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Reorganizing Nurses’ Work for COVID-19 and Beyond

During a 2017 business trip to Lithuania, Gulnaz Azhymambetova, one of the first nurses to graduate from a Kyrgyzstan higher education nursing program, had an epiphany. She saw that Lithuanian nurses were involved in all stages of care during a patient’s hospital stay. That was a sharp contract to the practice in Kyrgyzstan, where nursing duties are typically divided into three categories and nurses must defer to doctors for even minor decisions.

Her push for a different division of labor didn’t gain traction until the COVID-19 pandemic in 2020. Hospital COVID-19 “red zones” began rapidly filling with patients who needed constant monitoring. Still constrained by duty categories and hierarchy, nurses had to cover as many as 40 patients each. The workload quickly overwhelmed them.

A 2020 assessment that the Ministry of Health spearheaded found that facilities were not following basic care procedures for COVID-19 patients, such as checking expiration dates on medicines, wiping patients’ skin twice with alcohol before an injection, and cleaning the filter of the oxygen concentrator. Nurses didn’t have time to introduce themselves to patients, explain procedures before doing them, or regularly monitor patients’ temperatures, blood pressure, and oxygen saturation.

“Working in the red zones and carrying out routine doctors' orders, the nurses were unable to conduct effective observation of patients due to lack of time,” said Ms. Azhymambetova, now the Ministry of Health and Social Development’s Leading Specialist in the Department of Organization of Medical Care and Public Health.

The workload aggravated the more fundamental problem: the task-oriented human resources structure that assigned three different types of nurses, each with separate responsibilities, to care for a single patient. Under that model, she explained, when the patient load dramatically increased, it was impossible to properly attend to COVID-19 patients or coordinate care across the health worker team. The solution: a patient-centered approach.

From Three Nurse Roles to One

Ms. Azhymambetova approached the US Agency for International Development’s Abt-led Local Health System Sustainability Project (LHSS) for assistance in revamping Kyrgyzstan’s nursing system. She and Abt designed a pilot for three hospitals in the capital, Bishkek, focused on COVID-19 patient care in red zones and intensive care units. Abt also supported instruction of seven nurse-trainers and the development of job descriptions, checklists of new duties for nurses, and revised procedures. Under the pilot, nurses performed multiple duties for the same patient, and their workload was a much more manageable 8-12 patients in the general ward, or three in intensive care, instead of 40 or more. 

“The functions of three types of physician-directed nurses were merged into one patient-centered nursing role called the Universal Nurse,” said Cholpon Asambaeva, LHSS country director and a clinician with human resources experience. “There is now an effective staffing model that allows us to have better health outcomes with the same number of doctors and nurses.”

This pilot built on nursing regulatory reforms that the government approved before the pandemic. But doctors accustomed to complete control over treatment resisted their implementation. “I had to talk to the physicians to explain the usefulness of the innovation, that the patient should be at the center of all efforts and all activities of the nursing staff,” said Ms. Azhymambetova.

In all countries, medicine has historically been hierarchical, said Abt Project Senior Manager Kate Greene, LHSS senior technical advisor for human resources for health. “But there’s increasing recognition globally that nursing, rather than just being a doctor’s assistant, is an autonomous practice in its own right.”

Three factors lie behind this trend, Greene said: a shortfall of doctors in many countries, advocacy at the global and country level for strengthening the nursing profession, and a need for more efficient health service delivery. COVID-19 accelerated this trend, making it politically possible to adopt new models to meet demand.

Government will extend model to other hospitals

In Kyrgyzstan, 75 nurses trained in the Universal Nurse model now work in the three pilot hospitals, and the Ministry of Health plans to include the Universal Nurse in its registry of positions. The ministry also plans to discuss additional pay for those in the role. In 2021-22, the ministry will expand the Universal Nurse model to all departments of the three pilot hospitals and then to two other COVID-19 hospitals in the south. 

The Abt LHSS team will continue to play an important role in the health system’s evolution in Kyrgyzstan. “We hope to support the government in expanding this model to the primary care level to ensure that we have a patient-centered, effective health care workforce and are prepared to provide essential services for any future health care emergencies that may arise,” said Ms. Asambaeva. “The Universal Nurse model contributes to pandemic preparedness as well as overall health system strengthening.”

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