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Please cite this article in press as: Cheung PP, et al. The learning curve of nurses for the assessment of swollen and tender joints inrheumatoid arthritis. Joint Bone Spine (2013), doi:10.1016/j.jbspin.2013.06.006
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Original article
The learning curve of nurses for the assessment of swollen and tender joints inrheumatoid arthritis
Peter P. Cheunga,b,!, Maxime Dougadosa, Vincent Andrec, Natalie Balandraudd,p, Gerard Chalese,Q1
Isabelle Chary-Valckenaere f , Emmanuelle Dernisc , Ghislaine Gill f , Melanie Gilsong , Sandrine Guisd,p ,Gael Mouterdeh, Stephane Pavyi, Francois Pouyol j, Thierry Marhadourk, Pascale Richette l,q,Adeline Ruyssen-Witrandm, Martin Soubriern, Minh Nyugena, Laure Gosseco
a Paris Descartes University, Medicine Faculty, UPRES-EA 4058, AP–HP, Rheumatology B, Cochin Hospital, Paris, Franceb Division of Rheumatology, National University Health System, Singaporec Centre hospitalier du Mans, Le Mans, Franced AP–HM, rhumatologie I, hôpital Sainte-Marguerite, 13009 Marseille, Francee CHR-hôpital Sud, Rennes, Francef CHU de Nancy, Nancy, Franceg CHU de Grenoble, hôpital Sud, Échirolles, Franceh Rheumatology Department, Lapeyronie Hospital, Montpellier-1 University, UMR 5535, Montpellier, Francei Hôpital Bicêtre, Paris, Francej Hôpital Roger-Salengro, CHU de Lille, Lille, Francek Hôpital de la Cavale-Blanche, Brest, Francel Pôle appareil locomoteur, fédération de rhumatologie, hôpital Lariboisière, AP–HP, 75010 Paris, Francem CHU de Toulouse, Toulouse, Francen Hôpital G.-Montpied, 63003 Clermont-Ferrand, Franceo UPMC University, Pitié-Salpetrière Hospital, Paris, Francep Aix-Marseille University, CRMBM UMR CNRS7339, 13385 Marseille, Franceq University Paris-Diderot, Sorbonne Paris-Cité, 75205 Paris, France
a r t i c l e i n f o
Article history:Accepted 20 June 2013Available online xxx
Keywords:NursesRheumatoid arthritisDAS28EducationClinical examination
a b s t r a c t
Objectives: In rheumatoid arthritis (RA), nurses are now increasingly involved in joint count assessmentbut training is not standardized. The aim was to evaluate and describe the learning curve of nurses forthe assessment of swollen and tender joints in RA.Method: Twenty nurses from university rheumatology centres inexperienced with joint counts wereallocated to a rheumatologist from their centre (teacher). Acquisition of skills consisted of Phase 1:(training), a centralized 4 hour training session, with (a) lecture and demonstration, and (b) practicalsessions on patients with their teachers, followed by Phase 2: (practice) involving further practice on 20patients in their own hospitals. Primary outcome was achievement of adequate swollen joint agreementbetween nurse and their teacher (“gold standard”) at the “joint” level defined by prevalence adjustedbiased adjusted kappa (PABAK) > 0.60. Agreement at the “patient” level of swollen joint count (SJC), ten-der joint count (TJC) as well as DAS28 between nurse and their teacher were assessed with intra-classcorrelation coefficients (ICC).Results: During the training phase, 75% of nurses achieved a swollen joint PABAK > 0.60 when comparedwith their teachers, which further improved to 89% after the 20 practice patients (Phase 2). Medianswollen 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 DAS28agreement remained excellent throughout.Conclusion: Nurses inexperienced in joint counts were able to achieve excellent agreement withtheir 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 skillsretention.
© 2013 Published by Elsevier Masson SAS on behalf of the Société Française de Rhumatologie.
! Corresponding author. Division of Rheumatology, National University HealthSystem, 1E Kent Ridge Road, Tower Block Level 10, Singapore 119228.
E-mail address: peter [email protected] (P.P. Cheung).
1297-319X/$ – see front matter © 2013 Published by Elsevier Masson SAS on behalf of the Société Française de Rhumatologie.doi:10.1016/j.jbspin.2013.06.006
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Please cite this article in press as: Cheung PP, et al. The learning curve of nurses for the assessment of swollen and tender joints inrheumatoid arthritis. Joint Bone Spine (2013), doi:10.1016/j.jbspin.2013.06.006
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1. Introduction
Rheumatoid arthritis (RA) is a chronic inflammatory diseasepredominantly affecting the joints with synovitis as the hallmark.Detection of synovitis with regular assessment of disease activityand tight control are the over-arching principles of treating-to-target, leading to reduced radiographic damage and disability[1,2].
