JOGNN Nursing in the

CLINICAL ISSUES

Newly Independent States of the Former Soviet Union: An International Pa~nersb ip for Nursing Develop m en t Lauren Arnold, RN, PhD, lrina Bakhtarina, M D , Ann Marie Brooks, RN, DNSC, MBA, FAAN, ACHE, Sharon Coulter, RN, MN, MBA, CHE, Laura Hurt, RN, MHA, CNAA, Cynthia Lewis, Sharon Weinstein, R N , CR Nl , M S , Jane Younger, RN, MSN, ACHE

= Nursing in the newly independent states of the former Soviet Union has undergone a period of awakening since the fall of the Soviet system. Through international partnerships, health care providers and leaders are considering the importance of a well ed- ucated and appropriately managed nursing work force to the health of society. Nursing reform activities against the backdrop of the Soviet health system are described. JOGNN, 27, 203-208; 1998.

Accepted: October 1997

Health care in the newly independent states of the former Soviet Union has undergone remarkable change since the erosion of communism in 1991. The newly independent states, formerly grouped under the United Soviet Socialist Republic, include the republics of Armenia, Belarus, Georgia, Ka- zakhstan, Kyrgyzstan, Moldova, Russia, Turk- menistan, Ukraine, and Uzbekistan. The geo- graphic span of this region is wide, as is the cultural diversity of its people. The cultural make-up of the newly independent states is varied and includes people of Slavic, Asian, and Mongolian back- grounds. They bring vastly different historic, polit- ical, cultural, religious, and economic perspectives. Since 1945 these countries have operated under a centrally planned system providing access to all

MnrchlApril 1998

necessary goods and services, including food and health care. When communism eroded as the cen- tralized coordinating structure, many countries be- gan to consider and subsequently introduced in- dividual systems for meeting the needs of its peo- ple. Economic development, transportation, food distribution, and health care were the focus for early reform initiatives. These efforts continue as new political models are shaped and take hold.

With the 1991 breakup of the Soviet Union, each of the former Soviet republics suddenly became responsible for developing a self-sufficient system of health care. The sudden loss of the national health system’s infrastructure, especially in relation to the financial system that supported it, meant that re- gional and republican health ministries were given major responsibilities in areas in which they had little or no experience. Thus, health care reform in the newly independent states has taken on a sense of ur- gency as republics attempt to address the many chal- lenges presented when universal access is guaranteed in the f x e of limited resources.

Through many humanitarian aid programs, the United States has established programs to assist in the trnnsition from a communist model of cen- trally controlled and distributed health care ser- vices, to a decentralized model. Included in these programs is an ctfort to assist in nursing reform activities. This ;Irticle provides an overview of

JOG” 203

health care and nursing practice under the Soviet system and discusses nursing reform activities against two di- vergent perspectives: the Soviet model of health care and a new vision of health care for the future.

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The Socialist health care system existed since 1918, with the creation of Narkomzdrav, the National Com- missariat o f Health, the predecessor of the Soviet Ministry of Health. I t was designed to accomplish the following: 1 ) provide health care for all, free of charge, 2) approach health and medical care with a focus on both cure and prevention, and 3 ) make health care a high priority of the government. This design was promoted by the Bolsheviks as a reaction to the decades of neglect under the czarist health system. The predisposition of the new Soviet re- gime toward centralimtion and coordination of planning led to the creation of a system of hospitals and polyclinics under government administration. These principles, al- though admirable, never achieved the full impact prom- ised to the people at the time (Davis, 1989).

Although the Soviet health system ultimately was successful in reaching its goal of providing universal, free medical care, it was done in such a way that quality var- ied widely across populations. Separate health systems were maintained for different populations. The party/ government elite were provided unique access to the best facilities and providers and had made available to them necessary medications and therapeutic techniques. For other segments of society, medical care was provided as it was available, often with long waits and payments to physicians and hospitals for services and for therapeutics and supplies. Rural populations suffered even more than their urban counterparts because access to services and to providers was scarce in those communities. The orig- inal model was designed to focus on preventative, pri- mary care. In reality, curative approaches prevailed be- cause of access and quality problems. The Ministry of Health established productivity guidelines that were ex- cessively burdensome on physicians, despite the overall high number of physicians employed in the Soviet health system (Rowland & Telyukov, 1991).

A l t h o u g h the Soviet health system ultimately

was successful in reaching its goal of providing

universal, free medical care, it was done

in such a way that quality varied widely

across populations.

The Ministry of Health, as the coordinating and governing body for the supply and distribution of health care services and products, had jurisdiction over two sep- arate branches of health care: the sanitary-prevcntive network, which was responsible for public health activ- it ies a n d f LI nc t i on s, a id the c ii ra t i ve- preven t i ve network , which was responsible for the network of hospitals, polyclinics, ambulatories, and dispensaries. In addition, the Ministry of Health also had jurisdiction over medical education and medical research. Nursing education fell under medical education governance in this model.

