Abstract

Objectives. Rheumatological conditions are common and all health professionals (HPs) therefore need sufficient knowledge and skills to manage patients safely and effectively. The aim of this study was to examine current undergraduate education in rheumatology for HPs in the UK.

Methods. A questionnaire was sent to curriculum organizers and clinical placement officers for all undergraduate courses in adult nursing, occupational therapy (OT) and physiotherapy (PT) in the UK to ascertain the nature and amount of rheumatology theory and clinical exposure provided.

Results. Of the 47 adult nursing, 26 OT and 30 PT undergraduate courses surveyed, 85–90% responded. Overall, rheumatology teaching is 5–10 h over 3 yr. Nursing students receive moderate/in-depth teaching on rheumatoid arthritis (RA) in only 52% of courses (OT 91%, PT 96%) and on osteoarthritis (OA) in 63% (OT 91%, PT 92%). Clinical experience of RA is probably/definitely available in only 56% of nursing courses (OT 72%, PT 88%), with similar results in OA. Overall, nursing students receive the least rheumatology exposure, particularly in psychosocial issues and symptom management, while PT students receive the most. OT students have limited opportunities for clinical exposure to psychosocial and joint protection issues. Use of local rheumatology clinical HP experts is variable (18–93%) and cross-disciplinary exposure is limited (0–36%). Many educators consider their rheumatology training to be insufficient (nursing 50%, PT 42%, OT 24%).

Conclusions. Rheumatology training for undergraduate HPs is limited in key areas and often fails to take advantage of local clinical expertise, with nursing students particularly restricted. Clinical HP experts should consider novel methods of addressing these shortfalls within the limited curriculum time available.

Rheumatological conditions are present in 20–24% of the UK population and 43% of hospital in-patients, and account for 19% of general practitioner appointments [1]. Qualified health professionals (HPs) therefore need to develop skills in treating patients with rheumatological conditions or, at the very least, to acquire a sound awareness of the impact of rheumatological disease upon other conditions. For example, they need to understand the consequences for a patient with RA who is unable to take oral NSAID medication postoperatively, or the consequences of prolonged immobility for an RA patient with a fractured femur. Therefore, the management of major rheumatological conditions should be included in the curricula of all HPs during undergraduate training.

Nurses, occupational therapists (OTs) and physiotherapists (PTs) in the UK are educated over a minimum 3-yr period to degree level (some diploma level courses for nurses still exist). Education is organized by universities, where the theoretical component is delivered, while the required clinical experience is obtained during placements in hospitals or the community. Clinical placements may last from 6 weeks to 6 months, during which time students are generally supernumerary to the workforce. Education includes theoretical and practical elements designed to give HP students appropriate knowledge, skills and attitudes for their future roles. There are no national core curricula for any of the professions. University courses follow guidelines from the professions’ governing bodies [2–4], who also participate in course validation. Upon graduating, each HP student must register with his or her professional governing body in order to practise.

The professions face two problems in providing rheumatology undergraduate education. Firstly, there is pressure on time for theoretical input as the curricula become increasingly overcrowded, rheumatology having to compete with other specialties for timetable space. Secondly, there are limitations in clinical exposure to in-patients with chronic illness as in-patient facilities become concentrated on acute illness [5], leading to closure of rheumatology in-patient beds. Paradoxically, this threat to the availability of rheumatology theoretical and clinical experience comes at a time when the role of the rheumatology HP is expanding. Most rheumatology departments employ multidisciplinary teams, including specialist nurses at a senior level, who carry personal case loads [6], with similar specialist career posts for OTs and physiotherapists, and the first rheumatology or musculoskeletal consultant nurses, physiotherapists and OTs have been appointed.

Little has been published about the rheumatology content of undergraduate HP courses. A study of HP undergraduate rheumatology education in the USA and Canada 25 yr ago showed that, while programme directors believed the rheumatology theory content to be adequate (irrespective of the amount actually delivered), they generally believed clinical exposure to rheumatology was insufficient [7]. A more recent survey of Canadian physiotherapy undergraduate courses showed an average 22.5 h instruction, with clinical placements in rheumatology offered on 77% of courses [8]. The only UK study explored the teaching of general rehabilitation, disability and chronic illness issues to undergraduate nurses, and showed teaching to be both limited and superficial [5].