One problem with RA is there is no one single clinical or lab-oratory measure that can measure disease activity effectively [3].However, joint counts (tender and swollen joints) are still regardedby most physicians as a feasible gold standard in clinical dis-ease activity assessment [4]. Its importance is highlighted in itsinclusion in the core data set of variables such as in clinical tri-als in RA [5] and common disease activity indices such as theoriginal disease activity score [6], modified disease activity scoreof 28 joints (DAS28) [7] and Simplified Disease Activity Index(SDAI) [8] for example, as well as various remission criteria [9–11].Although not all physicians perform joint counts, and there areother parameters such as patient global level of health and acutephase reactants, being able to assess for tender and swollen jointsremain an important core skill to acquire in clinical practice. Nursesand even more recently, patients themselves have also participatedin assessment of tender and swollen joints to assist the physi-cian in management of RA. It is therefore of interest that nurseswho are directly involved in the care of patients with RA are ableto learn how to perform joint counts and also able to teach oth-ers such as patients themselves to assess for tender and swollenjoints.
Nurses play an important part in the management of complexchronic illnesses such as RA, and act as the “interface” betweenpatients and other members of the multidisciplinary team [12–14].The European League Against Rheumatism (EULAR) working groupon the role of rheumatology nurses [13] recently highlighted thatnurses may be able to assist the physician in the comprehen-sive disease management of chronic inflammatory arthritis, suchas monitoring and control of disease activity, as well as patienteducation about disease activity and monitoring of RA related co-morbidities. In whatever level of responsibility the nurse wouldtake on, it would be useful for nurses to be proficient at jointexaminations [13] so that they will be better equipped to educatepatients regarding the importance of regular disease assessmentsand potentially self-assessment of joints in the future. To date therehas been no data on the training and learning curve of nurses to jointcount.
One problem associated with joint count assessment is thepotential inter-observer variation [15,17]. Inter-observer variationis present, even among clinicians, particularly in the assessmentof swollen joints [15–20]. Proper training or standardization mayreduce this variation [17–21]. Although it would be ideal for thesame rheumatologist to perform joint counts on the same patientto achieve treating-to-target, it would be potentially advantageousfor a clinic nurse in university based practices or even large com-bined private practices to assist with structured disease activityassessments between formal clinician consultations. In order toachieve this, it is important to obtain a satisfactory level of agree-ment between the rheumatologist and nurse in the assessmentof swollen and tender joints. However, it is unclear how manypractice patients are needed or which type of training is requiredin order for nurses to be considered proficient at assessing tenderand swollen joints. To date, there has been no formal evaluationof nurses on learning how to assess for disease activity in RA[13].
The objective of the present study was to evaluate and describethe learning curve of nurses to evaluate for swollen and tenderjoints with the rheumatologist as the “gold standard”.
2. Method
2.1. Participants
Nurses from Rheumatology university centres around Francewithout previous experience in joint count assessment wereinvited to participate, provided they had a teacher from theirrheumatology centre available for the entire study. The trainingsession was part of the initial preparation for the COMorbidi-ties and Education in Rheumatoid Arthritis, COMEDRA (COMEDRA,NCT01315652) trial, a multicentre randomized study involving 18rheumatology centres in France (Fig. S1; see the supplementarymaterial associated with this article online), evaluating the impactof nurse-led co-morbidity monitoring and impact of a nurse-lededucation program aimed at educating RA patients to self-assesstheir disease activity through performing a TJC and SJC followed bya calculation of their DAS28. In order to achieve this, it was neces-sary to teach and train nurses how to satisfactorily perform a tenderand swollen joint count, and subsequently calculate a DAS28 so thatthey can teach patients how to perform this.
2.2. Study design
The education of joint counts was divided into two parts: Phase1 (training) and Phase 2 (practice). The basic principles includedinitial information and objective dissemination, demonstration,practice and subsequently, consolidation of the learning with feed-back. To minimise inter-observer variation, the teacher was thesame rheumatologist in both Phase 1 and 2.
2.2.1. Phase 1 (training)Phase 1 consisted of a half-day training session in Paris, Jan-
uary 2011. Training objectives and format of the sessions andteaching was outlined to the participants and teachers the daybefore. Information on clinical examination was prepared basedon the EULAR handbook of disease assessments in RA [22] andwas distributed to the participants in booklet form, and in video(http://www.rhumatismes.net). Participants had the opportunityto go through the material prior to the training.
