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On-line version ISSN 1980-220X
Rev. esc. enferm. USP vol.43 no.4 São Paulo Dec. 2009
The registered nurse and the battle against tuberculosis in Brazil: 1961-1966*
La Enfermera diplomada y la lucha contra la tuberculosis en Brasil: 1961-1966
Hercília Regina do Amaral MontenegroI; Antonio José de Almeida FilhoII; Tânia Cristina Franco SantosIII; Lucia Helena Silva Corrêa LourençoIV
IM.Sc. in Nursing. Coordinator of
the Continuing Education Service at Jacarepaguá General Hospital.
Nursing Supervisor at Santa Maria State Hospital. First Secretary at ABEn-RJ.
Rio de Janeiro, RJ, Brazil. email@example.com
IIPh.D. in Nursing. Researcher at Research Center on Brazilian Nursing History (Nuphebras). Member of the Permanent Faculty Board of the Graduate Program and Adjunct Professor at Fundamental Nursing Department at Anna Nery School of Nursing, Federal University of Rio de Janeiro. Rio de Janeiro, RJ, Brazil. firstname.lastname@example.org
IIIPh.D. in Nursing. Researcher and member of Nuphebras Directors Board. Member of the Permanent Faculty Board of the Graduate Program and Adjunct Professor at Fundamental Nursing Department at Anna Nery School of Nursing, Federal University of Rio de Janeiro. Rio de Janeiro, RJ, Brazil. email@example.com
IVPh.D. in Nursing. Researcher and member of Nuphebras Directors Board. Member of the Permanent Faculty Board of the Graduate Program and Adjunct Professor at Fundamental Nursing Department at Anna Nery School of Nursing, Federal University of Rio de Janeiro. Rio de Janeiro, RJ, Brazil. firstname.lastname@example.org
The objective of this study was to describe the circumstances that promoted the implementation of the new Program for Action Against Tuberculosis in Brazil (Programa de Ação na Luta contra a Tuberculose no Brasil) and discuss the strategies used by registered nurses from the Santa Maria State Hospital, Guanabara State, to adjust nursing care to the new program against tuberculosis. This was performed through document research, interviews, and statements from nurses working at the time of the reorganization. Documents were analyzed based on the concepts of habitus, field, and symbolic power by Pierre Bourdieu, and included written and oral documents as well as secondary sources. The reorganization of the nursing service was performed under the leadership of a nurse whose symbolic capital assigned power and prestige to implement the necessary changes. It is concluded that the work of that nurse made it possible to implement the new program and contributed to establishing the position and importance of the registered nurse in providing care to individuals with tuberculosis, for prevention and cure.
Key words: History of nursing. Tuberculosis, pulmonary. Leadership.
El objeto de este estudio fue la reconfiguración del Servicio de Enfermería del Hospital Estatal Santa Maria, frente a una nueva política contra la tuberculosis en Brasil. Objetivos: describir las circunstancias que permitieron la implantación del nuevo Programa de Acción en la Lucha contra la Tuberculosis en Brasil, y discutir las estrategias utilizadas por las enfermeras diplomadas del Hospital Estatal Santa Maria, en el Estado de la Guanabara, para adecuar la asistencia de enfermería al nuevo programa de combate a la tuberculosis. Estudio histórico social. Para su elaboración, fueron realizadas una investigación documental y entrevistas/declaraciones de enfermeras de la época. El análisis del corpus documental, apoyado por los conceptos de habitus, campo y poder simbólico de Pierre Bourdieu, se hizo con base en documentos escritos, orales y fuentes secundarias. Resultados: la reconfiguración del servicio de enfermería sucedió bajo el liderazgo de una enfermera cuyo capital simbólico le confería poder y prestigio para implementar los cambios necesarios. Se puede concluir que la actuación de esa enfermera posibilitó la implantación del nuevo programa, y contribuyó para delimitar el espacio y la importancia de la enfermera diplomada en la asistencia a los acometidos de tuberculosis, tanto en los aspectos de prevención como en los de cura.
Descriptores: Historia de la enfermería. Tuberculosis pulmonar. Liderazgo.
