Family Nursing Plays Key Role in Central Asian Health Reform Efforts

A new Family Nurse Training Curriculum—drafted by the Central Asia Region Nursing Coordinating Council (CARNCC) and approved by some 80 participants at an international conference held April 23-25 in Almaty, Kazakhstan—seeks to lay the educational foundation for nurses as they take on more responsibility for improving the quality and accessibility of patient care.

Members of CARNCC—a committee established with AIHA's support in 1999 to assist regional leaders in cooperative efforts to design educational and skills-based training programs that ensure nursing professionals are prepared to provide the people of Central Asia with high-quality primary care and prevention services—will submit the curriculum to the ministries of health of their respective countries. The document will serve as a guideline for the development of national programs at a time when primary care is becoming more central to the health system reform efforts under way throughout the region.

Stressing the importance of opening new educational doors to nurses in Central Asia, Zoya Nabieva, instructor at the Dushanbe Family Medicine Training Center established through the efforts of AIHA's Dushanbe/Boulder partnership and CARNCC member, says, "A major problem in Tajikistan is a lack of nurses who are specifically trained in primary care. In part, this is because opportunities for higher nursing education do not yet exist. The common curriculum will hopefully fill that void and enable us and others in the region to make rapid progress."

Adapting International Standards to Local Needs
As nurses in Central Asia work to elevate both the status of their profession and the breadth of care they are able to provide by improving opportunities for education and training, the new curriculum establishes the parameters of care a family medicine nurse can provide; details the philosophy, scope, and duration of the educational program; and sets course listings for various lectures, seminars, laboratories, and hands-on clinical training workshops.

Noting that the Family Nurse Training Curriculum incorporates the best aspects of primary care nursing curricula from four countries in the region and uses them to define core competencies for nurses practicing family medicine, Almaty/Tucson partner Zhumabike Romashova, chief nurse and head specialist on nursing at the Kazak Scientific Research Center of Pediatrics and Children's Surgery, explains that the new curriculum is based on World Health Organization (WHO) family nursing guidelines, yet adapted to conditions in Central Asia. "The curriculum provides an educational framework that will allow nurses to expand both their capabilities and their responsibilities. Nurses trained under this new program will be fully able to provide high-quality primary care services to patients of all ages."

One of the key adaptations apparent in the curriculum is duration of training, according to Bishkek/Kansas City partner Tamara Saktanova, head specialist for nursing at the Kyrgyz Ministry of Health.

"WHO standards call for 10 months of training, but nurses practicing in Central Asia are not allowed to be absent from work for that long. We addressed this problem by creating a number of shorter courses that focus on a single topic-breastfeeding or reproductive health, for example." Nurses who have completed these training modules receive certificates of completion and, when added together, the short courses are equivalent to WHO's recommended timeframe, Saktanova explains, noting, "To some extent, the curriculum resembles continuing education credits."

"This common curriculum is an important step because, essentially, it establishes the rights and responsibilities of nurses who work in a primary care setting," explains Darlene Weis, associate professor at Marquette University's College of Nursing, member of AIHA's Mtskheta-Mtianeti/Milwaukee partnership, and faculty at the conference. Calling it a step toward the standardization of nursing education as well as quality, Weis says, "For a single country to adopt the curriculum is important, but to have an entire region agree to a unified level and scope of education is truly a giant step forward. Add to that the cooperation of the ministries of health of four countries in the region and this curriculum will be a guideline for the development of better nursing programs."

Agreeing that the curriculum will help coordinate standards across individual countries while at the same time exposing them to the benefits of region-wide collaboration, planning, and sharing, Sheila Ryan, professor at the University of Nebraska Medical Center's College of Nursing, member of AIHA's Board of Directors, and faculty at the conference, notes, "The curriculum establishes the principles for a family nurse to focus on health promotion, disease prevention, and patient care regardless of the medical model or hospital nursing model in which she works. This will directly affect the quality of care available to people in the region."