The format of the training session was as follows: participantsreceived a (i) 30 minute group demonstration on how to performjoint counts on a patient, and (ii) a 30 minute lecture on how toevaluate for tender and swollen joints and calculation of com-posite disease scores such as a DAS28. Due to the size of thegroup, half the participants started with the group demonstra-tion while half started with the lecture. After the first 30-minutelecture/demonstration, nurses were paired with a rheumatologistfrom their rheumatology centre who would be their teacher for theentire duration of the study. During the training day, the teachershad also participated in an agreement consensus exercise as cal-ibration [21]. In this section, rheumatologists were disseminatedwith material on joint counts based on the EULAR handbook ofassessments, followed by three rounds of small group consensusexercises, with the achievement of median swollen joint PABAK of0.71 (Q1:Q3, 0.57, 0.79). Nurse-teacher pairs, in small groups, thenwent through a series of six exercises examining RA patients withvarious levels of disease activity (Table S1; see the supplementarymaterial associated with this article online). Individually, each par-ticipant, blinded to other nurses and teachers, performed tenderand swollen joint assessment of 28 joints (two wrists, ten metacar-pophalangeal, ten proximal interphalangeal joints, two elbows, twoshoulders and two knees), followed by their teacher on a RA patientat each exercise. Results were recorded and not discussed untileveryone in the group had finished their examinations. Joints withdiscordant results were re-examined to reach a consensus, withparticular emphasis on swollen joints. Each exercise lasted for at
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least 30 minutes. After the 3rd exercise, a short break was then fol-lowed by the second lecture/demonstration. A total of six patientswere examined during the half-day session with each nurse havingup to 7 minutes to complete a full joint assessment due to the sizeof the groups.
2.2.2. Phase 2 (practice)Upon completion of Phase 1, nurses continued with the
“practice” of joint assessment (Phase 2). This was completed in theirown rheumatology centre on 20 consecutive patients. Nurses wereencouraged to commence Phase 2 as soon as possible so that skillsand knowledge could be consolidated. The same rheumatologistcontinued to act as the “gold standard” for the nurse. The nurseand the rheumatologist made a formal blinded tender and swollenjoint assessment on at least the first and final practice patient, andsometimes on the 10th patient as well. Results were discussed afterthe blinded assessments and technique of tender and swollen jointswere reviewed if necessary.
2.3. Primary outcome
The level of swollen joint agreement between the nurses andtheir teachers at the “joint” level was evaluated at the end of eachof the six exercises in Phase 1 as well as the first and last patientof Phase 2. The primary outcome was the proportion of partici-pants achieving an agreement with their teachers with a prevalentadjusted biased adjusted kappa (PABAK) > 0.60 by the end of theprogram.
2.4. Secondary outcome
Secondary outcomes included the level of agreement in tenderjoint at the “joint” level between nurse and teacher (PABAK), andagreement of SJC and TJC between nurse and teacher (ICC: intra-class correlation coefficient) as well as DAS28 (ICC).
2.5. Statistical analysis
Statistical analysis was carried out using SPSS version 20 (SPSS,Chicago, IL). Specific sample size was not calculated but sample wasbased on the sample size estimated for COMEDRA.
2.5.1. Agreement of swollen and tender jointAgreement at the “joint” level was compared using the PABAK.
PABAK is a statistic, which adjusts kappa for skew in the data andfor consistent rater bias [23]. The strength of agreement was asfollows: PABAK < 0 was poor, 0–0.2 was slight, 0.21–0.4 was fair,0.41–0.6 was moderate, 0.61–0.8 was substantial and 0.81–1 wasexcellent. To visualize the learning curve of nurses from beginningof Phase 1 to the end of Phase 2, box plots of PABAK were created.Median PABAK of swollen and tender joints was also calculated ateach assessment time-point with inter-quartile ranges.
2.5.2. Agreement of tender and swollen joint count and DAS28 atthe “patient” level
Comparison at the “patient” level was assessed by comparingthe reliability of TJC, SJC and DAS28 derived by the nurse comparedto their teachers, who were perceived as the “gold standard”. Thiswas evaluated using ICC (two way model, single measure) with 95%confidence intervals [24].
