A validated Clinical Practice Guideline for Community Health Nurse Working in Tuberculosis Out-patient Clinics

Tuberculosis is a major contributor to disease burden in developing countries; it is considered the second fatal disease all over the world and the third most important public health problem in Egypt. The direct causes of increasing the burden of tuberculosis are the inconsistent and fragmented health services. The nursing interventions of tuberculosis in community settings require system of recommendation that ensures the consistency of care. The present study aimed at providing a valid clinical guideline that assist nurses to intervene consistently to the newly diagnosed pulmonary tuberculosis patient. The needs analysis of community health nurses working in out patient chest clinics in addition to the expectation of newly diagnosed pulmonary tuberculosis patient regarding nursing interventions. The guideline development process established according to the criteria of experts of guideline development organizations. The Scottish Intercollegiate Guidelines Network (Sign) research appraisal tools were used for the critical appraisal phase of the obtained evidence. AGREE instrument was used for assessing the internal validity of the guideline. The guideline and apprised for internal validity by academic nursing and medical staff, nursing, and medical practitioners. The scores of all appraisers in relation to scope and Purpose, stakeholder involvement, rigour of development ranged from (62.9-77.7%, 53.5-77.7%, and 66.6-76.2%), respectively. While the scores for the clarity and presentation were 5076.4, applicability were 61.968.5, and editorial independence were 8893. The four groups of revision strongly recommended the application of the guideline.


INTRODUCTION
Tuberculosis (TB) is among the top 10 causes of death in the world.TB is an important public health problem in the Eastern Mediterranean Region of the World Health Organization.Every year the disease kills 136 000 people and, affects 630 000 in that region (1) Tuberculosis is a major contributor to the disease burden in developing countries (2)   .It is considered the third most important public health problem in Egypt (3) .The global plan to stop tuberculosis recommended the sustainability and accessibility of the standardized short-course chemotherapy for all cases of tuberculosis (4) .The directly observed treatment strategy (DOTS) is required to ensure treatment adherence and it helps to reinforce patients' motivation to continue treatment (5) .
The main reasons for the increase of the global burden of TB are the following: inadequate health services, improper management practices resulting in poor case detection, diagnosis and treatment, demographic changes: increasing world population, changing age structure, and impact of the HIV as a pandemic disease (6) Treatment failure is a serious problem for tuberculosis control program in many countries.In Egypt, it accounts for 3%-5% of treatment outcome of new smear positive cases (7) .Treatment failure may occur due to poor compliance of the patient or to practitioner errors, irregularity and loss to follow-up (8) resulted from the fragmentation and inconsistency of the provided services.
Also poor quality of care results from routines and inadequate provider-patient relations, all contribute to poor treatment (9) .
Nurses play a crucial role in tuberculosis control program.The International Council of Nursing (ICN)   believes that nurses are in a position to advocate for strong tuberculosis control programs and to implement the elements of DOTS (10) .Nurses are a vital component in the control, treatment, and cure of tuberculosis.Most treatment nowadays is carried out in the community settings.Treatment is best supervised by nurses in regular contact with the patient.
The nurse who can best assure that each patient successfully complete treatment, the main principle of nursing intervention is the integrated organization of multiple activities to achieve specific outcomes for patients (11) The nursing intervention requires a system of recommendation that improving performance and support the quality of health services.This system of recommendation can be obtained through developing clinical guidelines that are defined as "systematically developed statements to assist practitioner and patient decision about appropriate health care for specific clinical circumstances. (12)inical practice guidelines are important tools used by interdisciplinary health care providers to specify? and standardize the processes of care for specific patient populations with defined health related conditions.They result from a synthesis of available scientific knowledge as well as expert consensus.

Regarding tuberculosis clinical
guideline it calls the attention to the under recognized health problems of tuberculosis patients as well as discourages the ineffective interventions to reduce the morbidity and mortality rates (15) .The present study has been accomplished to validate a clinical guideline that aim at improving nursing intervention and health out come of newly diagnosed pulmonary tuberculosis patients.

Operational definitions
Newly diagnosed patient: A patient who has never had treatment for TB or who has taken anti-tuberculosis drugs for less than four weeks (16) .

Internal validity of clinical guideline:
Appropriateness of the guideline to be published and ready for application ( 17) .nurse should be a link between patient and physician (Table 3).

Phase II: Developing guideline
The guideline was developed according to the criteria of the American Evaluation of evidence and grading guidelines recommendations was conducted on the following steps:

1-Study Validity Rating
All primary studies and reviews addressing the relevant topic were appraised using SIGN checklist that appropriate to the study design, and then were individually rated for internal validity using the following system (17) .available evidence was weak or absent.
So the recommendations in this situation were made based on the clinical experience and judgment of the experts.

Formulation of Guidelines Drafts
A draft of tuberculosis guideline including pathway of tuberculosis patient in chest clinics algorithm was drawn up.
The overall belief was that guidelines development and refinement is an evolutionary process.The guidelines development group met 16 times over a seven month period and the guidelines were redrafted three times before the final agreed format was ready for appraisal on the study clinics.

5-Guidelines Revision and Evaluation of internal validation
Drafts of the developed guidelines were circulated to the experts for revision before its publication.Academic and clinical experts to measure the content validity, reliability, and its applicability of the final guidelines recommendations and format by utilizing "Agree Instrument" (19) The number of appraisers according to the Agree instrument should not be less than two and preferably exceed up to four appraisers to ensure the appraisal reliability (19).The Guideline was appraised by six academic nursing and medical staff members as well as 6 practitioner nurses and 7 practitioner physicians who are working in out-patient chest clinics.

