially from

the 1990s. The criteria for the ‘research classification’ is

also described above and the classification was usually

made of the basis of title and abstract.

Table 3 shows the countries that have contributed

most to the research literature and here again the leaders

in this field are the UK and North America. However

other countries such as the Netherlands, Finland and

Korea are also beginning to make a contribution in this

area.

2.8.5. Categories of research publications

Those articles which were classified as ‘research’ were

further classified using Reference manager by the same

categories described above and listed below:

(a)
clinical;
(b)
patient education;
(c)
stress and pain;
(d)
role of the nurse;
(e)
service developments;
(f)
user perspectives.
Fig. 3 shows the results of this exercise. It is

interesting to note that the number of ‘research’

publications in each topic are in reverse order to the

overall number of publications (Fig. 2). So that among

the total number of publications, the ‘clinical’ topics

which are the focus of so many publications overall, are

the focus of very few research-based articles.

2.8.6. Main journals where the articles were published

The 444 articles were published in 150 journals which

covered a wide range of medical, nursing, health and

social journals. Table 4 shows the journals in which four

or more of the articles were published. Two hundred and

sixty articles were published in these 28 journals. The

remaining 184 articles were published in 122 journals.

Many journals only contained one or two relevant

publications which means that there is no ‘core’ set of

journals where relevant rheumatology publications

produced by nurses can be found. This is not a problem

if these journals are available ‘on line’ and if nursing

practitioners and researchers have access to ‘on line’

bibliographic searching facilities. However, many nurses

do not have this access and this means that the

dissemination of this knowledge will be limited.

Table 5 shows the journals where four or more

research articles were published. Since the majority of

the research articles came from UK or North American

sources (86 of 124 articles) then it is journals published

in these countries that feature in this table. Some details

of these journals are provided in Appendix A. Table 5

also shows the total number of research articles

ARTICLE IN PRESS

Table 5

Main journals where research articles were published (4 or more)

Journal Total research

articles in journal

UK

origin

US

origin

Other country

origin

Rheumatology (formerly British Journal of Rheumatology) 12 11 — 1

Annals of the Rheumatic Diseases 9 6 — 3

Journal of Advanced Nursing 8 2 3 3

Arthritis and Rheumatism 6 1 3 2

Arthritis Care and Research 5 — 5 —

Nursing Standard 4 4 — —

Journal of Clinical Nursing 4 2 — 2

Total research publications in the above journals 48 26 11 11

Table 4

Main journals in which the articles were published (4 or more publications)

Nursing Times (UK) 37

Nursing Standard (UK) 22

Rheumatology (formerly British Journal of Rheumatology) 21

Kango Gijutsu–Japanse Journal of Nursing Art 16

Annals of the Rheumatic Diseases (European) 14

Nursing Clinics of North America (US) 12

Nursing Mirror (UK) 11

Journal of Advanced Nursing (UK) 11

Arthritis and Rheumatism (US) 10

Kurinikaru-clinical study (Japan) 10

Professional Nurse (UK) 10

Meditsinskaia Sestra (Russian) 7

Journal of Clinical Nursing (UK) 6

Journal of Orthopaedic Nursing (UK) 6

Journal of Rheumatology (UK) 6

Pediatric Nursing (US) 6

Rehabilitation Nursing (US) 6

Arthritis Care and Research (US) 5

Nursing Research (US) 5

Rheumatologie (FR) 5

Nurse Practitioner 5

Journal of the American Academy of Nurse Practitioners (US) 5

Tijdschrift voor Ziekenverpleging (Netherlands) 4

Nursing Journal of India 4

Kangogaku Zasshi- Japanese Journal of Nursing 4

British Journal of Nursing (UK) 4

Kangogaku Zasshi (Japan) 4

Kango (Japan) 4

260

C. Hale, J. Hill / International Journal of Nursing Studies 43 (2006) 507–518514

published in these journals (column 1) and the

numbers that originated from the UK, North America

and the other countries (columns 2–4). Thus it can be

seen that the research articles are also spread thinly

across a number of journals which makes retrieval

difficult.