The objective of this study is to rebuild Nursing Services in the State Hospital Estadual Santa Maria (HESM), located in the former State of Guanabara, facing a new Program of Actions for the Fight against Tuberculosis in Brazil. The chosen time period is between 1961 and 1966. The beginning of the study period was marked by the definition of the new policy for combating tuberculosis through the National Campaign against Tuberculosis (NCATB). The study period ends with the management period when a nurse took over as Head Officer of Nursing Services in the HESM, with the task of making the necessary changes to health services in order to implement the new care proposal for pulmonary tuberculosis carriers in the State of Guanabara. The success of this new policy in the fight against tuberculosis signaled a new phase in tuberculosis treatment in Brazil.
Since the 1940s, epidemiological studies have demonstrated the severity of tuberculosis and its impact on Brazilian society due to high rates of morbidity and mortality. Some studies demonstrated that some Brazilian state capitals suffered as many as 300 to 500 deaths per 100,000 inhabitants, and in Rio de Janeiro - then the Federal District- the rate was approximately 320 per 100,000 inhabitants(1). Of 19 state capitals, 12 experienced increasing rates of pulmonary tuberculosis between 1936 and 1945. The situation was so severe that pulmonary TB was a major factor harming the performance of the Brazilian Expeditionary Force (FEB), created to act with the Allied forces in the Second World War(2).
In the face of the population's vulnerability to the disease, which was aggravated by the living and working conditions of underpaid workers, including the excessive working hours, inappropriate eating habits, and unhealthy housing conditions(3), the government of Eurico Gaspar Dutra (1946-1951) established the fight against tuberculosis as a health priority when elaborating the SALTE Plan (Health, Food, Transport and Energy). During the creation of the new constitution, President Dutra approved Decree No. 9387, officially establishing the National Campaign against tuberculosis (NCATB)(3). Doctor Raphael de Paula Souza became the head of this organization.
In the 1950s, especially after 1956, national and international researchers demonstrated that outpatient treatment was acceptable, regardless of the severity of the lesions and the socio-economic conditions of patients. Also, the patients did not require any medical leave from work. Research indicated that the regular use of combined medications, taken correctly, ensured a cure. This new paradigm brought about a redirection of the NCATB, which reorganized dispensers and implemented new services, including hiring, preparing and training personnel. Until this time, the major treatment objective had been the creation of more hospital beds(4), which greatly increased treatment costs.
Regardless, it was found in the 1950s that while tuberculosis mortality rates were declining, bacterial resistance to one or more drugs was also developing due to the inappropriate use of antibiotics. Health authorities already knew that appropriate treatment resulted in negative transmission sources in a period of three to four months after the beginning of the treatment and cure in 90% of cases, regardless of the type of injury(5). Institutions played an important role both in the implementation of both preventive measures and treatment. These measures included vaccination, early discovery of new cases, sanitary education for patients regarding transmission and tuberculosis treatment, and emphasizing the correct use of medication(6).
In nursing practice, the new trends in tuberculosis treatment required qualified professionals with up-to-date knowledge to care for patients in many health institutions. In order to provide for these needs a study called the Nursing Needs Survey in the State of Guanabara was carried out in the early 1960s by the Nursing Supervisory Commission of Guanabara State. This study depended on the participation of head nursing officers from all hospital units in the State. This study, which aimed to learn the qualifications of nursing professionals in state hospital units, demonstrated that there was a
significant amount of professionals without the required certification to provide care for hospitalized patients, and some of them were hired through political and election criteria(7).
The fact stood in opposition to the current legislation regarding nursing professionals and compromised the quality of nursing care provided in those institutions. Some professionals who did not have a nursing diploma were treated as qualified nurses and in some cases assumed the role of head officer of Nursing Services.
Both qualified nurses and nursing assistants had a low level of education. In addition, it was still common, especially in hospitals, to allow interns, most of whom had a low level of education including only basic literacy, to provide unpaid services with a view to obtaining nursing positions. There were the albergados: workers who received a very low quarterly payment, in addition to housing in a collective shelter, food, and uniforms. Also working in the hospitals were the gandulas, former patients with chronic diseases such as Hansen's disease or tuberculosis, or patients under recovery. These patients lived in the hospital and received uniforms and food in exchange for their service(7).
The inadequate education of those providing nursing services for the Health and Care Department of the State of Guanabara compromised the quality of care provided to hospitalized patients. These difficult conditions of this time period were also found in HESM. Therefore, with the emergence of new methods for tuberculosis control resulting from the evolution of chemotherapy and recognition of the value of voluntary treatment, it was necessary to adjust these demands in order to prevent the emergence of drug resistance.
