Leading Lights - May 2019

While most nurses prefer to avoid the limelight, the ICN TB/MDR-TB project wants to recognise the work of some outstanding TB nurses who are role models and leaders in their field.

The ICN TB/MDR-TB Leading Lights initiative aims to showcase the work of exceptional nurses, trained by the ICN TB/MDR-TB project, who are making an outstanding contribution to TB prevention, care and management in their local facility and/or community.

The Leading Lights Award highlights the contribution of those involved with caring for people affected by any form of TB and shows the world what an impact effective training and resources can have on this global disease.

ICN invites all the ICN TB project partners to nominate nurses and allied health workers who have demonstrated excellence in their efforts to teach their colleagues about TB, improve patient care or make changes to reduce transmission of TB. The winners will be highlighted on the ICN’s TB Project webpages, and will be presented with a certificate and a special pin by their national nurses association.

Calls for nominations will be sent quarterly and people will be able to access the form on the ICN TB web pages here.

Inspiration for this award came from exceptional nurses like these:

Polina Volkova, Chief Nurse, TB Dispensary, Mariy El Republic (Russian Federation)

Polina Volkova graduated from nursing school in 1977 and received a degree in education and nursing management in 2003. Today she is the chief nurse of the Mariy El Republic TB Dispensary, the main clinic that provides treatment for a large population of patients with TB, and oversees the work of district TB facilities.

Polina has spent more than 32 years of her professional life working in TB. From the beginning she has been very active, uniting a strong group of nurses to initiate many positive changes in nursing practice and TB management in her hospital.

In 2002-2003 she conducted her first study to investigate the TB rate among staff in her facility, to understand the risks for staff of developing TB and then to implement changes to address the risks. Based on the results of her study, she was able to get the hospital administration to agree to invest in resources for infection control and the protection of staff. Thanks to her efforts, hospital staff were supplied with personal protective equipment, including respirators and protective clothing. In addition, sputum collection was organised in a separate room away from others to reduce the risk of transmission.

At the same time, Polina joined the Russian Nurses Association (RNA) regional branch in Mariy El Republic and started to organize conferences and other training events for nurses.

In 2007 she developed a project funded through the national grant support system for training activities for health workers, patients and family members, as well as the community. This project allowed her to establish a continuous patient teaching model – a patient school, which took the form of small sessions for three to five patients and a nurse, allocating enough time and opportunities for those affected by TB to communicate and ask questions.

Polina also took part in a research workshop supported by the ICN TB/MDR-TB Project and the RNA, and developed another study aimed at analysing different patient teaching approaches and their influence on adherence to treatment. This study was highly valued and Polina received some seed money to further improve patient training in her region.

Through the years, Polina became a recognised leader supporting patients’ rights. She focuses on all issues related to the patients, including the provision of TB drugs for continued therapy. Each year she develops activities for World TB Day: together with nurses in her area she produces materials to attract attention to the problem of TB, educate the community about the condition and encourage them to get tested for it. Even after 32 years working as a TB nurse, she still has many ideas on how to improve care and how to extend the nurses’ role. These ideas are important and her actions have been effective: since 2008, there have been no cases of occupational TB registered among nurses in the Mariy El Republic.

Molelekeng Rosemary Ralethoko, Registered Nurse Midwife, Quthing Government Hospital (Lesotho)

Ralethoko Rosemary is a registered Nurse Midwife trained in TB/MDR by ICN while working at Mohalinyane Health Center in 2016. She was later transferred to Quthing Government Hospital.

Rosemary is very passionate about providing quality care to patients and implementing positive changes to her practice. After the ICN training, she did step-down training to nurses, community village health workers, support groups, teachers, students, and church members. Her main goal was to teach them about the pathophysiology of TB, universal precautions, proper use of personal protective equipment, such as surgical masks, and proper use of isoniazid preventive therapy (IPT).

She managed to carry out this training with the assistance of the Mohales Hoek TB Coordinator, referring to all manuals and guidelines that were provided during the ICN training. Following the ICN TB/MDR-TB training, she identified health system- and patient-based gaps in TB service delivery.

Among the health system-based gaps, she found that healthcare workers were hesitant about providing health education talks in the outpatient department (OPD). There were no wellness services available for staff, which contributed to delays in healthcare workers being diagnosed with TB. Healthcare workers were not screening patients for TB at all entry points of the facility. Providers were not providing IPT to eligible patients. In addition, she also found that sputum samples were not properly labeled, there was a shortage of transport to take samples from the health centre to the lab, and the health centre could only send 10 samples per week, which caused delays in getting results.

