Tuberculosis Management -some Aspects of the Role of the Nurse Manager

OPSOMMING Tuberkulosebeheer skep 'n uitdaging vir die verpleegadministrateur se bestuursvermoë. Weens haar deeglike kennis van die gemeenskap is sy 'n ideale lid van die tuberkulosebeheerspan. Eerstens moet streeksomstandighede soos demografiese, maatskaplike en omgewingsfaktore wat die verspreiding van tuberkulose in 'n spesifieke streek bevorder, bepaal word. Die beskikbaarheid van personeel, voorrade, vervoer en fondse moet ook vasgestel word. Hierdie inligting word gebruik om 'n probleemstelling te formuleer. Die opstel van 'n aksieplan behels interpretasie van beleid, prioriteits-en doelwitbepaling. Prioriteite word deels van die probleemstelling afgelei en deels deur nasionale beleid voorgeskryf. Nasionale prioriteite vir tuberkulosebeheer sluit in motivering, gevalopsporing, buitepasiëntebehandeling en primêre voorkoming deur BCG-inenting. Die verpleegadministrateur het verantwoordelikhede ten opsigte van die uitvoer van die aksieplan, finansiële beheer en die evaluering van die resultate aan die hand van die doelwitte wat gestel is.


BACKGROUND
E vidence suggests that the rapid spread of tuberculosis began in the early 1920s w hen the gold and diam ond m ines w ere established.In the late 1940s w hen th e first two tuberculosis drugs becam e available it was the doctor who prescribed and adm inis tered trea tm e n t to th e patients.A l though public health nurses w ere p re sent in the field at this stage, they w ere few and far betw een and could not con tribute much tow ards tuberculosis m an agem ent.
D uring the mid 1950s the doctor screened and prescribed the treatm ent for the patients in the rural areas.A t this stage the public health nurse becam e m ore actively involved in the treatm en t and m anagem ent of tu bercu losis by assisting with screening tests and the adm inistration of treatm ent as prescribed by the doctor.
The num ber of doctors at the func tional level of tuberculosis m anagem ent started decreasing during the 1960s and by the m id-seventies a shortage of doc tors w orking in th e field was experi enced.This shortage has rem ained until today.A t the sam e tim e, how ever, the num ber of public health nurses and o th er nursing categories in the field was increasing and their attention to tu b e r culosis intensified.
In N ovem ber 1979 the D epartm ent of H ealth, W elfare and Pensions in tro duced a N ational Tuberculosis Policy S tatem ent and shortly th ereafter a N a tio n a l T u b e r c u lo s is T r e a tm e n t Policy.T hese policy statem ents were p repared in consultation with leading internatio nal tuberculosis specialists.
W hen w ritten policy is actively im ple m ented it assists the nurse in establish ing her role in th e com m unity.Policy statem ents, to g eth er with procedure m anuals and jo b descriptions, are es sential to define th e com m unity health n u rse's practice and to legitimise her role.T he tuberculosis policies allow the com m unity h ealth nurse to develop her in d e p e n d e n t p r o fe s s io n a l f u n c tio n .They also pose a challenge for h er plan ning, supervision, adm inistration and general m an ag em en t skills.

TUBERCULOSIS MANAGEMENT BY THE NURSE
A b road outline of a supervisory com m unity health n u rse's role in a health region regarding tuberculosis m anage m ent is given and only the m ajor as pects highlighted.

ASSESSMENT
T he supervisory com m unity health nurse assesses th e regional conditions by taking into consideration the physi cal, social, psychological and environ m ental factors th a t predispose the p a rti cular com m unity to tuberculosis.H er intim ate know ledge of the area will greatly assist h er in this task.D ata is collected from records and through co n sultation, interview s and observation.T he type of d ata req u ired for tu b ercu lo sis m anagem ent could include the fol lowing:

Regional conditions
-population statistics; -a brief analysis o f the dem ography of the area; -com m unication facilities (postal ser vice, telep h o n e etc); -occupational conditions (type of m ines, factories etc); -socio-econom ic conditions (incom e, housing, san itatio n etc); -trad itio n al rites an d beliefs; -n u tritional status; -educational status; -im m unisation status;

Regional assets
-availability of m anpow er; -availability of stocks and equipm ent; -availability of tran sp o rt; -actual allocation of funds for the ser vice.
T he d ata collected should not be the supervisory com m unity health nurse's own in te rp retatio n of the tuberculosis situation in h er region and to avoid sub jectivity the d ata is checked to ensure th at the inform ation is factual and accu rate.
Problem s are identified and grouped as being eith er actual o r p oten tial.A w ritten analysis o f th e problem s is com piled from th e base-line inform ation.D etail in the p ro b lem statem en t is necessary to en su re th a t a c o m p re h en sive action plan will be devised.

