ICNP ® terminology subset for people with tuberculosis

Objectives: to develop an ICNP® terminology subset to care for people with tuberculosis. Methods: a methodological research that followed the following steps: identification and validation of empirical indicators of altered needs relevant to people with tuberculosis based on literature; cross-mapping of the empirical indicators of altered needs identified with ICNP® 2017 terms; construction of nursing diagnoses/outcomes and interventions; assessment of relevance of nursing diagnoses /outcomes and interventions and ICNP® terminology subset structuring. Results: an ICNP® terminology subset was developed to care for people with tuberculosis with 51 diagnoses/outcomes and 264 nursing interventions, assessed by nurses from Primary Health Care and structured according to Wanda Horta’s Theory of Basic Human Needs. Final Considerations: the subset is a technological instrument through which it is possible to identify the elements of nursing practice from the affected human needs.


INTRODUCTION
Tuberculosis (TB), even nowadays, leads thousands of individuals to get sick and die, remaining a public health concern worldwide (1) . According to the World Health Organization, 10.4 million people worldwide are infected with TB, of whom 1.7 million died in 2017 (2) . In Brazil, there were more than 72 thousand cases and 4.5 thousand deaths in 2018 (3) . It is observed that TB remains with significant numbers of cases, even though it is a curable disease and free treatment in Brazil.
For early identification and timely treatment by nurses, updated knowledge, educational interventions with a psychosocial focus, an approach with a psychological and social perspective beyond the biological point of view and using scientific instruments are needed (4)(5) . The International Classification for Nursing Practice (ICNP ® ) terminology subsets are instruments used to identify diagnoses and establishment of outcomes and appropriate nursing interventions, aimed at a specific group of clients (6) . The ICNP ® is a standardized terminology that represents the elements of nursing practice worldwide. Its structure is composed of a Seven-Axis Model, which allows organizing nursing diagnosis, outcome and intervention statements, promoting a proper nursing process application (7) .
To build and structure a subset, one must be guided by a theory of nursing or other domains (8)(9) . Thus, understanding that the needs of people with TB go through the psychobiological, psychosocial and psychospiritual needs, the present study used Wanda Horta's Theory of Basic Human Needs to support the subset, as it proposes that nursing should assist people in meeting their basic needs in order to make it independent of this assistance by teaching selfcare (10) , respecting their individuality, assisting in their recovery, encouraging their autonomy and returning to their daily activities.
There are some terminology subsets registered with the International Nurses Council (INC) such as hypertension, mental health, dementia in community care, community nursing, disaster nursing, critical care, family process, pediatric pain management and treatment adherence (6,9) . However, a subset aimed at people with TB was not found, despite being considered a priority area for developing subsets by INC.

OBJECTIVES
To develop an ICNP ® terminology subset to care for people with tuberculosis.

Ethical aspects
The study was approved by the Research Ethics Committee of the Health Sciences Center of Universidade Federal do Espírito Santo.

Theoretical-methodological framework
The ICNP ® terminology subset structuring was guided by the theoretical model of Basic Human Needs of Wanda de Aguiar Horta, following the development model of Nobrega and collaborators' terminology (9)(10) .

Type of study and target audience
This is a methodological study referring to the development of an ICNP ® terminology subset, which followed COREQ (Consolidated Criteria for Reporting Qualitative Research) in research organization.
The subset's target audience is nurses and nursing students.

Study setting
The study was carried out at Graduate Program in Nursing and at Epidemiology Laboratory (LABEPI -Laboratório de Epidemiologia).

