Nurses Broaden Their Role in Kazakstan's Medical System

by Curtiss and Shanta Swezy

The dramatic change in nursing taking place in Kazakstan is one of the few bright spots in a medical system plagued by severe shortages of medicines and basic supplies since independence. At hospitals and medical institutions around the country, nurses are updating their skills, taking on new roles as educators and managers, and filling the gap in health services delivery. The expanding role of nurses and the empowerment of this profession within the health care establishment is a change significantly stimulated by the American International Health Alliance, a USAID-funded hospital partnership program. Initiated in the spring of 1992, the project has established 25 partnerships between leading American hospitals and health care institutions with counterpart hospitals in 11 states of the former Soviet Union.

Kazakstan's two partnerships, Almaty/Tucson and Semipalatinsk/Houston, are focusing on upgrading the skills of nurses and empowering them to function independently and professionally. In the very short time since the initiation of these partnerships, clear changes in nursing education and service provision have occurred in Kazakstan. The improvements nurses have made in health services delivery are all the more remarkable considering the economic disruption and decline in health services the country is facing.

Almaty/Tucson

Four medical institutions in Almaty, including the Almaty Medical College (a nursing school), are partnered with eight hospitals in Tucson, Almaty's sister city. Short-term exchange visits have been regularly conducted between health professionals of these two cities since 1993. These exchanges have included 12 nurses from Tucson who visited Almaty and five nurses from Kazakstan who have visited hospitals in Tucson.

While each AIHA partnership chooses its own focus, one major initiative of the Almaty/Tucson partnership has been to upgrade the skills of nurses and expand their role in patient care. Both partners agreed that many important functions, such as intensive bedside care, were not being performed by either nurses or physicians under the current system. With this understanding, both sides set about to fill this gap, providing an opportunity for nurses to expand their traditional roles without being seen as competing with physicians. A variety of initiatives were undertaken to train nurses, both in Tucson and Almaty. But it soon became apparent that to make change permanent, the training would have to be institutionalized within the Kazak nursing education system.

Dr. Kalkaman Ayapov, president of the Almaty Medical College, gives much credit to the partnership's work for the changes that ensued. The standard three-year curriculum for nursing education was eliminated and an entirely new four-year curriculum designed. Built into the new curriculum are periods of practical training at area hospitals, which provide experience in the innovative concepts of nursing management, social hygiene and medical statistics that are taught at the Almaty Medical College. Partner hospitals in particular strive to provide an environment in which these innovations can take root. An external evaluation conducted by two American nurses in May 1996 of the changes at the Almaty Medical College concluded that, "the (new) core curriculum is comprehensive, current, and offers timely, relevant concepts critical to the development and implementation of the role of the nurse-manager."

Dr. Ayapov contacted the Ministries of Health, Education and Labor. An agreement was reached to create official government compensation levels for each year of the four-year nursing program completed. The first fourth-year class graduated in June 1996, and entered the job market at the same salary level as first-year physicians. Twelve other nursing schools throughout Kazakstan, with total student enrollment of over 7,000, have adopted, or plan to adopt, the new four-year curriculum developed at the Almaty Medical College.

The Almaty Medical College made one other addition to the program. Since most senior nurses in Kazakstan are graduates of an earlier two-year program, Dr. Ayapov started a night school for senior nurses so they could complete the last two years of the baccalaureate program. The first class of 50 began their studies in September 1995, studying four nights a week while continuing to work full-time.

Maya Ababkova, chief nurse of the Almaty City Health Administration, is one of the 50 nurses enrolled in the night school. She is a graduate of the old two-year program and intends to complete the third and fourth year to receive her baccalaureate. When asked why she chose to enter this rigorous program when she was already working full-time, she replied: "I am doing this because I want to develop higher skills and compete with the graduates from the day nursing school. Also, it is absolutely necessary nowadays to have knowledge of management, decision making and economics." By enabling her to perform her job more effectively, she said the training will change her life. "I will be able to teach students and do research. This makes me feel more self-confident."

Semipalatinsk/Houston

The nursing school in Semipalatinsk is among those considering implementing the new four-year nursing curriculum. The partnership between Houston and Semipalatinsk began in the spring of 1995. In the first year, five nurses from Semipalatinsk visited Houston. The partners have since established the unique position of "nurse educator" in the four partner institutions in Semipalatinsk. These are senior nurses who have received special instruction in educational strategies. They coordinate staff development among personnel on their units, work with student nurses, and provide ongoing instruction in areas such as bedside care, infection control, and personal health care and safety. Four of these nurse educators are now in place.

A second innovation has been the establishment of four model nursing stations, one in each partner hospital. Nurses at these stations implement the skills they have learned through partnership exchanges. The model stations have been designed to disseminate these techniques throughout the city.

New information has spread widely among nurses in Semi-palatinsk, a process helped by the establishment of the Semipalatinsk Nursing Association (SNA). The purpose of this organization is to promote professionalism through continuing medical education, establishing standards of care, promoting recognition of nursing, and joining nurses throughout the region. By July 1996, over 800 dues­paying members had joined. With a grant from the Counterpart Foundation, the association has purchased basic office equipment, established a nurse education room, and distributed the first of what will be a quarterly association newsletter.

The SNA has formed a partnership with the US-based Association of Operating Room Nurses (AORN). AORN will provide expert advice and guidance on the operation of nonprofit organizations, including discussions of board and staff roles, committee structure, financial management, fund raising and continuing education. This technical assistance will give momentum to SNA's efforts to become self-sufficient.

Remarkable changes have begun within the nursing profession in Kazakstan. Basic education has been upgraded and the opportunity for baccalaureate training instituted. Opportunities for senior management and leadership positions have opened. New roles in nursing care are leading to increased professionalism. As these nurses become empowered to take control of their professional lives, they gain new confidence as women and activists for better health care.

Curtiss Swezy is the director of reporting and evaluation for AIHA. Shanta Swezy, his daughter, recently completed three years of Peace Corps service in Taldykorgan, Kazakstan.

American International Health Alliance, 1212 New York Ave. NW, Suite 750, Washington, DC 20005; ph: (202) 789-1136, fax: (202) 789-1277; <aiha@igc.apc.org>