3. Discussion

3.1. Limitations of the study

The study has a number of limitations which affected

the accuracy and scope of the study and also the


classification structure. Arguably the main limitation

was the difficulty in ascertaining authorship of some of

the publications, particularly those articles which were

published in non-nursing journals and those presented

at non-nursing conferences. This meant that it was not

always possible to be clear about which articles had

nursing authorship and which did not. Clearly had more

time and resources been available then it might have

been possible to thoroughly check the professional

qualifications of the ‘dubious’ authors. The consequence

of this was that, despite the attempts made to ascertain

authorship, the assumptions made for the inclusion

criteria meant that it was quite likely that some

publications were included in error. However, by the

same token, it is also possible that some nursing

publications were omitted because nursing authorship

was not visible.

The location of the authors in the UK was source of

bias in that the authors were more familiar with the UK

Rheumatology community and had privileged informa-

tion about courses and unpublished work in the UK. To

obtain similar data about unpublished work in other

countries would have required international collabora-

tors and again that was outwith the scope of this study.

The limited time and resources available for the study

were a clear limitation to the scope if the study. Had

more time and resources been available then it would

also have been possible to develop a more sophisticated

search strategy for the electronic databases, hand search

journals, follow up citations and develop an more robust

system for identifying courses, books and conference

papers. All of this might have identified additional

publication. Therefore in the final analysis it is not

possible to say if the number of publications included in

this study is an accurate reflection of the total

publications in this field. However even if the accuracy

of the study is 75%, the number and type of publications

retrieved is encouraging for the development of this

nursing speciality.

A final limitation is that the selection and classifica-

tion of the publications was carried out by one author

(C.H.). Although previously agreed criteria were used,

had more than one person contributed to the selection

and classification of the publications, then this would

have strengthened the findings of the study by reducing

a potential source of bias and errors in classification

3.2. The number and source of publications

As stated above, the overall number of publications,

both research and non-research based was surprisingly

large since anecdotally it was thought by nurses working

in this area that there were relatively few nursing

publications. One of the reasons for this viewpoint

could have been because, as demonstrated in this study,

the journal articles are published in so many different

journals that it is difficult for a busy practitioner to be

aware of them all without a thorough and systematic

search of the literature. Nevertheless, even taking into

account the inclusion of the articles with ‘dubious’

authorship, this exercise does demonstrate that nurses

are increasingly disseminating their knowledge through

publication and conference presentation and also

participating in research in this speciality as lead

investigators and not just as data collectors for medical

and other projects.

Recognised speciality journals in orthopaedic nursing

already exist in the UK and North America, but as far as

the authors are aware there is no speciality journal for

rheumatology nursing. However the interdisciplinary

journal entitled Musculoskeletal Care (established 2003)

may in time become a major source of research

publications in both rheumatology and orthopaedic

nursing and help the further development of the

musculoskeletal speciality.

3.3. Comparing the publications and the role of the nurse

in rheumatology

The development of the role of the rheumatology nurse

was outlined above and the practice of rheumatology

nursing developed by the RCN Rheumatology Nursing

Forum was presented. When the classification of the

publications included in this study (Fig. 2) is compared

with the RCN Standards, it can be seen that there is a

reasonable match between the elements of the RCN

Standards and the topics of the nursing publications. This

demonstrates that there is congruence between the

nursing publications in this area and the practice of

nursing as defined by the practitioners. Where there is less

congruence is between the practice of rheumatology

nursing and the research publication. Apart from the

studies undertaken on pain and stress, there is very little

research carried out by nurses on other clinical aspects of

rheumatology nursing although there is some work

developing in the area of sexuality and fatigue (Tack,

1991; Hill et al., 2003). This study only recovered three

publications which were classified as ‘clinical’ and

attributed to nursing authorship (Goeppinger et al.,

1988; Houssien et al., 1999; Christen et al., 2003).

Since nurses are increasingly becoming more auton-

omous practitioners and more accountable for their own

actions, the development of the evidence base for clinical

decisions is a priority (Bryer, 2003) and to do this,

rheumatology nurses need to expand their research

repertoire and carry out more clinical studies.