In 1963, technical assistant Doctor José Galbo - a tuberculosis specialist, former director of the Department of Tuberculosis of the State of Guanabara and former director of São Sebastião Hospital - was nominated as the substitute for the director of HESM. When he took office, he invited Nurse Raimunda da Silva Becker to be the head officer of Nursing Services. It is important to point out that Raimunda da Silva Becker was head officer of Nursing Services in São Sebastião Hospital while she was the director of the hospital. Therefore, nurse Raimunda da Silva Becker, appointed for the position on February 19th of 1964, was in charge of developing Nursing Services to meet the new demands of tuberculosis control.
The present study has the following objectives: to describe the circumstances in which the new Program of Actions against tuberculosis was implemented and to discuss the strategies used by nurses in the HESM to develop nursing care to meet the needs of the new program of tuberculosis control.
This is a historical-social study because it reflects social development and dynamics, and the concerns and interests of classes and specific groups(8). It is a part of a dissertation for the Master's Degree course entitled The new social order in the fight against tuberculosis and the restructuring of nursing care in Hospital Estadual Santa Maria. The project was approved by the Research Ethics Committee of Anna Nery Nursing School/São Francisco de Assis Teaching Hospital in December 19th of 2006, according to statement no. 097/06.
Primary sources are composed of written documents and oral documents belonging to the Oral History Collection of the Documentation Center (OHCDC) of Anna Nery Nursing School (EEAN)/UFRJ and the ENSP/FIOCRUZ Library. Interviews with Professor Raimunda da Silva Becker and with Nurse Antonia de Oliveira Coelho were performed in the auditorium of Anna Nery Nursing School and at their homes. In addition, Nurse Jurema Cunha dos Santos provided a written statement. In both cases, ethical precautions were taken concerning their free and informed consent in accordance with Resolution 196/96 of the National Council of Health.
Statement excerpts, when presented in writing, will be identified by the initials of the corresponding speakers, as follows: Nurse Raimunda da Silva Becker (RSB), Nurse Antonia de Oliveira Coelho (AOC) and Nurse Jurema Cunha dos Santos (JCS).
In historical studies, it is important to place the human subject within the sociohistorical context were the phenomenon occurred, considering their role and position, among other aspects. Therefore, all subjects were aware of the impossibility of anonymity and agreed to these terms. Interviewees provided their statements to CEDOC of EEAN/UFRJ so that they can be examined by other researchers for scientific purposes.
Secondary sources used in this study were located in the Sectorial Library of Anna Nery Nursing School, Getulio Vargas Foundation Library and ENSP/ FIOCRUZ Library.
Both written documents and interview transcripts were used as texts to be interpreted, considered in the historical context in which they were produced. Data analysis made theoretical reference to Pierre Bourdieu's concepts of field, habitus, and symbolic power.
The fundamental issue in Bourdieu's writings is the understanding of the structured character of social practices in which subjects, due to their positions in various social structures, go through a series of characteristic experiences that internally structure their subjectivity and orient their actions. Raimunda da Silva Becker's actions with respect to tuberculosis as head of Nursing Services in HESM demonstrated the implementation of a specific capital, by means of altering her habitus in answer to the symbolic battle for the power of being seen, believed and known. Through the fight to impose a world vision, agents hold power proportional to their symbolic capital, which consists in acknowledgement from the group(9).
RESULTS AND DISCUSSION
The new social order in the fight against tuberculosis and the HESM
The new Action Program in the Fight against Tuberculosis in Brazil created the opportunity for significant changes in the treatment of tuberculosis patients. Voluntary treatment was valued so much that discussions in this new phase were based on the need to invest in short term hospital admittance. Prognostic classifications of patients lasting an average of three to six months were used for health education of interns, assisted medication and discharge communication control. This admittance model aimed at containing the bacterial resistance phenomenon and optimizing the use of hospital beds, reducing the cost of hospital admittance(10). Sanatoriums therefore performed restructuring to accommodate the most recent requirements for tuberculosis treatment, which emphasized medical installations and the implementation of services (Nursing, Nutrition and Rehabilitation) that could allow patients with favorable conditions to adjust to treatment(11) since sanatoriums did not present appropriate structures.
Raimunda da Silva Becker's statement reveals that in 1961 the HESM became the first hospital of the Medical Services Superintendence (SUSEME) of the general Secretary of Health and Care of the State of Guanabara to implement these changes. Two members of the Technical Commission of the NCATB were active doctors in this hospital: Flávio Poppe de Figueiredo and Jesse Pandolfo Teixeira.