To address these gaps, she developed an improvised health education exercise book to be completed by nurses to encourage them to provide health talks in the OPD. Rosemary advocated for screening of every patient at every entry point with proper documentation in the TB screening register. To improve relationships with the lab, she advocated for meetings between nurses and laboratory staff to improve labeling of sputum samples and to speed up the result turnaround time. She also collaborated with the Lesotho Nurses Association to establish a wellness corner in her facility to provide healthcare services to the staff in her facility.

Among the patient-based gaps, Rosemary identified that the majority of patient sputum samples were inadequate and mostly saliva. In addition, patients from remote areas failed to present sputum samples to health facilities, which contributed to a delay in diagnosis. To address these gaps, patients were taught how to provide a quality sputum sample, and she was able to secure funding to purchase a small refrigerator for storing sputum in the health centre between scheduled transport to the lab.

Through her efforts, more patients have been diagnosed with TB and started on treatment, and more eligible patients are now provided with IPT.

Wang Xiujun, Chief Nurse, Intensive Care Unit, Beijing Chest Hospital, Beijing (China)

Wang Xiujun is the Head Nurse of the Intensive Care Unit (ICU) at the Beijing Chest Hospital and has been a nurse for two decades. Wang was trained by her colleague, Nie Feifei (Leading Light awardee March 2016) who attended the ICN TB/MDR-TB Project training. This step-down training inspired Wang Xiujun to improve infection control in the ICU.

She made efforts to improve isolation measures for severe pulmonary TB patients on mechanical ventilation, including introducing closed sputum suction tubes and filters. She then promoted these infection control measures across the country.

Wang Xiujun has trained more than 1,000 nurses across China who are engaged in TB prevention and treatment. She developed quality patient-centred nursing services in her workplace and established a patient-centred service philosophy. She designed new, more comfortable hospital clothing for TB patients, and developed communication cards for ventilated patients to allow them to communicate more effectively.

To improve patients’ treatment adherence, she carried out health education about TB for patients and family members to encourage early detection and treatment.

Wang has lectured at the National Courses of New Progress in Tuberculosis Nursing and has published five articles on TB. She has presented at several national academic conferences and co-authored four books on TB nursing. She is a member of the Intensive Care Committee of the Chinese Nursing Association and has carried out scientific research and teaching on the subject, and she has shared her nursing experience in caring for patients with severe TB.

Through her efforts, Wang has made outstanding contributions in the area of infection control. As a result, the treatment success rate of critical TB patients in her hospital is higher than the national average.

Gibson C. Kabombo, Nurse, Mbayamusuma Health Centre, Southern Province (Zambia)

After attending the ICN TB/MDR-TB training in April 2016 Gibson Kabombo realised that in his catchment area many patients were diagnosed with drug- resistant TB (DR-TB) or had the condition in the past and had relapsed. He developed a health education plan for patients, community leaders, family members and household contacts, and he also developed a training plan for community health workers and TB treatment supporters. He trained more than 100 nurses, community health workers, treatment supporters, and clinical officers.

Gibson now provides health talks for patients while they are waiting to be seen in clinics. These focus on the importance of being screened for TB, especially if someone has a cough, the importance of adherence to treatment, and patient support from families and community members. He also trained community health workers and TB treatment supporters on proper sputum collection and the importance of adherence to TB treatment, which has resulted in improved adherence to treatment.

Since the training, he has placed TB registers in all departments, with help from the local district. Now his health centre screens patients in each department and collects sputum from all patients with signs and symptoms of TB. Through his efforts, the TB notification rate in his area increased through improved sputum collection and the introduction of GeneXpert. He also improved infection control in the health centre.

After the training, Gibson found it easier to work with TB patients and the patients feel more able to discuss anything with him. He always talks about TB in the community, and his supervisor and colleagues are happy to work with him and are more interested in TB management.

Gibson reported that the ICN TB/MDR-TB training materials assisted him in making changes to knowledge and practice in his setting.

Tatiana Chirkova, Chief Nurse, Leninsk-Kuznetskiy Branch of Prokopievsk TB Dispensary, Kemerovo Region (Russian Federation)

Tatiana Chirkova became a midwife in 1991. She has worked in TB for 23 years and in 2006 she received an advanced nursing degree. Tatiana started as a district nurse, and today is a chief nurse of a TB dispensary and head of the TB nurse network in Kemerovo, one of the largest and highest TB burden regions of Russia.