Entry into the health system was determined by numeroils factors. Initial access to care might be based on geography or employment, party membership, vet- eran statis, or financial status. These factors determined the type of care made available. However, for most of the population, a patient’s path into the system was de- termined largely by his or her place of residence. Pa- tients, ultimately, did not have choice about their pro- viders. This pattern continues to dominate.

A district system coordinates care for populations. Subdistricts or iichastoks are populated with approxi- mately 5,000 individuals. Clinics in these areas are typ- ically staffed by feldshers (similar to nurse practitioners in the United States). Approximately 10 to 15 subdis- tricts make up a district or rnyoii. Each rayon has a com- plete health system, with a hospital system and network of polyclinics. Districts are grouped into oblasts, serving approximately 1 to 5 million individuals. Within an oblast are comprehensive health services at all levels. However, for most individuals health care is sought at community-based polyclinics and ambulatories. Individ- uals were, and in many cases still are, assigned to pri- mary care professionals, usually feldshers, who provide basic diagnostic and treatment services (Ryan, 1978).

Access to care, built on a primary prevention model, in theory promised improved health status for individuals. The original notion of making health care a high national priority met resistance as competing agen- das developed throughout the century. The Soviet gov- ernment designated only 4% of the gross national prod- uct for financing the health care system because the system was considered to be an unproductive industry. By 1989, state funding for health care was only 3% to 4% of the gross domestic product, compared with an OECD average of 7.3% percent in 1987. Resources that might otherwise have been used for health care werecon- sumed by a robust defense program and by other com- peting initiatives, leaving the health care system broken and the Soviet people in despair about their health status (Rowland & Telyukov, 1991). However, until the fall of communism, the Soviet people believed their health sys- tem to be of comparatively high quality. One health min- ister relayed the impression that for 40 years they were led to believe that their system of care and their tech-

204 JOGNN Volrinie 27, Nuwiher 2

nologies were state of. the art. Now as they are able to learn about the health care developments in other coun- tries, they see how wrong their beliefs were. Awakening from that helief has been a shock for many. Recent com- parisons of health indicators present a population-wide, national picture of poor health, declining life expec- tancy, rising rates of communicable diseases.

The medical and nursing education systems under the Soviet system continue today with only minor mod- ifications. Would-be medical and nursing professionals enter professional school directly from secondary or high school. Nursing school consists of approximately 2 years of basic science and health curriculum structured and taught by physicians. Education for feldshers is a year longer than that for nurses. In the third year of the cur- riculum, feldshers specialize in either a clinical area or in a service sector (such as industrial nursing). In the field of maternal-child health, midwives are the advanced practice specialists who provide care in polyclinics, birth- ing houses, and in ambulatory clinics. Their education is specialized from initial entry into nursing school, at which time they declare their clinical specialty. Physician training school also begins immediately after secondary education, with a 6-year curriculum focused on general sciences with approximately 1 year of practical educa- tion (Picard & Perfiljeva, 1995).

Nursing practice under the Soviet system was char- acterized by low status, poor wages, and underdeveloped skills and role functions. The role of the nurse was de- signed to serve other professionals (usually physicians), rather than patients. Compared with their international counterparts, nurses employed in hospitals under the So- viet system functioned a t a technical level more similar to that of nursing assistants than to professional nurses. That comparison continues to hold true in many cases. However, advanced practice nurses, feldshers, and mid- wives experienced a high level of autonomy. This is true today, particularly in community and industrial settings, where they hold responsibility for prevention, health promotion, and illness care.

C o m p a r e d with their international

counterparts, nurses employed in hospitals

under the Soviet system functioned at a technical

level more similar to that of nursing assistants

than to professional nurses.

Under the Soviet system, medical and nursing ed- ucation programs produced large numbers of physi- cians and nurses, so there is a manpower oversupply. Full employment for all, guaranteed under the Soviet system, found job opportunities for the many gradu- ates of nursing and medical education programs. Un- der the evolving health care structiire, employment rates previously supported under the Soviet system will not be affordable. One of the many issues facing health care leaders is how best to adequately size the work force and how best to implement strategies to reduce the oversupply of providers available. Today the countries of the former Soviet Union have an over- supply of capacity in all segments of the health care system. Large hospitals with low occupancy rates place a burden on health care financing. Personnel oversupply additionally burdens the underfinanced health system.

t mergi ng f r o m the S o \ i ct S !,\ t c i i i : C LI r rcn t ii lid Fu t 11 r c I)i rec t i o 11 s for- Health CAW Reform

With the breakup of the Soviet Union and demise of the communist government, each of the former Soviet republics became responsible for developing a self-sufficient health care system. The elimination of federal level institutions to legislate and oversee the supply and distribution of goods and services left the republics with an undefined system of health care. Thus, local authorities were required to take greater control and responsibility for the financing and regu- lation of health care. However, the capacity of local authorities to manage health care delivery in the face of shrinking resources is limited. As a result, most hos- pitals report a shortfall of funds, and many providers find themselves in precarious employment situations (Bernal, Church, Arevian, & Schensul, 1995; Picard & Perfiljeva, 1995).