3.4. The visibility of nursing research in a

multiprofessional environment

Rheumatology nursing practice is increasingly taking

place in a multiprofessional environment where bound-


aries between the activities of the various professionals

are becoming blurred. Nursing practitioners are now not

only ward based but also run clinics and manage a

variety of patients at home as well as in hospitals. The

authors of this article know of at least seven consultant

nurses in rheumatology practice in the UK and a large

number of specialist practitioners. It is primarily this

group of practitioners who have the opportunity to

become involved in research studies, but if no recogni-

tion is given to the different professional groups that

carry out the research, then the contribution of nurses to

the research agenda will remain invisible. The difficulty

of attributing nursing authorship to some of the

publications in this study has already been discussed.

Doubtless some would argue that in a multiprofessional

environment, professional titles are irrelevant and this

view certainly has some credence. However at a time

when research activity in nursing is still comparatively

small, it is helpful if those nurses who do carry out

research ensure that their work is given recognition. In

this way research will increasingly become to be seen as

a legitimate activity for nurses rather than an added

extra to be undertaken outside of their ‘real work’. As a

final comment on this issue it is useful to remember that

if the different professionals involved in a piece of

research do not declare their professional background,

then how are readers to know whether or not the

research is multiprofessional.

4. Conclusions

This study was carried out with the aim of locating

and classifying the nursing publications in the area of

rheumatology. The main conclusions of the study are

that:

1.
Over the last 40 years nurses have been increasingly
contributing to the world wide literature on rheuma-

tology nursing.

2.
The last 10 years have seen a considerable increase in
the number of research publications particularly in

the UK and North America.

3.
The publications produced by nurses are consistent
with the clinical work undertaken by nurses working

in this area.

4.
There is a need for nurses working in this area to
undertake more ‘clinical research’ to provide evi-

dence for their developing practice.

5.
Further work should be undertaken to review the
quality of the research publications identified in this

paper.

However the difficulty experienced by the authors in

actually identifying nursing publications suggests that if

nurses want to ensure that their contribution to the

multiprofessional agenda is recognised then they need to

ensure that their research output is recognised and

visible. The authors also recommend that in order to

facilitate the dissemination of knowledge and particu-

larly based knowledge, then the rheumatology nursing

community should encourage, support and publish in a ‘

core set’ of journals to develop the quality, focus and

impact factor of these journals.

Appendix A

A.1. Brief details of the journals where four or more

research articles were published

Rheumatology (formerly known as the British Journal

of Rheumatology) is an official journal of the British

Society for Rheumatology and is an international peer

reviewed journal publishing papers on the full spectrum

of rheumatological conditions, musculoskeletal medi-

cine and surgery.

Arthritis Care & Research is an official journal of the

American College of Rheumatology and is a peer-

reviewed publication for health professionals interested

in the rheumatic disorders. AC&R publishes original

articles concerning clinical problems and research

relevant to the care of rheumatic disorders as well as

articles analyzing economic, educational, and social

issues.

Arthritis and Rheumatism is a peer reviewed official

journal of the American College of Rheumatology and

covers all aspects of inflammatory disease.

The Annals of the Rheumatic Diseases is the official

journal of the European League Against Rheumatism

(EULAR). It publishes work on all aspects of rheuma-

tology and disorders of connective tissue and also

welcomes laboratory and clinical studies.

The Journal of Advanced Nursing is an academic

journal published in the UK. It publishes scholarly

papers that recognise the eclectic nature of global

nursing, midwifery and health care, and which con-

tribute to their development and advancement. Papers

that have a sound scientific, theoretical or philosophical

base, and which reflect the diversity, quality and

internationalism of nursing are also considered for

publication.

The Journal of Clinical Nursing is an international

scientific journal that seeks to promote the development

and exchange of knowledge that is directly relevant to all

spheres of nursing and midwifery practice. It publishes

high quality papers on issues related to clinical nursing.

It’s aim is to promote a high standard of clinically

related scholarship which supports the practice and the

discipline of nursing and promote the international


exchange of ideas and experience that draws from the

different cultures in which practice takes place.

Nursing Standard is an official journal of the RCN in

the UK. It publishes original research and clinical

articles relevant to the practice of nursing. It also

publishes a comprehensive news section and a range of

opinion pieces on topical issues.

All of these journals are available ‘on line’.

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