Tatiana has always focused on safety and infection control. She has been successful in providing her staff with necessary safety tools, such as respirators, and has established ongoing training for nursing assistants on infection control. Due to her efforts, since 2008 no cases of occupational TB were registered at her clinic.

She took part in a ‘training the trainer’ course and extended her activities to cover health workers in general hospitals and outpatient clinics: they are important colleagues who can assist in early detection of TB cases and initiate them on treatment.

Tatiana attended multiple training activities in Saint Petersburg and Tomsk, and became passionate about ensuring that patients have the social support they need to help them adhere to treatment. Many patients lose their jobs due to the length of treatment and have low incomes, which can affect their motivation to adhere to treatment. Tatiana established patient training programmes, led by nurses, to improve patient knowledge about TB and treatment adherence. If a patient has difficult social circumstances, nurses try to help each patient and organise activities to connect the patient to the appropriate social services.

Tatiana prepares informational materials for World TB Day every year to improve patient teaching skills, and goes out to general clinics to inform nurses and patients about the risks of TB, and the importance of early diagnosis. Her ultimate goal is to make Kemerovo free from TB.

He Ke, Head Nurse, TB department and TB Research Institute, Eighth Medical Center of PLA General Hospital, Beijing (China)

He Ke has been engaged in TB clinical nursing and management for 28 years. She received training from her colleague Sheng Li (Leading Light awardee March 2018) who attended the ICN TB/MDR-TB training in 2011.

To improve TB treatment, the treatment of MDR-TB and patient adherence, He Ke provides innovative TB care services to patients. She led a care team in her department to carry out TB health education, which included knowledge about TB, general wellness, mental health and disease prevention and control, using lectures, interactive sessions and brochures. So far, 117 sessions have been carried out, and 5,815 patients and their families have participated in the training. In 2015, He Ke created an online social network with her colleagues called “Xin You Qian Qian knot” to provide health education about diagnosis and treatment to TB patients, family members and treatment supporters. It has more than 2,000 followers and has improved the management of TB patients, and the hospital ‘lost to follow-up’ rate has fallen to 7%.

He Ke’s nursing team also started providing telephone follow-up calls and support for patients after discharge. This has greatly enhanced the awareness of TB patients, improved their treatment adherence, and increased their autonomy and self-efficacy. The patient satisfaction rate has reached 99.8% and 100% of patients receive health education.

He Ke has held seven training sessions for 153 respiratory specialists in the army, mainly about TB care. She has led ten training sessions for 2,553 nurses and 18 sessions for 4,539 interns. These sessions have contributed to increased knowledge among healthcare workers on the prevention and control of TB, improvements in care, and increases in the capacity of healthcare workers to prevent and control of TB. On World TB Day, she taught TB prevention and treatment in schools and in the local community. He Ke conducted seven lectures, distributed 5,272 TB prevention and control pamphlets, and provided information about TB to 4,665 people.

He Ke has published 15 papers, co-authored three books, and holds patents for seven inventions.

Abdirahman Ahmed Muse, Head Nurse, Internal Medicine (TB and medical wards) Sultan Hassen Yabare Referral Hospital, Jijiga, Somali Region (Ethiopia)

Following the ICN training in 2016, Abdirahman arranged with his hospital management for permission to train other healthcare workers in his hospital. There was no financial support, but he trained 130 medical students and other healthcare workers in his hospital. With the help of the hospital management Abdirahman established an Infection Prevention and Patient Safety Committee in his hospital following the training. He reported that at the time of the training the rate of TB in the staff was high and there was a need to prevent transmission of TB in the hospital. He provided health education to healthcare workers and patients, and he educated patients on how to produce and collect sputum. This was significant because, before attending the ICN training, he and his colleagues just gave the patients the sputum bottles without any education: the sputum rejection rate was high as they were often only collecting saliva. Now there is a designated area for sputum collection and the quality of the sputum has improved. He provided training on TB screening and sputum collection for health extension workers in 20 health posts. All of this has resulted in more patients being diagnosed and treated.

Abdirahman says there are several challenges in his hospital. There is stigma attached to working in TB and most staff do not want TB training as they think if they are trained, they will be made to work in the TB clinic or ward. The lack of protective equipment (N95 respirators) – the staff do have some masks, but not enough and have to make them last seven days - means staff refuse to work in the TB clinic/ward. Abdirahman suggests that TB nursing should be recognised as a specialty area to attract more nurses to work in the field.