Research into undergraduate medical education in rheumatology has shown that teaching provision is variable in both time and content [9]. Whilst all faculties of medicine provide rheumatology teaching, it is only offered to or taken up by 50–75% of students, and the total time spent teaching rheumatology in 2000 was half that reported in 1992 [10]. This may reflect increasing time pressure on curricula where specialities compete for space, which is a common problem in the training of all clinical professionals.

The arthritis research campaign (ARC) has produced consensus standards for qualified HPs entering into extended clinical roles in rheumatology [11]. An American professional body, the Association of Rheumatology Health Professionals, has also published competencies for entry and advanced level therapists and nurses [12]. However, these recommendations apply to qualified staff who wish to make a career in rheumatology and do not necessarily reflect the minimum rheumatology knowledge, skills and attitudes that would be appropriate for undergraduate students and qualified HPs working in the community or other specialisms.

If rheumatological education for HPs is limited at undergraduate level, this will have important implications. First, the care of rheumatological patients outside specialist units might be compromised by HPs having insufficient background theory and practical skills to address rheumatological issues. Second, it might account for some of the difficulty in attracting newly qualified staff to the speciality, as they will not have been exposed to rheumatology as a career option as undergraduates. Indeed, research in other areas has shown that increasing undergraduate exposure to a speciality can increase recruitment of qualified staff [13].

HP education needs to evolve in order to reflect changes in the population, innovations in treatment and developments in professional skills and ways of working. We have an ageing population with rising numbers of people with chronic rheumatological conditions and HP education needs to respond to this; for example, by addressing government initiatives on self-management for patients with long-term conditions [14]. Innovations in therapy such as the rapidly increasing use of biological therapies, with growing use of rheumatology day beds to deliver treatment, is changing the roles of nurses in particular, and needs to be reflected in training. In addition, new and exciting roles for all rheumatology professions are developing as national guidelines recommend exploring new ways of working and the expansion and blurring of professional boundaries [15]. For example, the use of health professionals in rheumatology triage (e.g. back pain), the rise of nurse-led clinics and multidisciplinary approaches to case management now need to be addressed in undergraduate training.

No information is available on the current level of rheumatology input in undergraduate HP training in the UK. This is essential in order to assist in developing rheumatology HP education further. The aim of this study was therefore to identify the breadth and depth of rheumatology education at undergraduate level for nurses, OTs and physiotherapists in the UK, by conducting a national survey.

Method

Participants

All educational institutions in the UK offering undergraduate education in adult nursing, OT or physiotherapy were identified through the NHS careers website listings [16]. Contact was made with every institution by phone or e-mail to obtain contact details of those responsible for designing the theory content of their pre-registration curriculum for each nursing, OT or physiotherapy course (curriculum organizers). Each curriculum organizer was invited to participate in the survey. They provided contact with the staff responsible for organizing the clinical practice components of their courses (clinical placement officers or those with a similar title), who were also invited to participate.

Questionnaires

The curriculum organizer and clinical placement officer(s) for each course were invited to complete a questionnaire relating to the rheumatology content of their courses: what was taught, how it was taught, whether it was examined formally, the availability of clinical placements, the existence of local clinical rheumatology services (out-patients, in-patient beds, HP specialist clinics) and whether these were used in either theory teaching or clinical placements. Questionnaire topics were proposed by the multidisciplinary steering group. The questionnaire was piloted in nine nursing courses and minor amendments were made prior to the full study. The curriculum and clinical questionnaires were identical, with the exception of the first question, where the curriculum version queried the depth of coverage of musculoskeletal topics taught to students, with response options of ‘in-depth’, ‘moderate’, ‘brief’ and ‘not covered’. The clinical questionnaire asked about the probability of students encountering these issues during their placements (definite, probable, possible, not offered). Opportunity for additional comments was available. Participants were advised that all responses would be anonymous and that institutions would not be identifiable in any reports. Questionnaires were posted to the participants with a prepaid envelope and a reminder was sent out to non-responders after 1 month.