Work steps
1) Identification and validation of terms related to relevant altered needs for people with TB based on literature.
To develop the first step, a systematic literature search was carried out in order to identify altered needs of people with TB relevant to professional practice. The review was guided by the following guiding question: which empirical indicators of altered needs of people with TB are relevant to nursing practice? The articles were extracted from the Virtual Health Library: Latin American and Caribbean Literature in Health Sciences (LILACS) and Medical Literature Analysis and Retrieval System Online (MEDLINE) databases using the Health Science Descriptors (DeCS) "Tuberculosis" and "Nursing" through the Boolean operator AND.
Articles with abstracts available in the databases, in Portuguese, English or Spanish and published between 2009 and 2018 were included. Papers presented at congresses, dissertations, monographs, theses, letters to the editor, reflection studies and articles on other topics or on TB unrelated to nursing were excluded.
Thus, 119 articles were found in LILACS and 123 in MEDLINE, whose titles and abstracts were read by two researchers and the inclusion and exclusion criteria were applied; with disagreement, it was decided by consensus, reaching the selection of 24 articles. After reading the articles, all excerpts that presented altered needs were highlighted through the identification of stressful, conscious or unconscious conditions resulting from hemodynamic imbalances fundamental to life and that can affect human beings' balance (10) .
After extracting the empirical indicators of altered needs of people with TB, they were decomposed into simple terms (e.g., noun, verb) or compound terms (e.g., adverbial phrases, verbal phrases, compound nouns) and organized in alphabetical order in Excel spreadsheets. These terms were submitted to validation by two specialist nurses: the first nurse had twenty years of experience in assisting people with TB and held a PhD in TB; the second had five years of experience assisting people with TB and specializing in Family Health Strategy. The specialists were asked to select the terms that represented the empirical indicators of altered needs in their practice in caring for people with TB. In this step, the criteria were considered: Agree: yes or no. Disagreements were sorted out through consensus.
of ICNP® terminology subset for people with tuberculosis Silva LPZ, Primo CC, Prado TN.
In this step, a manual spreadsheet cross-mapping of all terms extracted in the first step with ICNP ® 2017 Seven-Axis Model terms was carried out (11) . Constant and non-constant terms were identified, organized in alphabetical order, excluding synonyms and repetitions. Then, the terms not included in the ICNP ® Seven-Axis Model were submitted to analysis for similarity and comprehensiveness following the criteria, which establish: if an ICNP ® term is similar to the identified term, i.e., when it does not have the same spelling, but the meaning is the same; if a term is more comprehensive, when it has a greater meaning than the existing term in the ICNP ® ; if the term is more restricted, when it has less meaning than the present in the ICNP ® ; and, finally, if there is no agreement, when the term is totally different from the term in the ICNP ® (9) . This step resulted in a bank of nursing language terms related to caring for people with TB, which was used to construct nursing diagnosis, outcome and intervention statements following the recommendations of INC (8) and ISO 18.104: 2014 -Informatics in Health: categorical structures for the representation of nursing diagnoses and nursing actions in terminology systems (11)(12) .
3) Construction of nursing diagnosis/outcome and intervention statements.
In this step, the construction of the statements of nursing diagnoses, outcomes and interventions was carried out in accordance with the INC recommendations. For each diagnosis, a Focus axis term and a Judgment axis term were used, and other terms could be added depending on the need and specificity of Judgment, Client, Location, and Time axes. For each Intervention, an Action axis term and a Target term were used, considered as a term of any of the axes, except Judgment (9) . It was also considered the ISO 18.104: 2014 -Health Informatics: categorical structures for the representation of nursing diagnoses and nursing actions in terminology systems, in which a nursing diagnosis can consist of a single Focus term along axis at the end of Judgment axis or a clinical finding (11) .
The constructed nursing diagnoses/outcomes and interventions were typed in a spreadsheet, in alphabetical order and compared with the concepts contained in the ICNP ® 2017 (11) through manual cross-mapping, resulting in constant and non-constant sentences. The non-constant statements were submitted to analysis for similarity and comprehensiveness in relation to the pre-combined terms contained in the ICNP ® 2017, following the criteria previously described (9) . This process resulted in a list of nursing diagnoses, outcomes and interventions related to people with TB. 4) Assessment of relevance of nursing diagnosis, outcome and intervention statements by nurses who care for people with TB in Primary Health Care.
The nursing diagnoses, outcomes and interventions constructed in the previous step were submitted to assessment of relevance, by consensus, by nurses.
Primary Health Care nurses in a city in the Southeast Region of Brazil, who had experience in caring for people with TB, who had more than five years of graduation, with a minimum degree of specialist, were invited to participate in a small and homogeneous group. Nurses were contacted via invitation letter, which explained the research and indicated a time and place for the meeting, if they agreed to participate.
At the beginning of the meeting, guidance was given regarding research, Wanda Horta's Theory of Basic Human Needs, and ICNP ® . The judges read the material and filled out the instrument for assessing the relevance of the subset's nursing diagnoses, outcomes and interventions. Then, only the items where there was disagreement were discussed and, by consensus, decisions were made to remain, remove or rewrite a statement. The meeting was audio recorded for later analysis, lasting one and a half hours.
After the meeting, the proposed changes were written by the researcher and socialized via electronic mail. Participants had seven days to read and consider writing.