Minimum and maximum scores for dominos and appraisers
The standardized domain score will be:

Statistical analysis:
Simple frequency tables were used to illustrate the obtained data.

Recommendation: Assess the present and past health history
On the basis of four case control studies (graded level 2++) (23,(31)(32)(33) and one standard of care (28) , in addition to one guideline (graded level 4) (32) , it is emphasized that knowledge and believes of the patient regarding tuberculosis affect his compliance to treatment.

Recommendation: Obtain information about patient's knowledge and perception about tuberculosis
On the basis of one cohort study (graded level) 2++ (36) and two guidelines (graded level 4) (27,30) , it is indicted that the nurse should monitor and follow the conduction of diagnostic measures, namely: chest X-ray, tuberculin skin test, and three sputum specimens.

Recommendation: Ensure that patient complete the required diagnostic measures
On the basis of one expert opinion (3) and four guidelines (graded level 4) (27,28,32,37) , the contacts should be assessed for tuberculosis infection within maximum of 15 days.

Nursing diagnosis:
On the basis of two guidelines (graded level 4) (10,31) , the recognition of health needs and problems of patients is important base for nursing interventions.
Furthermore, clear understanding of patients' situation is a key for objective intervention.

Recommendation: Identify the patient's health needs and problems
On the basis of three guidelines (graded level 4) (31)(32)37) , it is recommended that contact assessment is evidence of active case finding.

Recommendation: Identify the contacts' health needs and problems
Nursing care plan: On the basis of three guidelines (graded level 4) (10,28,31)

Health education
According to one cohort study (graded level 2++) and three guidelines (graded level 4) (5,10,32) , it is revealed that health education is an important part of
Other cohort study (graded level 2++) (24) revealed that uncontrolled blood sugar interfere with the effect of antituberculosis medication.

Recommendation: Monitor the patient health condition monthly
Recommendation: Check blood sugar level for patient with co-morbid diabetes mellitus On the basis of one guideline (graded level 4) (31,39,41) , if the patient disappointed one visit, the health care worker should conduct a home visit to him for ensuring treatment continuity.

Recommendation: Report the social workers about the patient who dropped out an appointment of treatment or follow-up
Recommendation: Ensure that social workers conduct a home visit for the dropped out patient or conduct it by herself (according to policy)

Documentation and reporting:
On the basis of two guidelines (graded level 4) (28,31) they concluded that all patient information regarding progress, intervention, visits schedule, and obstacles should be recorded accurately and clearly in special formats and reported to the assigned health care providers.In addition to one systematic review (graded level 4) (42) , it emphasized the confidentiality of patient's information.
The present guideline demonstrates which will increase its applicability process in the future. (37)e present guideline based on different types of studies, namely: cohort studies, systematic review, case-control, cross sectional studies, and guidelines.
In further phase, the feedback should be obtained from members and practitioners regarding the guideline's effectiveness, and then the degree of guideline adherence and its clinical impact should be evaluated.This further phase is strongly recommended for the present guideline to be implemented in the future.

RECOMMENDATIONS
work was accomplished during the period from February 2006 up to April 2008, through out two phases: the first phase included needs assessment of tuberculosis patients and nurses working at chest out patient clinics.The second phase included the developing of the intended clinical guideline for nurses working at chest out patient clinics, which is based on the results of the first phase.

Patients:
A convenient sample of 36 patients all admitted newly diagnosed patients was included from the six chest out patient clinics during the period from 1 st March to the end of June 2006.Each out patient clinic was visited twice/month with a total 8 visits for each clinic.The expectations of newly diagnosed tuberculosis patients about nursing intervention were obtained from patients through short interactive interview.Patients recommended that the role of nurses must be unique and clear.Patients mentioned that they require for proper communications, accurate time of medication, continuous follow-up, and

[
Obtained scoreminimum possible score/Maximum possible score - weekly visit during the complementary four months to receive a day observed dose and take the dose for the rest of the week Recommendation: The nurse should provide motivation and incentives to increase the treatment compliance effective control program that has a good cure rate.The health education should include patient, contacts and care providers.It must address all aspects of disease, treatment regimen, side effect of medication, healthy behavior, and social relationship.Health education targeted to correction of patient's perception.
the overall assessment of the guideline, two-thirds of academic nursing and medical staff strongly recommended the guideline for use in practice and the majority of practitioner nurses as well as three quadrants of practitioner physicians recommended the guideline for use in practice.
several strength points; firstly, it elicits patient perspectives during the guideline development process, secondly, the guideline was evaluated by the intended users (nurses) and their work partners (physicians) who are working in chest outpatient clinics.Most of them mentioned that the guideline is effective, recommendation stated clearly, and could be easily implemented by nurses and they are in need for such guideline.Finally the guideline attached with supportive tools which will facilitate the nursing interventions.In addition, the guideline formulated within the scope of the WHO guideline for National program, on the needs of the intended users of nurses and end points beneficiaries, i.e., patients.It was strongly recommended by the reviewers and stockholders to be used in the outpatients chest clinics.It is recommended that the guideline should disseminate to the authoritative level to be applied in the chest out patient clinics and evaluated for applicability and achieved outcomes.