World Osteoporosis Day interview with Fracture Liaison Service (FLS) Nurse Agnes Offenberg

Nurses play a central role in post-fracture care coordination programmes in their capacity as coordinators and as medical caregivers who interact closely with the patients to provide targeted post-fracture care and advice. Below, we present an interview with Agnes Offenberg, an experienced nurse practitioner at Zaans Medical Center, Zaandam, the Netherlands. Ms Offenberg has worked as a nurse practitioner and as a clinical nurse specialist since 2008, dedicating herself to the prevention of subsequent fractures in her patients. She is also a board member of the Dutch Professional Nurse Practitioner Organisation (V&VN VS), an IOF Capture the Fracture® mentor, and the Founder and Chair of the Endocrinology Nurse Specialists Network. She has valuable experience in first and second-line care and is currently working on setting up a transmural care path in the region. We thank Agnes for sharing her important insights!

From your point of view, what are the main challenges for osteoporosis management in the Netherlands?

One of the challenges we face in the Netherlands is connecting care and the care providers. I am thinking here in terms of the different disciplines, but also the different departments. The patient needs good continuity of care, which means that any implemented policy must also be continued outside the hospital. Patients repeatedly indicate that they feel alone and abandoned once the diagnosis is complete and the medical care ('the prescription') has started. I believe that patient care could be more integral/holistic. Although we know that having a chronic condition such as osteoporosis has a considerable impact on the patient's entire wellbeing, we offer patients little care that combines with bio-psycho-social aspects. 

In the Netherlands, we have been trying to create a nursing guideline for years, but it has proven difficult to meet the framework conditions. However, there is hope that we can start developing it soon despite the obstacles that keep appearing. Also, it would be my wish to facilitate connectivity between international nurses and nurse practitioners. It would be great if we could exchange knowledge and expertise across borders. This could give an enormous boost to the quality of care and stimulate and inspire nursing leadership in osteoporosis care. 

In the field of Value-Based Health Care, there are many opportunities to improve care, stimulate shared decision-making, and be cost-efficient. We need professionals to start working on this and to organise training on how to do so. Connections are also essential in this respect. With regards to our Fracture Liaison Service (FLS), we are now trying to put this into practice with the general practitioners. Ultimately, we hope to use a bundled payment to pay for care in the entire region. We will then be jointly responsible for the quality of osteoporosis care. I believe that the patients will benefit from this. 

What has not yet received much attention is how climate policy also affects our osteoporosis care. We should be talking about this together, at conferences and meetings. At the European level, there is policy talk of reducing the consumption of animal products, but what about our advice on calcium intake? Are we going to continue to promote dairy products? Or do we need to promote alternatives? Is there going to be research into evidence-based alternative advice?

Based on your experience, do you find that patients are well aware of their disease and the need to take treatment to prevent future fractures?

I notice that patients are not always aware of what osteoporosis is and what the consequences may be. There are also patients who are very afraid of (new) fractures. This is especially true for patients who have experienced very nasty fractures or whose parents had severe osteoporosis, or who know of someone else in their vicinity who did so. Such patients are extra driven to do everything to strengthen their bones and not fall. Other patients try to live very consciously and take good care of themselves, but lack certain knowledge, which leads to misunderstandings about medication. For example, they want to take care of their bones but refuse to take medical treatment. Every patient is different and has his or her own needs. That is what I like about my job, to find out what each specific patient needs and to provide the best possible tailor-made care.

Often, patients think that osteoporosis is not treatable - that you must accept the condition as a state of affairs and that it is bad luck. Patients are surprised when I tell them about the various treatment options. This certainly applies to patients who stopped treatment due to side effects without considering alternative treatments. This is a missed opportunity, and our FLS has the important task of communicating this fact to the patients.

It always gives me pleasure to educate patients about the skeleton and to see the amazement on their faces. Our skeleton is a beautiful and ingenious organ. When patients realise this, they are even more motivated to work for strong bones.

Why do you think Fracture Liaison Services can make a difference to the patient’s experience?

An FLS is a centre of expertise and knowledge in the field of osteoporosis care, at various levels, including in terms of care and treatment, as well as organisation and logistics. However, the FLS must not be an island or ivory tower, neither within the institution nor to the outside world. On the contrary, it must be easy for other professionals and stakeholders to interact with the FLS to facilitate good cooperation and share expertise. The patient must be able to experience that the entire patient journey is well organised.

Are there any special skills a Nurse should have to work in an FLS? Or can you share experiences of any challenges that need to be met daily in an FLS setting?

An FLS nurse should not be too shy to be an advocate for the patient and for the FLS itself. Experience has taught me that you must act like a pioneer and that you have to be persistent. When something doesn't work out the way you want it to, you have to find an alternative and not give up. You should also stay true to yourself. Ask yourself “what kind of healthcare provider do I want to be” and strive for that, even if you sometimes meet resistance.

What would you say is most important when it comes to collaboration within the multidisciplinary team?

It is very important to ensure that all disciplines remember you and your FLS, so that with every high-risk patient they think... hmm... should I refer this patient to the FLS? It is important to realise that every professional contributes to multifaceted care. All in all, care is better when all needs are met. The synergy, the exchange of knowledge, and the complementarity will improve the quality of care. It also creates opportunities to provide the right care in the right place, making care more efficient and more affordable.

And any further insights...?
The sense of urgency of a well-functioning FLS must always be felt. The continued work of the FLS needs to be supported. The hospital Board and management must realise the importance of the work done by the FLS staff, as do the healthcare policymakers. The FLS nurse should keep bringing the importance of the FLS into the spotlight, and World Osteoporosis Day is a good opportunity to do so. Give a presentation or an interview for a local newspaper or think of something playful. It helps!