NURSING APPROACH TO THE CONTROL OF TUBERCULOSIS: SCIENTIFIC PUBLICATIONS (2002-2011)

As a disease of chronic evolution, Tuberculosis (TB ) requires more health care professionals, especial ly nursing staff, to encourage the patient not to aban don the treatment and achieve a cure. Thus, this st udy aimed to describe the state of the art of scientifi c publications regarding the approach that is given to nursing aids regarding TB control. The literature s earch was performed on the database of the Virtual Health Library, The Lilacs, indexed with the follow ing descriptors: tuberculosis, nursing, nursing car e, nursing services and nursing team. We established t following inclusion criteria: Papers published i n Brazil between 2002 and 2011. Selected articles wer e s parated into three categories: “daily practice of nursing care or planning for TB control”, “research and teaching in nursing” and “biosafety”. We selec ted twenty-four articles which met the criteria of the study. It was observed that there was an increase i n the number of publications since 2005, with 70.9% of ar ticles published in specific nursing journals; 54.2 % dealt with actions related to the daily practice of nursi ng n TB control, 37, 5% were related to the occupa tion l hazard caused by the direct care of patients with T B and just over 8% were related to the teaching and research of the disease for nurses. These findings highlight the interest in understanding the role of nursing care for patients with TB, raising relevant issues with resp ect to knowledge and skills of these professionals to fulfill their task, including concern about the risk of dis ease, since they are so exposed to the disease they become part of the care plan for the patient and also to t he family of which this patient belongs.


INTRODUCTION
According to the WHO (2012), Brazil is one of the 22 countries with the highest Burden of Tuberculosis (TB) in the world, occupying 20th place in this ranking. Also according to WHO documents for 2009 data, TB incidence was 43 cases/100 000 population, the mortality rate was 2.6/100,000 population, with a detection rate of 88% and cure rate of 72%.
Being considered a disease of chronic evolution and with a stigma and prejudice still related to TB patients, the disease requires from health services and especially from health professionals, a great responsibility towards assuring patients' adherence to treatment and not endangering their own and the populations' lives with an increasing chance of contamination between contacts (Monroe et al., 2008;Villa et al., 2008).
Faced with the complexity of the problem, nurses as well as nursing assistants become essential for patient and family encouragement in coping with the disease Montenegro et al., 2009). The link between nursing staff and TB patient becomes as important as the drug intake, thus promoting the implementation of an individual and collective care plan,

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involving the trust that the patient and the patient's family lay in such professionals (Brunello et al., 2009). Therefore, understanding the importance of nursing care performance for TB patients and their involvement in health services planning for efficiency in providing care, this study aimed to identify the state of art in scientific articles published over the past nine years in Brazil and which approach is given to nurses in TB control. Thus, we seek to understand the role of nursing to fight this disease, in both prevention and cure.

MATERIALS AND METHODS
State of the art consists of a bibliographical study whose main challenge maps and discusses what is being produced on some aspects and dimensions related to a thematic (Ferreira, 2002).
The scientific literature search was conducted in April 2012, in the LILACS website (http://lilacs.bvsalud.org/), the most important index of scientific and technical literature of Latin America and the Caribbean. We used the following terms indexed in the Brazilian health subject headings thesaurus (DECS-http://decs.bvs.br/I/homepagei.htm): tuberculosis, nursing, nursing care, nursing services and nursing team in the database.
We established the following inclusion criteria for the study: • Be classified as scientific articles, thus excluding documents, manuals or thesis • Held in Brazil • Published between 2002-2011 We excluded publications classified as editorials, letters to the editor and re-publications of articles with historical analysis.
To refine the search, we opted for some combination of terms, as shown in Table 1.
A database was built in Excel with the 55 publications. Articles that were found more than once by the combination of terms were eliminated and 24 articles remained for reading, which were classified according to the following categories: • Year of publication • Journal in which it was published • Study Subject Items categorized were:

Daily practice or Planning in Nursing Care for TB Control
Articles dealing with nursing care in health services, whether hospital-based or primary care-based; directly concerned with practices carried out by nursing staff with patients for TB control whether in case identification, disease control, supervision of contacts or drug intake.

Research and Teaching in Nursing
Articles related to research and education for TB control involving nursing professionals or nursing students.

Biosafety
Articles dealing with the vulnerability of nursing professionals and students in acquiring TB infection in the workplace.
The content analysis to produce the categorization of articles was based solely on an exhaustive reading of the works selected for the study. Due to the design of the study, there was no need for authorization from the Ethics Committee of the institution.

RESULTS
The publications involving TB and nursing have been increasing since the year 2005, maintaining an average of three articles published per year in Brazil in the studied period ( Table 2).

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PB, Brazil, in view of decentralization of disease control. Of the 24 articles selected for analysis in this study, 70.9% were published in journals in the area of nursing (41.7%), public health (16.7%) and pulmonology (12.5%). The remaining articles (29.1%) were published in journals covering various themes, from medicine in general to occupational and mental health ( Table 3).

