Cheung Peter P, Dougados Maxime, Andre Vincent, Balandraud Nathalie, Chalès Gérard, Chary-Valckenaere Isabelle, Dernis Emmanuelle, Gill Ghislaine, Gilson Melanie, Guis Sandrine, Mouterde Gael, Pavy Stephan, Pouyol Francois, Marhadour Thierry, Richette Pascal, Ruyssen-Witrand Adeline, Soubrier Martin, Nguyen Minh, Gossec Laure
Paris Descartes University, Medicine Faculty, UPRES-EA 4058, AP-HP, Rheumatology B, Cochin Hospital, Paris, France; Division of Rheumatology, National University Health System, Singapore.
Paris Descartes University, Medicine Faculty, UPRES-EA 4058, AP-HP, Rheumatology B, Cochin Hospital, Paris, France.
Joint Bone Spine. 2014 Mar;81(2):154-9. doi: 10.1016/j.jbspin.2013.06.006. Epub 2013 Aug 6.
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.
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).
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.
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.
在类风湿关节炎（RA）中，护士现在越来越多地参与关节计数评估，但培训并不标准化。目的是评估和描述护士在RA中评估肿胀和压痛关节的学习曲线。
从大学风湿病中心挑选20名没有关节计数经验的护士，分配给他们中心的一名风湿病专家（教师）。技能习得包括第1阶段：（培训），一次为期4小时的集中培训课程，包括（a）讲座和示范，以及（b）与教师一起对患者进行实践课程，随后是第2阶段：（实践），在他们自己的医院对20名患者进行进一步实践。主要结果是护士与其教师之间在由患病率调整偏倚调整kappa（PABAK）>0.60定义的“关节”水平上达成充分的肿胀关节一致性（“金标准”）。使用组内相关系数（ICC）评估护士与其教师之间在肿胀关节计数（SJC）、压痛关节计数（TJC）以及DAS28的“患者”水平上的一致性。
在培训阶段，75%的护士与教师相比肿胀关节PABAK>0.60，在20例实践患者（第2阶段）后这一比例进一步提高到89%。到第2阶段结束时，肿胀关节PABAK中位数从0.64（四分位间距1：四分位间距3为0.55，0.86）提高到0.83（四分位间距1：四分位间距3为0.77，1）。在“患者”水平上，SJC一致性总体保持稳定（ICC为0.52至0.66），而TJC和DAS28一致性始终保持良好。
在关节计数方面缺乏经验的护士能够通过短期培训在压痛和肿胀关节评估中与教师达成良好的一致性；实践进一步提高了这种一致性。需要进行更大规模的纵向研究来评估技能保持情况。