2.5.3. Sensitivity analysesAn exploratory sensitivity analysis was performed to evaluate
whether level of disease activity (i.e number of joints), experience
Nurses screened N=29
Nurses
Phase 1 training N=20
Nurses not randomly assigned N=9 Proficient in joint assessment
(n=5) Trainer from own centre
unavailable (n=4)
Phase 2 training N=20
N=9
N=9
Discontinued* N=1
Discontinued* N=1
Intensive n=10 Standard n=10
Fig. 1. Flow chart of participant allocation. *One nurse discontinued due to changeof job, the other did not complete due to structural re-organization of that particularrheumatology unit.
and age of the participants affected the level of agreement, in par-ticular swollen joints.
3. Results
3.1. Participant characteristics
All the 29 nurses from the COMEDRA trial were considered forthe study (Fig. 1), of which nine were not included: five were pro-ficient in joint count assessment and four did not have a teacheravailable for the entire study. In all, 20 participants were included.All of the participants completed Phase 1 (training). There were17 (81%) females with a median age of 46 years (Q1:Q3, 33.5:50),experienced with median of 18 years (Q1:Q3, 3.3:24.5) since qual-ification and 7 years (Q1:Q3, 1.5:15) of experience working in arheumatology unit. Twelve (57%) nurses had participated in a clini-cal study before. Subsequently, 18 out of 20 nurses completed Phase2 (practice) as illustrated in Fig. 1.
The interval from the initial “training” session (Phase 1) to com-mencement of the “practice” section (Phase 2) was median of 11days (Q1:Q3, 6:40) with a median time to completion of 33 days(Q1:Q3, 21:56).
3.2. Patient characteristics
There were 12 RA patients in Phase 1 with equal numbers ofmales and females. Median age was 62.6 years, with long mediandisease duration of 16 years. Patients had moderately active dis-ease with a median DAS28 of 3.63 (Q1:Q3, 2.62:4.31) with medianSJC of 4 (range 0–16) and median TJC of 1 (range 0–19). DuringPhase 2 (learning and practice section), patients had moderate dis-ease activity with median DAS28 3.73 (Q1:Q3, 3.32:4.93) and 3.53(Q1:Q3, 2.70:4.20) for the first and last practice patient respectively.
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Fig. 2. Learning curve of nurses – boxplot of PABAK between nurses and rheuma-tologist in swollen joints through training and practice phases. *Phase 1: lecture ordemonstration. "Start of Phase 2 practice patients. PABAK: patient adjusted biasedadjusted kappa.
3.3. Agreement of swollen and tender joint between nurse andrheumatologist at “joint” level
The learning curve of nurses is illustrated by median PABAKbetween the nurse and teacher in Fig. 2. Followed by the initiallecture/demonstration, the median PABAK at the end of Exercise 1was 0.64 (Q1:Q3, 0.57:0.86), which improved in Exercise 2. AfterExercise 3, where a further 30-minute lecture/demonstration wasgiven, the median PABAK made further improvements in Exercise4 and 5 reaching PABAK of 0.79 (Q1:Q3, 0.59:0.84), before a drop inmedian PABAK to 0.64 (Q1:Q3, 0.50:0.84) at the end of Exercise 6.During the practice patients in Phase 2, there were further improve-ments with nurses achieving a median swollen joint PABAKfrom 0.79 (Q1:Q3, 0.57:0.93) to 0.83 (Q1:Q3, 0.77:1) with theirteachers.
The proportion of nurses achieving a satisfactory level of agree-ment in swollen joint assessment over the training day (Fig. 3)illustrates that the proportion did increase from 60% up to 75% inPhase 1. Improvements in the proportion achieving an acceptableagreement continued to improve in Phase 2 and on the last practicepatient, 89% of the nurses were able to achieve a satisfactory levelof agreement (PABAK > 0.6).
For tender joints, agreement remained excellent with a medianPABAK between 0.82 and 0.96 throughout the study (Fig. 4).
Fig. 3. Learning curve of nurses – proportion (%) of nurses achieving PABAK > 0.6 inswollen joint agreement compared to teachers through training and practice phases.*Phase 1: lecture or demonstration. "Start of Phase 2 practice patients. PABAK:patient adjusted biased adjusted kappa.
Fig. 4. Learning curve of nurses – boxplot of PABAK between nurses and rheuma-tologist in tender joints through training and practice phases. *Phase 1: lecture ordemonstration. "Start of Phase 2 practice patients. PABAK: patient adjusted biasedadjusted kappa.