Planning
T he planning p hase involves in te rp re ta tion of policy, d eterm in in g priorities, setting o bjectives as well as selecting and recording an action plan.T he p ro tocol for planning a tuberculosis service is in a b ro ad sense laid dow n in the N ational T uberculosis Policy, as the n ational p rio rities regarding tu b e rc u lo sis m o tivation, intensified case finding, supervised tre a tm e n t and prim ary p ro tection have b een d eterm in e d .
T he supervisory com m unity health nurse now has to apply these priorities to her region w hile tak ing into account the data collected and th e w ritten p ro blem statem en t.
O n a national basis tuberculosis m oti vation is o f th e highest priority and therefore high risk areas are identified, the financial allocation is exam ined and the priority areas for appointing o r in creasing tuberculosis m otivators are de term ined.
The case-finding priorities are as fol lows: -bacteriological case-finding by cul tu re of th e sputum ; -bacteriological case-finding by m icroscopic exam ination of the sputum in cases w h ere th e re is little doubt on clinical exam ination th a t the p atien t is suffering from tu b e rc u losis; -radiological case-finding by selective X-ray cam paigns only w here they can be p reced ed by intensive tu b e r culosis ed ucation and m otivation program m es; -case-finding via contacts of positive cases and via contacts of positive tu berculin reactors.In consultation w ith the supervisory medical officer th e com m unity health nurse d eterm ines w hich case-finding m ethod w ould be th e m ost feasible and successful in each identified priority area.A p articular m ethod may not be com patible w ith local conditions in a given area due to , for exam ple, lack of tran sp ort, p o o r road conditions, lack of com m unication facilities.
The priorities w ith regard to tre a t m ent are to en courage supervised am bulatory/dom iciliary trea tm e n t for the m ajority of p atien ts in th e R epublic and to hospitalise only those cases w ho are too ill for o u t-p atien t tre a tm e n t, who are domiciled w here no out-p atien t treatm ent facilities exist and w ho re quest hospitalisation.T he four national trea tm e n t regim es are studied and the costs involved in each established.T he d ata collected for assessm ent purposes is of infinite value in planning the type of trea tm e n t to be used.U sing this data th e following are ascertained: -the num ber of p atients to be treated on an ou t-p atien t basis for one fi nancial year; -the n um b er of patien ts to be hospi talised during one financial year; -which trea tm e n t schedules are to be used in an o u t-p atien t service and to w hat extent.U n d er the item of prim ary p ro tec tion, the policy introduces a four-dose B C G regim en to b e ad m inistered percutaneously to th e following: -all new -borns; -at th ree m onths of age; -all school-beginners; -all school-leavers.
T he supervisory com m unity health nurse determ ines th e b irth -rate, the num ber o f first atten d an ces at childhealth clinics, th e n u m b er o f school-be ginners and school-leavers, th e financial im plications, th e am o u n t o f B C G vac cine and vaccinating ap p aratu s to be o r dered and the am o u n t to be distributed to the various service points.
Priorities with regard to training of nursing personnel in the various aspects of tuberculosis m anag em en t are also d e term ined and th en classified eith er as inform al staff d evelopm ent education or as form al continuing education, taking into account th e financial im pli cations of each.
T he next phase th a t th e nurse-m anager deals w ith is th e setting of o b jec tives.A n objective is a clearly defined statem ent of a desired result th a t has to be achieved by a set d ate.T he objective should m easure o u tp u t and not input, in o th e r w ords, it refers to the end result and not to the activities.If the o b jec tives are clearly fo rm u lated in term s of outputs and su p p o rted with an action plan, it keeps the nurse m an ag er's at tention focused on th e m a tte r th at counts -the en d result.E xam ples of objectives th a t have b een set are: Tuberculosis motivation: th a t within a given financial year 30 % of a tu b e r culosis m otiv ato r's co n tact group will actively respond and rep o rt at a service point.