In order to cope with the demands of implementing a new tuberculosis action program, there was a need to review nursing personnel. In 1960, a study aiming to examine the situation in order to reorganize nursing services in medical institutions was carried out to examine the deficiencies of non-certified nurses, because gandulas, albergados and interns had no diploma(7).
The research was carried out by the Nursing Supervising Commission, led by Nurse Ariadne Lopes de Menezes - the former head of the Nursing Team of the Organization Technical Services (SORTEC) - in the period of June to November of 1960. The Commission depended on the cooperation of nurses from the State Health Services and the Rachel Haddock Lobo Nursing School, now the Nursing College of the Federal University of Rio de Janeiro(7).
The situation described by the commission demonstrated the existence of two groups of nursing professionals, one consisting of graduate nurses and another consisting of nurses without formal nursing education. Although a school diploma indicates competence providing credit or authority to the owner according to its conventional, formal and legal value(12), these groups were competitors for power in hospitals.
Nurse Antonia de Oliveira Coelho clarifies in her statement that in HESM, which was the location for the implementation of hospital care standardization for tuberculosis patients under a new NCATB therapeutic proposal, non-graduate nurses placed graduate nurses in closed locations such as Surgery Centers when determining work shifts. They believed that such placement of graduate nurses neutralized the potential threat they posed. Direct care for hospital patients was mostly provided by gandulas, albergados and interns.
The absence of qualifications for selecting people to work for some health institutions in the Federal Capital caused some head positions in nursing services to be taken by unqualified non-graduate nurses. Reports also demonstrated that regulations, routines and work techniques were not updated and these circumstances were aggravated by the poor means of execution and a disorganized administration(7).
An excerpt from the statement of an HESM nurse demonstrates that non-graduate nurses did not have the required qualifications to provide quality care for patients, especially with respect to the new care model for tuberculosis:
[...] The team did not have much technical knowledge, and included some non-graduate nurses; they executed tasks, but had no nursing diploma. Two of them were nursing assistants who went through a public tender for the State; since they did not require documentation at the time, they took the test and were approved, and as they filled their position, they did not present a diploma, so they were denominated entitled nurses (JCS).
When the report issued by the Nursing Supervising Commission reached Carlos Lacerda, Governor of Guanabara, he ordered that all recommendations within the reports should be effected and published in Guanabara's Official Register on March 15th of 1962.
HESM Nursing Services:
An anti-establishment movement appears
The HESM, which was linked to the Medical Services Superintendence Tuberculosis Department (SUSEME), was subordinated to the Guanabara State Secretary of Health and Care. In order to provide for the new demands of tuberculosis treatment, Haroldo Voigt Meyer, a well-known TB specialist and thoracic surgeon, was appointed director.
Regarding the necessary changes to Nursing Services, the governor of Guanabara appointed nurse Raimunda da Silva Becker as the head officer. Becker was part of the Coordinating Group of the First International Workshop in Tuberculosis Chemotherapy, carried out by the TB specialists and Pulmonology Institute of the former University of Brazil. The Tuberculosis Central Laboratory of the State of Guanabara, led by Professor Hélio Fraga(13), also participated in this exercise.
Also, nurse Raimunda da Silva Becker was known to important medical authorities in tuberculosis because of her actions in other institutions where these people had important administrative positions. In her statement, she acknowledges the importance of the prestige given to the graduate nurse in professional relations routines with the director of institutions and the medical team in general:
[...] We had all the prestige [ ] When the director praises the nursing team, doctors follow their model. In Santa Maria it was like that(RSB).
Hence, different types of symbolic capital (cultural, social and scientific) and her effectiveness are set within powers that define probabilities of field gain(9).
The prestige nurse Raimunda da Silva Becker held in HESM was a product of the cultural, social and scientific capital she accumulated. Cultural capital is considered a greatness that is transmitted, grows, decreases or disappears - a subjective greatness that marks those who carry it with legitimacy. It must be understood as a principle of dominant hierarchy, and also an object of dispute between these groups(14). Social capital can be described as a power relation between positions that ensures its members a sufficient quantum of social power to enter into these fights for power(9). Scientific capital represents an institutional power connected to the occupation of important positi-ons in scientific institutions, in addition to the power of production and reproduction that this occupation represents(15).