3.4. Agreement of tender joint count, swollen joint count andDAS28 at “patient” level
The reliability of TJC was excellent even at the start of trainingin Phase 1, ranging from ICC 0.85 to 0.94. This remained excellentin Phase 2 with ICC ranging from 0.86 to 0.91. On the other hand,the agreement of SJC at the “patient” level was variable throughoutthe training program ranging from ICC 0.40 to 0.71 during training(Phase 1) compared with ICC between 0.57 to 0.72 during practice(Phase 2). DAS28 ICC between nurses and rheumatologists wasexcellent even at the beginning of the training session with ICC0.89 (95%CI 0.75–0.95) and increased up to 0.97 (95%CI 0.92–0.99)at the end of the practice section in Phase 2 as illustrated in Table 1.
3.5. Sensitivity analysis
An exploratory sensitivity analysis showed that age, years afterqualification, rheumatology experience and level of disease activ-ity did not significantly affect the swollen joint agreement of nurseswith their rheumatologist at the start of training or at the comple-tion of the practice phase.
Table 1Agreement of the various measures of disease activity between nurses and theirteachers (rheumatologists) at the “patient” level.
Reliability of SJCICC (95%CI)
Reliability of TJCICC (95%CI)
Reliability of DAS28ICC (95%CI)
Phase 1Baseline 0.52
(0.13, 0.77)0.92(0.81, 0.97)
0.89(0.75, 0.95)
End 0.60(0.23, 0.81)
0.85(0.67, 0.94)
0.90(0.77, 0.96)
Phase 2Baseline 0.72
(0.40, 0.89)0.91(0.78, 0.97)
0.97(0.82, 0.99)
End 0.66(0.29, 0.86)
0.90(0.74, 0.98)
0.95(0.88, 0.98)
ICC: intra-class correlation coefficient; SJC: swollen joint count; TJC: tender jointcount; DAS28: Disease Activity Score of 28 joints.
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4. Discussion
In this study, a half-day training session was effective in improv-ing the ability of nurses to assess for swollen and tender jointswith a satisfactory level of agreement with their teachers. Swollenjoint agreement further improved after the additional practicepatients. Although reliability of SJC remained variable, reliability ofTJC and DAS28 was excellent, with the latter continuing to improvethroughout the training program. In addition, the proportion ofnurses achieving a swollen joint PABAK > 0.6 with their teacherimproved from 60% initially to 89% at the end.
This study has strengths and limitations. Limitations of the cur-rent study were as follows: the sample size was small and twoparticipants were unable to complete Phase 2 for reasons unrelatedto the study. As a result of the small sample size and the trial proto-col required in COMEDRA, there was no comparison with a controlgroup of nurses inexperienced in joint counts who had no trainingwith the current cohort and therefore needs further evaluation. Thetime interval from Phase 1 and 2 was varied largely because nursescame from rheumatology centres indifferent geographical regions,with varying levels of workload; even though commencement ofPhase 2 immediately after Phase 1 was recommended. Although itwas encouraged to select patients with at least moderate diseaseactivity during the practice phase, to overcome the potential of nothaving enough tender and swollen joints per patient, the primaryanalysis of agreement was made using PABAK at the “joint” level.
One strength but also potential limitation is the decision forthe rheumatologist to be the “gold standard” rather than ultra-sonography. This was because joint counts are more practical andfeasible than ultrasonography and most rheumatology centres areusing joint counts as regular structured disease activity assess-ments. In addition, a single rheumatologist was considered a valid“gold standard” as they had already undergone a consensus and cal-ibration exercise among the other teachers in the study. Althoughultrasonography would have determined the real ability of nursesto assess for true synovitis, the objective was for nurses to be pro-ficient, in particular in the assessment of swollen joints in order tobe calibrated with the rheumatologist who would likely be look-ing after the “same” patient. An extension of this evaluation forthe nurse and treating rheumatologist would be calibrating againstultrasonography, as the gold standard for true synovitis.
It is widely known that training and standardization hasthe potential to improve inter-observer variation in joint counts[17–21]. Grunke et al. conducted a large multicentre internationalstudy, which reported a reduction in variance of tender and swollenjoint counts after a training session consisting of a lecture followedby three supervised joint examinations [20]. In that study, partici-pants included a heterogeneous group of experienced metrologists(doctors, technicians and clinical trial nurses) participating in RAdrug trials. Our current study focused on evaluating the learningcurve for a homogenous group of rheumatology nurses inexperi-enced in joint assessment, at a national level that are not part ofclinical drug trials. The training involved a single teacher from theirown centre who had already undergone calibration through con-sensus and remained consistent from the initial training session tothe consolidation phase during the practice patients. This is doneto reflect clinical practice, as part of the objective is to have the“same” nurse-doctor pair to do repeated joint assessments in theirRA patients in clinic [25]. Continuation of standardized comparisonfrom training to practice with the rheumatologist enabled nurseparticipants to have a true continuous learning curve. The additionof the practice session phase was believed to be important in orderto assist nurses with consolidation of the learning as the intensenature of the exercises during Phase 1 (nurses often had 7 minutesto perform a 28 joint count) may not have provided enough timefor nurses to consolidate their learning during the training session.