5) ICNP ® terminology subset structuring guided by Wanda
Horta's Theory of Basic Human Needs.
The subset was structured with the list of nursing diagnoses, outcomes and interventions, organized according to Wanda Horta' s Theory of Basic Human Needs (10) , following the INC recommendations (8) .

Data analysis
The nursing diagnoses, outcomes and interventions constructed were considered validated in the presence of consensus by specialist nurses.

RESULTS
Thus, 61 indicators of altered needs relevant to care for people with TB were identified from the 24 articles selected in the review. These indicators went through a normalization process, resulting in 46 validated terms and five excluded because they do not represent caring for people with TB. The 46 validated terms were submitted to manual cross-mapping with ICNP ® 2017 Focus Axis terms, and it was found that all were constant (Chart 1).
From the constant and non-constant terms in the ICNP ® , 54 nursing diagnosis/outcomes were constructed, submitted to manual cross-mapping with the ICNP ® 2017, which resulted in 40 constant diagnoses/outcomes and 14 non-constant diagnoses/ outcomes in ICNP ® 2017, marked with asterisks in Chart 2.
For each diagnosis constructed, a set of nursing interventions was created, resulting in 467 nursing interventions. Of these, 06 interventions are not listed in the ICNP ® 2017, being broken down below: 1) guide the use of a mask in the first 15 days; 2) forward sputum sample to the laboratory; 3) to stimulate expectoration; 4) obtain data on weakness; 5) schedule home visits; 6) refer for social and psychological support.
After this process, diagnoses/outcomes and interventions were submitted to the assessment of relevance, by consensus, with nine nurses. The average age of judges was 40.88 years, with 88.89% being female. As for graduation length, the judges have more than 10 years of graduation, with an average of 16 After the consensus assessment, three diagnoses were excluded and two had their wording changed, resulting in 51 diagnoses/outcomes. Of these, 37 diagnoses are constant and 14 are not constant in the ICNP ® 2017. The diagnoses/outcomes elaborated in this study were organized according to the structure of psychobiological, psychosocial and psychospiritual needs of Wanda Horta's Theory of Basic Human Needs. Among the psychobiological needs identified in this study, are oxygenation, nutrition, elimination, exercise and physical activity, sexuality, regulation, therapy, body care, physical security and perception. The psychosocial needs identified are gregarious, love, acceptance, learning, self-esteem, safety, and self-fulfillment. As for psycho-spiritual needs, only the religious was identified. As for interventions, there were changes and adjustments, and the repetitions were removed according to each need, ending with 264 interventions, 256 of which were constant and eight not constant in the ICNP ® 2017. Thus, the subset's final configuration is described in Chart 2. regimes to people' routine, as well as family, social and emotional support, are fundamental in the singular care of each person (12) . Individuals with TB have insufficient knowledge about the disease and its treatment, due to the low level of education, which can lead to therapy regime non-adherence and abandonment. In this context, nurses, when identifying the diagnoses Lack Of Knowledge Of Disease, Of Treatment Regime and Of Medication should, throughout the process, seek to create a bond, co-responsibility and provide adequate information. Individuals who receive guidance about the disease, about the importance of treatment and possible side effects, as well as the consequences of irregular treatment regime, are more likely to adhere to treatment (4,13) .
On the other hand, there is a poor prognosis in individuals who have the diagnoses Alcohol and Drug Abuse, since alcohol consumption leads to changes in the action of medications, compromises the immune system and causes treatment to be abandoned. Moreover, using drugs causes biological changes, hinders Adherence to Regime and leads to social segregation, triggering barriers to family support (14) .
Among the psychosocial needs, the diagnoses/outcomes Social Isolation, Discrimination, and Stigma stood out, which, historically, are linked to people with TB, affecting their social life and acceptance of disease (4,15) . People with TB feel stigmatized by society, family and friends, leading to their withdrawal from social life and causing them to feel depressed (16) . Prejudice and stigma affect individuals' perception of themselves, triggering a behavior of keeping disease secret, due to the prescription of judgment, humiliation, and isolation (15) .
Concerning psycho-spiritual needs for people with TB, only the diagnosis Belief was identified. Belief is related to the process of coping with people in relation to disease, their knowledge and experiences, involving issues of understanding disease as divine punishment associated with negative feelings, such as depression, fear and insecurity, resulting in impaired treatment adherence. However, if belief is linked to will, hope and courage, it will contribute to the positive outcome of treatment (16) .