Another excerpt from Raimunda da Silva Becker's statement shows the acknowledgement of her best work as a nurse, clarifying that it is the source of her cultural capital, and was strengthened by the reorganization of nursing services:
[...] I had a great chance, a great work opportunity I consider the work I did in Santa Maria [HESM] my best nursing work there is nothing better [ ] it was such a huge chaos and was so good that I consider it my best work (RSB).
Agents' prestige depends on their symbolic capital - in other words, acknowledgement, institutional or not, received from a group or from a speaker authorized to speak on behalf of the group.
In the perception of Nurse Raimunda da Silva Becker, institutional support was needed for the director to implement the necessary changes:
[...] I had a complete free hand, both from the clinics head officer and the hospital director anything that regarded nursing, he would say: talk to Raimunda [ ] They would give me full autonomy, they could see that the job was being done.
As soon as Raimunda da Silva Becker became the head officer of Nursing Services, the graduate nurses were redistributed into hospital sectors in such a way that they had positions according to their professional qualification. Consequently, their work routines changed. The reactions of these nurses are described by an older nurse:
[...] Tasks that were pertinent to the Nursing Supervision position were constituted. Among them, Event Logs, nursing station visits, patient visits, mainly more severe patients, in addition to following up the development of the shift team (JCS).
It is important to emphasize that these changes did not occur without any resistance from the medical team. Raimunda da Silva Becker noticed that some doctors did not perform medical visitation to patients on a regular basis. They limited themselves to repeating previous prescriptions. Patient discharges for lack of discipline were frequent. This punitive measure had a significant impact on the control of tuberculosis because it made it difficult, or even impossible, to readmit patients to other hospitals in the public network for tuberculosis treatment.
These situations did not conform to the new care model. The nursing head officer raised these concerns with the hospital board, which gave its total support, even giving doctors warnings for not following the terms of new proposal for tuberculosis treatment.
Doctors' dominant position in the tuberculosis specialty at this time led them to assume a conservative strategy to maintain the medical care already developed in the HESM. This led to intense debates between the Nursing Services head officer and some tuberculosis experts in the hospital.
The significance of official speech was favored by men's authority. This distinction is natural and rooted in family relations, since gender division at work is often a consequence of the division of domestic tasks established in the family organization(16). Therefore, nurses, who were state employees, tended to reproduce the same speech, and conflict episodes consequently increased inside HESM.
The alliance between Raimunda da Silva Becker and the director of the institution not only provided the necessary political support for the necessary changes to Nursing Services at that hospital, but also ratified social differences by acknowledging the need for such an alliance with the person occupying the most important position in the institution. Nurse Raimunda da Silva Becker made the following statement about this subject:
[...] The acceptance of the graduate nurse within the functional hierarchy was a true challenge that was confirmed by the perfect involvement of the three executives of the hospital: director, nursing and administration head officers (RSB).
In addition to the need for re-distributing nurses throughout various sectors of the hospital, the head of the service identified the need to qualify nursing personnel for many activities that were considered as priorities:
[...] sanitary education, implementing medication, center streptomycin administration, adjust nursing service shifts, make information available for the patient's family and suspend all nursing activities during visitation periods with a view to providing a better service for the family. (RSB)
Becker believed that in order to secure the participation of the nursing team while pursuing these priorities, it would be necessary to create a training program that would involve the whole nursing team, including nursing technicians and assistants, since they represented the majority of professionals in the service. Sanitary education for the family would be the responsibility of the nursing team (AOC). In addition, the institution's head nursing officer would seek to learn more about the individual aspects of nursing team members; an important measure if members' behavior was considered to indicate necessary actions/strategies(17).
Therefore, Raimunda da Silva Becker was able to collaborate with the hospital staff to achieve success in that hospital. Eighteen months after the implementation of the new Program of Action for the Fight against Tuberculosis, satisfying results were apparent. There was an improvement in almost all reference rates regarding patients' recovery and regression in that hospital, as shown in a report published in the National Magazine of Tuberculosis in 1965. This report counted Brazilian scientific authorities on tuberculosis among its authors. Raimunda da Silva Becker(18) was one of them. Some indices referring to the implementation of the new Program of Action for the Fight against Tuberculosis are illustrated in the following table:
Table 1 indicates that, throughout this period, there was a considerable reduction in the average duration of the hospital stay, and also significant increase in discharges due to medical initiative, which improved treatment efficiency. The data also demonstrate a substantial reduction of the rate of discharge percentage for patients who did not demonstrate bacterial conversion in the sputum exam and an increase in favorable results regarding the treatment of patients responsive to standard drugs.