Ethics

Ethics approval for the study was given by the South West Multi-Centre Research Ethics Committee, with agreement that return of the questionnaires would imply consent.

Analysis

Questionnaire responses were entered into an Excel spreadsheet and summary totals calculated for each question. Data regarding the number of theory and clinical hours given to rheumatology and the percentage of trainees offered placements were analysed using measures of central tendency and frequency. Data are presented as the curriculum organizers’ perceptions of undergraduate training, and the clinical placement officers’ perceptions of training, for each of the three professions.

Results

Forty-seven higher education institutions offering undergraduate courses in adult nursing were identified (OT 26, PT 30). Response rates were similar across the professions, with either the curriculum or the clinical questionnaire returned by 40 nursing institutions (85%), 22 OT institutions (85%) and 27 physiotherapy institutions (90%). Seventy per cent of nursing institutions returned the curriculum questionnaires and 68.1% returned the clinical questionnaires, with slightly higher response rates for OT (85%, 69%) and physiotherapy (87%, 83%).

Nursing students’ theoretical and clinical exposure to major rheumatological topics was limited, with just over half of students receiving moderate or in-depth classroom teaching (RA 52%, OA 63%), with similar levels of clinical exposure (56%, 63%) (Table 1). In terms of patient symptoms and problems, only 61% of student nurses were taught about the theory of key nursing elements such as psychosocial issues of chronic rheumatological disorders, only 56% about the management of major symptoms such as stiffness and fatigue, and only 31% received information on joint protection principles, with slightly higher chances of clinical exposure to these issues during placements (61%, 69%, 52%). Medication is an important nursing issue, but only 52% of nurses were given theoretical coverage into management of rheumatology medication, although clinical placement officers felt that more students would receive exposure on clinical placement (81%).

Table 1.

Rheumatological issues taught on the curriculum and offered during clinical placements

 Nursing
 
 OT
 
 Physiotherapy
 
 
 Curriculum Moderate/ in deptha (%) Clinical Probable/definiteb (%) Curriculum Moderate/ in depth (%) Clinical Probable/definite (%) Curriculum Moderate/ in depth (%) Clinical Probable/definite (%) 
Disease       
    Rheumatoid arthritis 52 56 91 72 96 88 
    Osteoarthritis 63 63 91 83 92 96 
    Osteoporosis 50 54 60 44 69 78 
    Ankylosing spondylitis 16 33 38 28 80 58 
    Connective tissue diseases 20 38 40 44 12 33 
    Fibromyalgia 15 17 27 38 
    Juvenile idiopathic arthritis 17 32 21 17 
Problems/symptoms       
    Stiffness/fatigue/sleep 56 69 73 67 58 83 
    Joint protection 31 52 86 55 69 83 
    Activities of daily living 64 78 91 83 73 92 
    Psychosocial issues 61 61 77 56 77 67 
Medical treatments       
    Drug therapy 52 84 38 22 54 75 
    Surgical therapy 53 61 48 22 62 75 
Self-management       
    Patient education 80 78 86 72 100 96 
    Pain management 88 78 82 61 100 88 
    Medication management 52 81 36 33 50 79 
    Exercise 32 58 41 33 92 96 
Professional issues       
    Multidisciplinary team 70 85 68 75 93 92 
    Disability issues 81 81 85 72 67 75 
 Nursing
 
 OT
 
 Physiotherapy
 
 
 Curriculum Moderate/ in deptha (%) Clinical Probable/definiteb (%) Curriculum Moderate/ in depth (%) Clinical Probable/definite (%) Curriculum Moderate/ in depth (%) Clinical Probable/definite (%) 
Disease       
    Rheumatoid arthritis 52 56 91 72 96 88 
    Osteoarthritis 63 63 91 83 92 96 
    Osteoporosis 50 54 60 44 69 78 
    Ankylosing spondylitis 16 33 38 28 80 58 
    Connective tissue diseases 20 38 40 44 12 33 
    Fibromyalgia 15 17 27 38 
    Juvenile idiopathic arthritis 17 32 21 17 
Problems/symptoms       
    Stiffness/fatigue/sleep 56 69 73 67 58 83 
    Joint protection 31 52 86 55 69 83 
    Activities of daily living 64 78 91 83 73 92 
    Psychosocial issues 61 61 77 56 77 67 
Medical treatments       
    Drug therapy 52 84 38 22 54 75 
    Surgical therapy 53 61 48 22 62 75 
Self-management       
    Patient education 80 78 86 72 100 96 
    Pain management 88 78 82 61 100 88 
    Medication management 52 81 36 33 50 79 
    Exercise 32 58 41 33 92 96 
Professional issues       
    Multidisciplinary team 70 85 68 75 93 92 
    Disability issues 81 81 85 72 67 75 