Despite this, nurses were able to achieve good agreement afterthe half-day training session with their teachers, which furtherimproved after the practice patients. Therefore, it is important toevaluate this learning curve before nurses can effectively contributeto the participation of comprehensive disease management in RA.
From the study, it was apparent that calculation of DAS28 wasan easy skill to learn, largely because some of the componentssuch as TJC used to calculate the score were not as liable to inter-observer variation as the SJC. Since swollen joints are important forthe assessment of clinical synovitis, it is important that training befocused on refining this aspect. Swollen joint agreement requiredlonger practice, which was perceived to be easily obtainable inany rheumatology unit with nurse specialists involved in routinecare of patients. There was an improvement in Phase 1 in swollenjoint agreement with median PABAK up to 0.79 but reduction wasobserved after the last exercise, partly because participants andpatients were fatigued by the 6th exercise. It was apparent thatin the setting of their own hospitals, the additional practice of 20patients improved swollen joint agreement with median PABAK upto 0.83. This could be explained by consolidation of the knowledgein Phase 1 and also nurses were not stressed by the constraints oftime as compared to in Phase 1 where they had limited time tocomplete a joint count assessment.
An increasing body of research on clinical skills acquisitionshows that learning is more effective if there are well-definedobjectives sequenced coherently and takes place in the contextin which it is to be applied [26]. Observation and feedback byteachers, based on well-defined outcome measures and masteringof tasks by students through repetition are critical componentsof this approach, which have been incorporated to the design ofthe current study [26]. It would be important to see whether thenurses through time maintain this level of skill after the training.In addition, evaluation in its feasibility in daily clinical practicein a bigger sample of nurses will be required. Larger studies willbe also necessary to assess the level of intensity of feedback andtraining during the practice/consolidation phase. There is also alarge body of evidence that students learn from patient educatorsin developing skills from musculoskeletal exam, which shouldbe examined in the future [27]. In this study, patients chosenfor the training and practice were neither trained to teach nortrained at synovitis detection. The only formal interaction was toindicate whether the joints were painful on palpation. Hence, therheumatologist provided an important “point of reference” for thenurses. A large amount of improvement no doubt would be fromknowledge and skills acquisition and with consolidation of thisthrough practice and feedback.
In conclusion, a training day followed by additional practice of20 patients with the guidance of a rheumatologist was consideredsufficient for nurses to proficiently assess for tender and swollenjoints. Future challenges would be incorporation into rheumato-logy nurse training curriculums in respective countries.
Disclosure of interest
The authors declare that they have no conflicts of interest con-cerning this article.
Acknowledgements
We thank all the nurses that participated in the training study:Anne-Marie Appere, Missoum Bacha, Ghislaine Boitard, DominiqueBonischot, Marie-Helene Cerato, Laurent Chabrefy, Maeva Dieu,Francoise Fayet, Sylvie Goulloux, Rejane Gruel, Patricia Iemfre,Marie-Claude Metzinger, Sylvie Miconnet, Delphine Le Chauve,Audrey Le Goff, Dominique Perennou, Olivier Peyr, Rosemarie Poil-verd, Isabelle Polome, Emilie Rabois, and Marie-Laure Tanguy. In
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Please cite this article in press as: Cheung PP, et al. The learning curve of nurses for the assessment of swollen and tender joints inrheumatoid arthritis. Joint Bone Spine (2013), doi:10.1016/j.jbspin.2013.06.006
ARTICLE IN PRESSG ModelBONSOI 3890 1–6
6 P.P. Cheung et al. / Joint Bone Spine xxx (2013) xxx–xxx
addition, we thank Professor Lyn March for her comments andadvice in the preparation and data analysis of this manuscript.
We also thank Roche-Chugai France for financial support of theconsensus meeting and joint count didactic materials.
Appendix A. Supplementary data
Supplementary data (Fig. S1, Table S1) associatedwith this article can be found, in the online version, atdoi:10.1016/j.jbspin.2013.06.006.
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