Tuberculosis
case-finding: that w ithin a given financial year th e ratio of positive to negative sputum results will increase by 15 % (indicating effective, selective case-finding program m es.) Tuberculosis treatment: that in a given financial y ear th e n u m b er of patients on supervised am bulatory/dom iciliary tre a tm e n t will increase by 15 % .
Primary protection: that in a given fi nancial year the num ber of children who have been actively im m unised with BC G vaccine will increase by 2 % (the low percentage increase is due to the fact th at 80 % of the children in this area are already effectively vaccinated with B C G and the 2 % increase is the estim ated population increase for one year).
In o rd er to get the organisation to w o rk , th e s u p e rv is o ry c o m m u n ity health nurse m ust gear the nursing staff into action.This is achieved by com pil ing an action plan which is defined as being a w ritten statem en t o f the key activities to be perform ed to achieve the set objectives.Only w hen each stated objective is accom panied by the key activities necessary to ensure its achieve m ent is the planning process com plete.T he initial plan of action can be m odi fied as m ore facts, indicating oth er courses of action, becom e available.T h erefo re the m anagem ent team regu larly reviews and m odifies the plan.

Implementation
T he action plan is usually p u t into p rac tice in th e field by nursing team m em bers and th e tuberculosis p atien t.Today the p a tie n t's family and the com m unity are becom ing increasingly involved in initiating the im plem entation of the action plan, for exam ple by a voluntary request for treatm en t or for inform ation ab o u t tuberculosis or by assisting in supervised treatm en t.T h ere are various ways in which the action plan may be im plem ented and the m anagem ent team ensures th at the key activities can be carried out with the available re sources.Im plem entation of the action plan is m ade easier for the nursing team by providing standardised form s and records, good teaching m aterial and flow charts.Exam ples of flow charts that simplify some aspects of the leng thy N ational Tuberculosis Policy state m ents can be seen in: Figure 1: B acteriological investigations to be done on new cases.Figure 2: Bacteriological investigations to be done on old cases (re lapse or re-infection).Figure 3: Investigations and follow-up to be carried out for patients that default.

Evaluation
The supervisory com m unity health nurse to g eth er with the m edical officer, the pharm acist and the adm inistrative officer (the tuberculosis m anagem ent team ) evaluates or m easures th e effec tiveness of the action plan on a m onthly basis.
T he criteria for m easuring effective ness have been set out in the objectives.All relevent inform ation is collected from the authorities and clinics in the field and com pared with the objectives.The team then decides w hether th e o b jectives will be achieved, partially achieved o r not achieved.T he problem s that have been found are investigated and the action necessary to alleviate them is decided upon.T he very im por tant aspect of controlling the quality of nursing care is carried out in the same m anner provided an objective has been set to determ ine this.If not, quality is controlled by form al individual evalua tion.
Financial control is carried out by the assessm ent of a variety of com puterised p rint-outs.P rojections are m ade to as certain the expected expenditure by the end of a given financial year for each authority ren d erin g a tuberculosis ser vice in th e region.A ny over-expendi ture or un d er-ex p en d itu re is investi gated and co rrected to ensure th at the allocated funds are n ot exceeded.The m anagem ent team also m akes provision to curb over-ex p en d itu re resulting from practices such as overclaim ing on subsi dies and hoarding of m edicines and vac cines.
Statistical d ata regarding the ep i dem iological tren d s of the various types of tuberculosis are m onitored and eva luated regularly.A change in the tren d m ay necessitate a revision of th e action plan and/or the objectives.
T he com m unity h ealth nurse is the ideal person to becom e a m em b er of the tuberculosis m anagem ent team because she has developed an excellent sense of responsibility by being th e key m em ber concerned with th e h ealth o f th e com m unity in a specific geographical area.She has the ability to analyse and react to health p roblem s, to fo ster team -spirit and to stim ulate enthusiasm am ong collegues.H er experience in planning and arranging program m es in h er area is in valuable.T h e fu tu re tuberculosis nurse m anager needs th e skills, abilities and experience of th e com m unity health nurse.