Study limitations
Although the relevance of this subset is evident, some points must be considered: the stage of assessing the relevance of nursing diagnosis, outcome and intervention statements for people with TB occurred in a small group and with a specific population, an event that may limit the applicability of this study to other settings. With this, submitting this study to an external assessment, which considers several settings, can improve its awareness and specificity.

Contributions to nursing
The ICNP ® terminology subset for people with TB is an instrument that can support nurses' clinical decision-making in assisting this person, respecting their needs and favoring the documentation and inclusion of this terminology in nursing practice (7,17) .

FINAL CONSIDERATIONS
The ICNP ® terminology subset for people with TB, structured according to Wanda Horta's Theory of Basic Human Needs, has 51

DISCUSSION
In 2014, the World Health Organization launched End TB strategy. To this end, it established as one of strategy's pillars an integrated care centered on people with TB, in order to reduce their suffering. In this perspective, nursing assumes a fundamental role in TB control. Through nursing care, it is possible to build a care plan based on basic human need indicators identified in this individual, collaborating with the disease favorable outcome (2) . Individuals with TB have biological, social and spiritual needs manifested by empirical indicators, which were identified through a literature review and anchored in Wanda Horta's Theory of Basic Human Needs (10) . Among the psychobiological needs, the diagnoses Expectoration, Fever and Impaired Weight were the most expressive. These symptoms are the first to manifest in people with TB, causing changes in their body and quality of life (4)(5) .
For timely treatment, diagnoses related to Adherence to Regime are essential, covering behavioral, psychological and social aspects, as well as health staff's skills and social support network. During the therapeutic process, information and adjustments of therapy diagnoses and 264 nursing interventions, 24 diagnoses distributed in psychobiological needs, 26 diagnoses in psychosocial and one diagnosis in psychospiritual. Concerning psycho-spiritual need, there is a need, revealing that there is a lack of research that addresses the psycho-spiritual needs of people with TB.
The subset is an effective technological tool for identifying relevant needs of people with TB, being able to contribute to nurses during consultation in Primary Health Care, assisting in developing actions to promote, prevent and recover people' health individually.
The ICNP ® terminology subset for people with TB is an educational and care technology that collaborates with the teaching and learning process, as it relates the elements of a nursing theory with a terminology of diagnoses, outcomes and interventions, contributing to the knowledge of classifications and supporting its use in teaching and health institutions.