Inter-observer variation in paediatric clinical signs between different grades of staff examining children admitted to hospital in Tanzania

Abstract

Children are often admitted to district hospitals in Africa without an adequate record of clinical examination, a problem that could be reduced by greater involvement of nurses in their assessment. We aimed to ascertain whether hospital nurses in a district hospital could conduct paediatric examinations as reliably as clinical staff, when provided with a short structured training session. Hospital nurses (HN), hospital clinical officers (HCO) and research clinical officers (RCO) repeated examinations on children admitted to the paediatric ward shortly after the first examination by an RCO. Kappa scores were used to compare the agreement on the presence or absence of basic clinical signs by different categories of staff. Among 439 paired examinations the agreement between RCOs on clinical signs was slightly higher than for HCOs or HNs; the mean (median) Kappa scores for all signs examined were 0.54 (0.57) for RCO-RCO, 0.49 (0.49) for RCO-HCO and 0.50 (0.49) for RCO-HN. Levels of agreement were lower if children were under the age of 18 months or if they cried during the examination. Nurses with basic training appear to perform as well as clinically trained staff in eliciting essential signs in acutely ill children. Their role in the initial and ongoing assessment of these children should be reviewed in light of the critical shortages in clinically trained staff in African hospitals.