aModerate or in-depth curriculum coverage.

bProbable or definite clinical exposure.

OT students had greater exposure to RA and OA teaching and clinical placements (72–91%) along with more input on the theory of psychosocial issues (77%), but only half of OT students were likely to have clinical exposure to psychosocial issues (56%) (Table 1). Almost all OT students were taught the theory of joint protection and activities of daily living (ADL) in a rheumatological context (86%, 91%), but opportunities for clinical experience in joint protection were only likely for half of the students (55%).

Physiotherapy students had good exposure to RA and OA teaching and clinical placements (88–96%), and higher levels of exposure to osteoporosis and ankylosing spondylitis theory and clinical placements than other HPs, as would be appropriate for this profession (58–80%) (Table 1). Theory teaching on the control of major rheumatological symptoms, joint protection techniques and ADL issues was not universal (58–73%), but clinical exposure was higher (83–92%). Almost all physiotherapy students received theory and clinical experience in exercise in a rheumatological context (92%, 96%).

Many students from all professions were likely to receive input on the theory of some common, important rheumatological areas, such as patient education (nursing 80%, OT 86%, PT 100%), although the possibility of receiving related clinical experience was lower (78%, 72%, 96%) (Table 1). Theory and clinical experience around multidisciplinary team working varied but appeared to be reasonably well covered (theory 70–93%; clinical 85–92%). However, whilst all professions offered reasonable teaching on the theory of pain management (nursing 88%, OT 82%, PT 100%), related clinical placements were poor for OT students (OT 61%, nursing 78%, PT 88%).

Theory teaching in the university classroom and practical experience in the clinical area may encompass a variety of teaching styles. Nursing students received mainly formal lectures and experienced fewer other teaching styles such as group work, self-directed learning, videos/leaflets or project work, compared with either OT or physiotherapy students (Table 2). OT and PT students on clinical placements were most likely to be given ARC material (71%, 68%), compared with just 35% of nursing students. Clinical placements where students were likely to encounter rheumatology patients were available on most courses (83–88%). However, when asked what percentage of their students would be offered such a placement, those who responded believed that only 10–15% of nursing and 28% of OT students were likely to gain clinical exposure to rheumatology patients, compared with almost all physiotherapy students (Fig. 1) (23 and 25% of nursing and OT respondents found it difficult to estimate). Single day visits to clinical areas to gain rheumatology experience in the absence of longer placements were rarely used (12–36%) (Table 2).

Fig. 1.

Percentage of students offered rheumatology placements.

Fig. 1.

Percentage of students offered rheumatology placements.

Table 2.

Teaching methods used in teaching theory (curriculum) and practice (clinical)

 Nursing
 
 OT
 
 Physiotherapy
 
 
 Curriculum (%) Clinical (%) Curriculum (%) Clinical (%) Curriculum (%) Clinical (%) 
Lectures 94 76 95 65 100 84 
Group work 67 52 91 71 92 80 
Self-directed 73 62 95 94 96 92 
Videos/leaflets 33 38 77 59 52 60 
Projects 24 17 59 47 44 24 
ARC material 15 35 55 71 48 68 
Clinical placement 76 83 95 88 88 88 
Placement days 21 28 18 29 12 36 
 Nursing
 
