The learning curve of nurses for the assessment of swollen and tender joints in rheumatoid arthritis.
OBJECTIVE
In rheumatoid arthritis (RA), nurses are now increasingly involved in joint count assessment but training is not standardized. The aim was to evaluate and describe the learning curve of nurses for the assessment of swollen and tender joints in RA.


METHODS
Twenty nurses from university rheumatology centres inexperienced with joint counts were allocated to a rheumatologist from their centre (teacher). Acquisition of skills consisted of Phase 1: (training), a centralized 4hour training session, with (a) lecture and demonstration, and (b) practical sessions on patients with their teachers, followed by Phase 2: (practice) involving further practice on 20 patients in their own hospitals. Primary outcome was achievement of adequate swollen joint agreement between nurse and their teacher ("gold standard") at the "joint" level defined by prevalence adjusted biased adjusted kappa (PABAK)>0.60. Agreement at the "patient" level of swollen joint count (SJC), tender joint count (TJC) as well as DAS28 between nurse and their teacher were assessed with intra-class correlation coefficients (ICC).


RESULTS
During the training phase, 75% of nurses achieved a swollen joint PABAK>0.60 when compared with their teachers, which further improved to 89% after the 20 practice patients (Phase 2). Median swollen joint PABAK improved from 0.64 (Q1:Q3 0.55,0.86) to 0.83 (Q1:Q3 0.77,1) by the end of Phase 2. At the "patient" level, SJC agreement remained globally stable (ICC, 0.52 to 0.66), while TJC and DAS28 agreement remained excellent throughout.


CONCLUSIONS
Nurses inexperienced in joint counts were able to achieve excellent agreement with their teachers in assessment of tender and swollen joints through a short training session; practice further enhanced this agreement. Larger longitudinal studies are required to assess skills retention.
Paris Descartes University, Medicine Faculty, UPRES-EA 4058, AP-HP, Rheumatology B, Cochin Hospital, Paris, France; Division of Rheumatology, National University Health System, Singapore. Electronic address: peter_cheung@nuhs.edu.sg.
Peter P
PP
Cheung
Paris Descartes University, Medicine Faculty, UPRES-EA 4058, AP-HP, Rheumatology B, Cochin Hospital, Paris, France.
Maxime
M
Dougados
Centre hospitalier du Mans, Le Mans, France.
Vincent
V
Andre
AP-HM, rhumatologie I, hôpital Sainte-Marguerite, 13009 Marseille, France.
Nathalie
N
Balandraud
CHU-hôpital Sud, Rennes, France.
Gérard
G
Chalès
CHU de Nancy, Nancy, France.
Isabelle
I
Chary-Valckenaere
Centre hospitalier du Mans, Le Mans, France.
Emmanuelle
E
Dernis
CHU de Nancy, Nancy, France.
Ghislaine
G
Gill
Department of rheumatology, University Hospital of Grenoble, Echirolles, France.
Melanie
M
Gilson
AP-HM, rhumatologie I, hôpital Sainte-Marguerite, 13009 Marseille, France; Aix-Marseille University, CRMBM UMR CNRS7339, 13385 Marseille, France.
Sandrine
S
Guis
Rheumatology Department, Lapeyronie Hospital, Montpellier-1 University, UMR 5535, Montpellier, France.
Gael
G
Mouterde
Hôpitaux universitaires Paris Sud, Le Kremlin Bicêtre, France.
Stephan
S
Pavy
Hôpital Roger-Salengro, CHU de Lille, Lille, France.
Francois
F
Pouyol
Hôpital de la Cavale-Blanche, Brest, France.
Thierry
T
Marhadour
Pôle appareil locomoteur, fédération de rhumatologie, hôpital Lariboisière, AP-HP, 75010 Paris, France; University Paris-Diderot, Sorbonne Paris-Cité, 75205 Paris, France.
Pascal
P
Richette
UMR 1027 Inserm, Université Paul Sabatier Toulouse III, centre de rhumatologie Hôpital Purpan, CHU de Toulouse, Toulouse, France.
Adeline
A
Ruyssen-Witrand
Department of Rheumatology, CHU de Clermont-Ferrand, Clermont-Ferrand, France.
Martin
M
Soubrier
Paris Descartes University, Medicine Faculty, UPRES-EA 4058, AP-HP, Rheumatology B, Cochin Hospital, Paris, France.
Minh
M
Nguyen
Paris Descartes University, Medicine Faculty, UPRES-EA 4058, AP-HP, Rheumatology B, Cochin Hospital, Paris, France; UPMC University, Pitié-Salpetrière Hospital, Paris, France.
Laure
L
Gossec
D001172:Arthritis, Rheumatoid / Q000175:diagnosis* / Q000451:nursing; D002983:Clinical Competence; D005260:Female; D006801:Humans; D007596:Joints; D059032:Learning Curve; D008297:Male; D008875:Middle Aged; D010808:Physical Examination
Clinical examination; DAS28; Education; Nurses; Rheumatoid arthritis