Shared Challenges, Common Goals
In addition to discussion and approval of the curriculum, attendees also focused on ways to improve the quality of nursing care, methods of assessing the value of existing nursing education, the use of distance learning as a means of continuing education, and the recent activities of regional nursing associations. The event also provided a venue for nurses from Kazakhstan, Kyrgyzstan, Tajikistan, and Uzbekistan to meet with officials from local and national ministries of health and education, representatives of various associations and international organizations, and nurse educators from Central Asia and the United States.

Like other regions in the world, nurses in Central Asia are facing an uphill battle as they try to change the way nursing is perceived by the medical establishment and the general public, Ryan explains. "Although many health officials and nurse leaders are working to change the status of nursing and the level of respect given to the profession, resources, and the commitment of high-level policymakers are often lacking." Another obstacle, according to Ryan, is the low expectations other professionals have about nurses. "It's as though people have no idea that nurses can become leaders capable of shaping the health of their communities and that education is the key that will unlock this potential."

Saktanova agrees, stating that resistance from physicians remains an ongoing challenge to nursing reform efforts in Central Asia, as well as the rest of Central and Eastern Europe and Eurasia. "We are constantly working to overcome our physician colleagues' opposition to delegate some of their responsibilities. What is ironic about this is that, in reality, some of these duties already fall to nurses."

Weis also cites this "second-class" status as a key problem. "The bottom line is that nurses are not really viewed by physicians or anyone else as a valued group. In Central Asia, as in many former Soviet Republics, I often hear lip service paid to the notion of doing something to change this by making new opportunities for education and increased responsibilities available, but physicians seem very reluctant to hand over any authority even to those nurses who have advanced degrees," Weis explains. "Nursing reform needs a true champion to bring about change to the status quo."

Despite opposition from the medical community, however, both Nabieva and Saktanova contend that in their respective countries the governments have backed nursing reform efforts. "One of our greatest strengths has been the support of our government," Saktanova observes, noting the passage of new healthcare laws, implementation of several state-run nursing development programs, and introduction of the position of head specialist for nursing at the Kyrgyz Ministry of Health as key examples.

AIHA, too, has played an important part in expanding the role of nurses in Central Asia, according to Rikhsinisha Salikhodzoeva, head specialist for nursing at the Ministry of Health of Uzbekistan, president of the Uzbek Nursing Association, deputy chairperson of CARNCC, member of AIHA's Tashkent/Chicago partnership, and International Nursing Leadership Institute (INLI) graduate. Explaining that professional exchanges, conferences, and workshops sponsored by AIHA helped lay the groundwork for nursing reform efforts, Salikhodzoeva states, "For us, our involvement with the partnership was the beginning of all the achievements we have made over the past several years. Establishing nursing schools, creating nursing management positions, organizing nursing associations, and drafting the Family Nurse Training Curriculum—to a great extent these are all fruits of our partnership collaboration."

Learning from one another's experiences and working together as a team, in fact, is a boon to the nurses as they seek to implement change, notes Gulzhakan Kashafutdinova, senior lecturer at the Kazakh School of Public Health and member of the Almaty/Richmond partnership. "There are more than a few obstacles that stand in the way of nurses in Kazakhstan, not the least of which is the slow pace of the country's health reform process," Kashafutdinova observes. "Unlike some other nations in the region, there is no ministerial position of chief specialist for nursing in Kazakhstan; this leaves our cadre of nurses without representation at the Ministry of Health. Nevertheless, our nurse leaders have created two or three nursing associations [to act as their voice] with ministry officials and actively seek out educational and funding opportunities to further the profession."

Predicting that the Family Nurse Training Curriculum is only the first of many collaborative efforts to reform nursing in the region, Ryan says, "There is strength in numbers and part of that strength comes from the sharing of resources to solve common problems. This collaboration allows the nurse leaders to explore strategies for moving into new areas of growth such as nursing research, accreditation, and licensure. But, perhaps the most important outcome is the respect nurses gain for themselves and for one another as they work and grow together. This will directly translate into a stronger nursing profession and a higher quality of patient care."

Kashafutdinova agrees, concluding, "The CARNCC permits an active flow of information among nursing professionals and advocates for reform. Through term limits, the nature of the Committee ensures that more and more individuals will have a voice in the decision-making process. We have so much to share and international cooperation is a precious commodity as we work for change."