 OT
 
 Physiotherapy
 
 
 Curriculum (%) Clinical (%) Curriculum (%) Clinical (%) Curriculum (%) Clinical (%) 
Lectures 94 76 95 65 100 84 
Group work 67 52 91 71 92 80 
Self-directed 73 62 95 94 96 92 
Videos/leaflets 33 38 77 59 52 60 
Projects 24 17 59 47 44 24 
ARC material 15 35 55 71 48 68 
Clinical placement 76 83 95 88 88 88 
Placement days 21 28 18 29 12 36 

When asked to estimate the number of theoretical and practical hours given to rheumatology during the 3-yr training, a quarter of institutions across all three professions felt unable to do so. Those who did respond described a wide range of hours allocated to rheumatology with a median of 5 h theory and 10 h practical for nurses, and 10 h of each for both OT and physiotherapy.

Rheumatology was taught as an individual subject in its own right in only a quarter of all institutions. It was more commonly taught as part of orthopaedics (all professions), care of the elderly (nursing students) or skills for practice (OT students). Formal assessment of rheumatological knowledge varied across the three professions, with OT and physiotherapy courses much more likely to assess their students formally either for rheumatology theory (OT 85%, PT 90%) or clinical skills (94%, 76%) than nursing courses (theory 28%, clinical 26%).

Respondents were generally aware of the existence of clinical rheumatology specialist HPs locally. Seven per cent of nursing respondents were uncertain about whether there were any local nurse-led clinics, 16% of OT respondents were uncertain about OT clinics and 8% of physiotherapists were uncertain about physiotherapy clinics. A third of all respondents were unsure about the presence of an academic rheumatology unit locally (nurses 33%, OTs 30%, PTs 28%). Students had limited exposure to their own profession's clinical experts for teaching or placements (Table 3). Even though 57% of nurse educators knew of local nurse specialists, they were only utilized for teaching by 19–33% of courses and less than half of courses made use of them for clinical placements (42–54%). Awareness was greater in OT respondents (73% aware of local rheumatology OT services), with about half of courses using staff for teaching (52–59%) and 81–82% taking advantage of clinical placements. Awareness was highest for physiotherapy respondents (82%) but use of local PT experts in teaching was much lower (27–35%), although clinical placements were utilized (77–83%). There was little cross-disciplinary exposure in either teaching or clinical placements (OTs 0–23%, PTs 10–18%, nurses 12–42%). Local academic rheumatology units were rarely used, despite almost half of the respondents knowing they existed. Overall, 50% of nursing respondents felt that rheumatology coverage was insufficient in their undergraduate courses, as did 42% of PT respondents and 24% of OT respondents.

Table 3.

Different aspects of local rheumatology services used for teaching or for clinical placements (%)

 Nursing
 
    Occupational therapy
 
    Physiotherapy
 
    
  Used in teaching  Used for placements   Used in teaching  Used for placements   Used in teaching  Used for placements  
Local services Awarea Curriculumb Clinicalc Curriculum Clinical Exist Curriculum Clinical Curriculum Clinical Exist Curriculum Clinical Curriculum Clinical 
In-patient beds 95 18 26 89 93 95 52 59 95 94 100 35 39 83 91 
Out-patients 100 32 74 80 91 26 13 69 73 94 23 23 45 59 
Nurse clinics 57 19 33 42 54 39 12 23 36 10 12 
OT clinics 73 12 24 20 36 87 52 59 81 82 44 10 18 15 18 
Physiotherapy clinics 82 12 25 16 42 63 13 15 90 27 35 77 83 
Academic unit 35 47 20 13 59 18 20 10 
 Nursing
 
    Occupational therapy
 
    Physiotherapy
 
    
  Used in teaching  Used for placements   Used in teaching  Used for placements   Used in teaching  Used for placements  
Local services Awarea Curriculumb Clinicalc Curriculum Clinical Exist Curriculum Clinical Curriculum Clinical Exist Curriculum Clinical Curriculum Clinical 
In-patient beds 95 18 26 89 93 95 52 59 95 94 100 35 39 83 91 
Out-patients 100 32 74 80 91 26 13 69 73 94 23 23 45 59 
Nurse clinics 57 19 33 42 54 39 12 23 36 10 12 
OT clinics 73 12 24 20 36 87 52 59 81 82 44 10 18 15 18 
Physiotherapy clinics 82 12 25 16 42 63 13 15 90 27 35 77 83 
Academic unit 35 47 20 13 59 18 20 10 

aCombined perceptions of curriculum organizers and clinical placement officers about the existence of local services.

bPerceptions of curriculum organizers.

cPerceptions of clinical placement officers.