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Regarding to the study objective, most articles (54.2%) approached nursing actions for TB control and daily practice and planning in nursing care, which involves the day-to-day assistance for TB patients and their families in health services, from diagnosis through to treatment. Other articles (37.5%) addressed the concern with the occupational health of nursing professionals and students related to TB infection when exposed to the patients, showing the concern with the biosafety of these professionals ( Table 3). The theme of teaching and research in nursing was the least discussed (8.3%) among the studies analyzed, showing that this objective is still rarely covered in research conducted in Brazil. It is noteworthy that in 58.3% of the papers, nursing was not even mentioned in the title, nor in the study objective, showing that in most studies, nursing is discussed throughout the text by mentioning practical aspects of nursing care for TB patients and families.

DISCUSSION
The link between nursing practice and control of TB has a long history relating to the policies of disease control in Brazil (Baptista et al., 2006;Almeida-Filho et al., 2009), where nurses have autonomy in test ordering and also in starting treatment to fight the illness.
In 1998, Directly Observed Therapy (DOT) began to be implemented in Brazil in order to reduce drop-out of the treatment, improve cure rates and increase case identification (BMH, 2002). Thus, this may explain the number of articles published over the past nine years. The nursing staff became one of the main links between patient and health service, acting directly for adherence to treatment (Brunello et al., 2009), which may also suggest that the increase in studies related to the theme could be an attempt to evaluate and analyze the new policies established in Brazil after DOT.

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Once it had become a field of interest to nursing practices in health services, because the nurse and nursing staff in most cases are primarily responsible for TB case monitoring and supervision of drugs intake (Gabriel et al., 2005;Reiners et al., 2008), we noted that most of the articles were published in journals specific to the nursing area, followed by journals in public health, justified by social and living determinants of TB (Brunello et al., 2011;Vendramini et al., 2006;. The categorization of articles reflects the responsibilities involving the care provided to patients with TB case detection, through daily practice of nursing in health services and care planning for TB assistance. Studies selected for analysis in this study showed that nursing staff need to have innovative and efficient tools for patients and their families for early diagnosis (Castro et al., 2011;Silva at al., 2011), as well as effective strategies for monitoring TB treatment (Maciel et al., 2010;Rodrigues et al., 2008).
As well as addressing the day-to-day practices of direct nursing care to patients, families and vulnerable groups, we highlight the need for nurses in previous care planning, identifying the vulnerable groups for TB disease within the community and then perform active case identification Melo and Campinas, 2010;Nobrega et al., 2010), to increase case detection rates among the population.
Another aspect raised among the studies analyzed, was the training of nursing professionals to promote awareness of TB transmission and prevention, in addition to the organizational problems of health services with human resources. We also identified discussions about addressing active case identification in the community and strengthening professional-patient interaction in areas of high health care professional turnover (Muniz et al., 2005;Bertazone et al., 2005;Rodrigues et al., 2008;Clementino and Miranda, 2010).
A significant portion of the selected studies showed the fear of scholars with the possibility of nursing students and professionals in acquiring TB during their profession (Avelar et al., 2006;Souza and Bertolozzi, 2007;Prado et al., 2008;Coelho et al., 2009;Sousa et al., 2011). Thus, discussions about the occupational risk of developing active TB is a frequent concern, raising questions about time of exposure and contact with TB patients, tuberculin skin testing among nursing students (Moreira et al., 2007), as well as the use of safety equipment (Lorenzi and Oliveira, 2008). Additionally, a study conducted in Brazil in 2008 (Lorenzi and Oliveira 2008) outlined some indicators concluding that the risk of developing active TB is higher among nurses, because they are in longer contact with patients.
The worksheet offered on TB for nurses' formation (Villa et al., 2006) and nursing students' knowledge of TB (Malveira et al., 2002) was the approach found in two articles selected for the study. We can see the concern with the wrong knowledge about TB transmission that nursing students still have, as well as the little time that is dedicated to teaching and practice in the area. This shows a deficit in health education and prevention of this disease among future health professionals, leading to barriers in identifying cases, since some students leave education unprepared to take over the management of similar TB cases (Malveira et al., 2002;Villa et al., 2006).
Though only two articles with a teaching and research approach were selected, according to Villa (2008), nursing has contributed significantly to research in the TB field, especially in operational studies, which allows the generation of new knowledge of the social and political determinants surrounding the disease.
It shows superficiality in the studies as regards to the control of TB, since research abides to more technical knowledge aspects in the field of nursing, which may explain the low number of outputs connected to TB research and teaching as well, with little or no involvement of nursing in the political and managerial programs of disease control in Brazil.

CONCLUSION
The results of this study indicate that there is a greater concern about the practices and performance of nursing professionals who deal directly with TB patients in health services, showing that nursing is recognized as an important element in disease control. Therefore, the planning of care from detection to treatment of the case is most often up to the professionals.
The selected articles show the interest in understanding the role of nursing care for TB patients, raising relevant issues of professionals' knowledge and skills to fulfill their task and includes concern about infection risks, since the professionals are so exposed to Mycobacterium tuberculosis that they are actually part of the care plan to which the patient belongs.
Thus, it is essential for the continued interest of scholars, in the context of nursing professionals and in addressing more often the issues facing the teaching and research of TB in nursing training, practice and research.