According to the authors, these favorable rates indicate that this hospital can be classified as a high-performing institution for carriers of tuberculosis.
We can observe that patients who continued outpatient treatment under the technical-administrative responsibility of the hospital also presented important positive indicators, as shown in Table 2.
Data presented in Table 2 reveal that the treatment dropout rate, considering TV (new to treatment), PS (possibly resistant) and C1 (Chronic Type 1) patients was approximately 12%. This rate was lower than others in the State at the time.
The efficiency of the sanitary education performed by nurses during the hospital stay also contributed to favorable outcomes(18). An important indicator regards both bacterial and radiological regression in relation to the measures implemented in the hospital. These data are demonstrated in Table 3.
Table 3 indicates that the number of patients who presented regression was reduced in comparison to outpatients of this hospital institution, and that the incidence of regression was higher in chronic patients, in particular those resistant to standard drugs. These data also show that regression in chronic patients was both bacterial and radiological, while NT and PR patients presented only bacterial regression. These findings demonstrate the impact of the measures adopted at the hospital, in which the participation of the nursing team, under the leadership of Raimunda da Silva Becker as head officer of Nursing Services, was fundamental.
These positive results enhanced the visibility of the graduate nurse group, and in particular the image of Raimunda da Silva Becker. The following year in 1965, she was invited to participate in a work group that aimed to propose nursing measures and techniques in order to standardize medication administration and control for tuberculosis patients and to make recommendations for the nursing care of admitted patients from arrival to discharge. The functional record of this work group is titled Service Order P SUA/No. 193.
This group was created by the order of the Director of the Care Services Department of SUSEME on June 16th,1965. It was composed of a president, Dr. José Galbo, and two more head officers of Nursing Services, from São Sebastião State Hospital and Clemente Ferreira State Hospital.
In 1966, also resulting from this work, Raimunda da Silva Becker received and accepted an invitation from Professor Hélio Fraga to be the head officer of the Nursing Sector of NCATB, and thus the successor of Nurse Adalgisa Matos, supervisor of the Public Health Special Service Foundation(5).
It is important to point out that NCATB Nursing Sector had been configured as a consulting organ of the Tuberculosis national Service, uniting experts in nursing issues with the aim to elaborate programs and work regulations that would be adopted by health services under the orientation and supervision of NCATB(5).
Changes in tuberculosis treatment between 1961 and 1966 required qualified nursing professionals with up-to-date knowledge to care for patients in many health institutions. In the HESM, the changes to the professional habitus of the nursing team occurred under the leadership of Nurse Raimunda da Silva Becker, whose symbolic capital gave her the required prestige to provide legitimate speech about nursing care issues relevant to the new paradigm for tuberculosis treatment.
In the nurses' statements, we notice the consistent perception of resistance on the part of doctors, and the alliances and power relations utilized by the head officer of Nursing Services in the execution of her objectives, because solid alliances were necessary with important people in the hospital such as the director and administrator. These alliances were strategies in the fight for a legitimate monopoly by a prestigious nurse in the field of tuberculosis expertise who used her symbolic capital (cultural, social and scientific) as exchange currency in the fight to achieve progress in Nursing Services in that hospital.
This nurse, with her broad experience in nursing administration, noticed that successful implementation of the new political proposal for tuberculosis control depended directly on the working teams composing the HESM personnel, because the behavior of group members points the way to pertinent actions/strategies. Therefore, integration among members of different groups (medical, nursing, administrative) was the objective of the head nursing officer of that hospital.
We can therefore conclude that the actions of Raimunda da Silva Becker as the Head officer of Nursing Services in the HESM, not only enabled the implementation of the new Program of Action for the Fight against Tuberculosis in that hospital, but also helped to mark the position and importance of the graduate nurse in care for tuberculosis carriers, with respect to both preventive and curative medicine in the Guanabara State hospital setting.
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Received: 18/03/2008 *
Extracted from the thesis "A nova ordem social na luta contra a tuberculose
e a reconfiguração da assistência de Enfermagem do Hospital
Estadual Santa Maria", Anna Nery School of Nursing, Federal University of Rio
de Janeiro, 2007.
* Extracted from the thesis "A nova ordem social na luta contra a tuberculose e a reconfiguração da assistência de Enfermagem do Hospital Estadual Santa Maria", Anna Nery School of Nursing, Federal University of Rio de Janeiro, 2007.