Discussion

This first national survey of the rheumatological content of all nursing, OT and PT undergraduate courses did identify evidence of good training in some areas, particularly in physiotherapy, which provides reassurance that at least some major issues are being addressed across the curricula. However, the bulk of the findings show that rheumatological exposure is varied. Nursing courses are the most limited in terms of rheumatology exposure, and there is poor exposure to some of the key components of nursing, such as psychosocial issues and medication. However, OT students also have limitations in areas such as the opportunity to encounter joint protection techniques clinically. In contrast, undergraduate physiotherapy courses appear to cover a wider range of rheumatological issues. The courses for all the professions were limited in their exposure to cross-disciplinary roles and teaching, and often did not utilize local clinical experts for either teaching or placements.

Each profession draws on a unique set of skills; therefore, training should not be uniform as certain topics will naturally receive greater emphasis depending on their relevance to the individual profession. Thus whilst it is reasonable that OT and physiotherapy students receive little training in rheumatology medication, it is inappropriate that only 50% of nurses are offered good theoretical exposure in this area. In contrast, there are some generic topics relevant to all HPs, such as psychosocial issues and symptoms, including stiffness and fatigue, but even these were not addressed in depth by 30–50% of courses.

Data showed that although a wide range of teaching styles was used for OT and PT students, nursing students largely received formal lectures. This may be related to the larger numbers of student nurse intakes making small group work cumbersome.

The study was limited in that no information was requested on the use of interprofessional teaching, or the use of patients as teachers (but neither were these spontaneously mentioned by any respondent). Second, the study has examined the provision of rheumatological education for undergraduate HPs by surveying those responsible for designing and delivering the courses. However, teachers may not fully appreciate the overall experiences gained by their students; therefore, a further research project will use qualitative methods to explore the experiences and perceptions of nursing students about their rheumatological exposure. Third, whilst data were obtained from the majority of institutions offering undergraduate HP courses, it proved difficult to gain a precise picture of the current situation. Although there was overall consistency within the curriculum organizers’ responses and within the clinical placement officers’ responses, there were sometimes differences between the two respondents for an individual course, or about course content or clinical opportunities. This might reflect a general sense of uncertainty as to what is actually being delivered in the classroom or what experience is being offered in a clinical setting. Data may have been easier to collect in studies of medical student rheumatology training [9, 10] as there are relatively few courses, and rheumatology theory and clinical teaching is generally led by a single, clinical rheumatologist, who would have clear information on the theory and clinical experience offered to students during their attachments.

Medical student teaching is largely driven by specialist topics, using primarily clinical placements, which are based around speciality ‘firms’ that often include rheumatology and/or orthopaedic firms. HP training has evolved to depart from the traditional disease-based model towards a generic training with the emphasis on transferable skills, and respondents in this study estimated that less than a third of nurses and OTs are offered placements where they will encounter rheumatology patients. In medical training, course design, theory and clinical teaching are all carried out by practising clinicians, most of whom will not have formal teaching qualifications. In contrast, undergraduate HP training more often separates theory and practice: course design and theory teaching is largely in university settings, by HP educators who are usually qualified teachers but not practising clinicians; clinical placements are led by clinical HPs who have usually received at least basic training in teaching and assessing. The disease-based training of medical students led by clinicians is likely to enhance the ability of each speciality to enthuse the next generation of practitioners.

However, comparison with rheumatology teaching for medical students is not straightforward as there are several key differences. The number of medical students is far fewer, at perhaps 250–320 per year, compared for example, with nursing, where a faculty may accept 650 students a year. These large numbers have major consequences for the way in which theory teaching can be delivered, for the availability of sufficient areas for clinical placements and for the length of placements (frequent changes of large groups of students on wards is very disruptive). For example, a student nurse may have just two 20-week clinical placements during a year, whereas medical students may have four or five 8-week firm attachments, allowing them to encounter a much broader range of clinical experience. Finally, in medicine, the system of using clinicians as the prime source of teaching is often supported by official recognition of teaching sessions, whilst clinical HPs generally have no teaching time allocated within a job description, perhaps limiting their ability for closer involvement in teaching [17].

Many aspects of rheumatological care are more appropriate to postgraduate speciality training rather than undergraduate training; therefore, it would be helpful for clinical experts to agree a core set of knowledge and skills to be addressed during undergraduate training for each profession. Consensus on key undergraduate training elements has been achieved in other specialities (e.g. the neurology component of OT training) [18] and for specialist rheumatology staff at both entry and advanced level [11], which has led to the development of a national postgraduate diploma [19]. Key undergraduate elements could be developed for each profession, and the possibility of some common core subjects for the three professions explored. Such consensus should be developed by a collaboration of expert rheumatology clinicians in partnership with curriculum organizers and clinical placement staff, in order that the key elements will be appropriate, realistic and achievable. A broader view could also be gained by exploring rheumatology patients’ experiences of receiving care within both non-specialist wards and specialist rheumatology units. This might identify some important basic skills, such as making allowances in the hospital routine for early morning stiffness, or acknowledging the patient's expertise in managing their medication and symptoms.

If core skills for undergraduate training can be agreed, innovative ways of providing such core teaching or experience need to be developed to fit in with the time constraints of the curricula, the conflicting needs of other topics and the limitations in in-patient rheumatology facilities for clinical placements. These might be individual to each profession and also include some common interprofessional themes. Harnessing local opportunities and enthusiasm is likely to be crucial. For example, clinical experts could offer a teaching session, single day visits or short intensive placements nested within longer placements such as general medicine, and utilize out-patient clinics. Placement-based learning days or projects may make better use of scarce curriculum time, and greater use of ARC material could be valuable. It has been shown that introducing even brief teaching and clinical exposure to patients with disabilities or rheumatological conditions can change HP students’ skills and attitudes [20, 21]. The use of patients as teachers is a rapidly expanding field [22], as is the use of interprofessional teaching for core skills [23], and these may be cost- and time-effective ways of addressing some of the training gaps identified in this study, such as psychosocial issues and patient self-management.

The data show that there are HP courses where teaching and clinical placements provide good opportunities for rheumatology exposure, especially in physiotherapy. However, the findings suggest that provision is patchy and often deemed inadequate by the educators themselves. These shortcomings in rheumatology exposure for HPs (particularly nurses) may have implications not only for adequate rheumatology patient care in non-specialist areas, but also for attracting staff into the speciality, and the provision of training that reflects the role of HPs. The agreement of core undergraduate rheumatology knowledge, skills and attitudes, and the development of novel interventions to deliver these should be pursued jointly by clinical experts in rheumatology working with educationalists and clinical placement officers. Without national and cross-disciplinary agreement on core skills and realistic ways of delivering them, rheumatology teaching and exposure at undergraduate level is likely to remain limited or even to decline in future due to other increasing curricular pressures, such as a need to increase teaching in conditions targeted by National Service Frameworks. The findings of this study are a wake-up call to rheumatology clinical HP experts to drive this area forward and improve the training of undergraduates, which will both enlarge the pool of rheumatology specialist HPs and enhance rheumatology patient care throughout the health service.

graphic

S.H. and B.C. were principle investigators and C.A. managed the project. All authors contributed to the study design, analysis and interpretation, and commented on drafts of the paper. S.H. and C.A. controlled the decision to publish.

The authors would like to thank the Arthritis Research Campaign, UK, for funding the study, and the participants for responding to the survey.

The authors have declared no conflicts of interest.

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Author notes

Academic Rheumatology, University of Bristol, 1School of Adult Nursing, University of the West of England, Bristol, 2School of Health and Rehabilitation, Keele University, Keele, 3Rheumatology Unit, Derbyshire Royal Infirmary, Derby, 4Rheumatology Department, Haywood Hospital Stole on Trent and 5Rheumatology Unit, Newcastle upon Tyne, Freeman Hospital, UK.

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