Health reform in the newly independent states en- compasses a wide array of initiatives, ranging from fi- nancing to provider utilization and role definitions. Nursing leadership has entered the reform arena with the energy and commitment to establish a professional model of practice, built upon: a nursing education model designed and taught by nurses; a nursing-based gover- nance structure to legislate and direct practice; a care delivery model that uses the skills and abilities of nurses. Leaders in the reform movement are working to improve health status indicators and to advance the status of nurses (Smith, 1994).

Health care developments in the newly indepen- dent states include not only system reforms, but also technology transfer. Techniques not previously possible are proliferating in most specialties of practice. Health

MarchlApril 1998 JOG" 205

care providers, both physicians and nurses, are being challenged to acquire new knowledge and skills at a rapid pace. New and future generations of providers will be expected to attain a level of cspertise and technical competence comparable to that o f their international counterparts. This rapid growth is exponential, not generational.

Pivotal reform in nursing education is required to meet society’s demands for an improved health care product. Reform activities are under way. Looking to- ward the future, nursing education leaders have de- clared the need for self-control over curriculum design and teaching and for the movement toward a univer- sity base for educational programs. Toward that end, disc us s i o ns and t i ego t i a t i o ti s w i t h mi t i is t r y of fic i a Is have begun.

For practicing nurses, efforts are under way to redefine their roles and responsibilities, to enhance their s k i 1 Is, a ti d to d e v e 1 o p organ i z a t i on a 1 111 ode I s that move tow a r d s e 1 f - de t e r in i t i a t ion of practice , a u - tonomy, and accountability. Leaders in this arena are working tow a r d gove r t i a nce structures that leg i sl a te and direct practice through licensure, standards, and other initiatives. The formation of professional as- sociations in each of the republics has been a high priority of nursing leaders. With these associations modeled after international counterparts, it is hoped that they will provide the forum for reform initia- tives. Association presidents have been elected in many of the republics. With help and assistance from U.S. partners and other international counterparts, association leaders have begun the task of defining their mission and priorities as they address the task of reforming nursing.

Through education and practice reform

initiatives, health ministry leaders have become

newly educated about the pivotal importance of

nursing in health care delivery.

Through education and practice reform initia- tives, health ministry leaders have become educated about the pivotal importance of nursing in health care delivery. Through partnership activities with nurses of the United States and other countries, health ministers have been educated about the benefits society derives from a well educated and properly governed nursing work force. I t is apparent that they are beginning to

see that appropriately educated nurses can care for pa- tients with complex medical problems and can assist i n the t r a t i s fe r a n d i t i co r p o r a t i 0 1 1 of tech t i o log ic ad - vances into the health care delivery system. They also have become educated about the economics of etn- ploying well educated nurses. Negotiations to expand nursing roles and responsibilities are under way; it is hoped that ultimately a care delivery model will be developed that appropriately employs nursing resources.

The Russian health system, now grossly under- funded and seriously disorganized, is crippled by a lack of resources. The general population suffers. For women and children, conditions are worse. They are victims of economic exploitation and political margin- alization. Women earn one-third less than their male counterparts. Lack of access to services, particularly family planning programs, places them a t high risk for m u 1 tip I e a bo r t i ons a nd infection -re 1 at ed i I1 n es ses . In 1995, infant mortality was 2 7 deaths per 1,000 live births (Bellamy, 1997) . Many infants and children lack appropriate nutrition and suffer economic hard- ship. Schools are overcrowded, and environmental hazards abound. In 1995, only 21% of 6 - to 7-year- old children were reported to be in good health. For the same year, maternal mortality was 75 per 100,000 live births (Bellamy, 1997). These maternal-child health indicators are alarming, placing Russia among the countries with the worst such statistics worldwide.

The health system founded in Russia emphasized community-based programs and prevention. Health system elements not valued were patient rights, pri- vacy, consent, and the development of clinically ap- propriate programs. The birthing experience is cold, isolated, stressful, and not private. Births typically oc- cur in birth houses or in maternity hospitals. The en- vironment of many of these settings is unwelcoming, cold, dark, dreary, and threatening. The staff appear to approach their work from a detached perspective, offering little help and guidance to birthing families. Modern equipment is seldom available to diagnose complications of labor and birth, properly anesthetize patients, or warm or resuscitate infants. Until recently, fathers and significant others were not allowed to at- tend births. Informed consent and patient education have begun to be incorporated into care.

Through hum an i ta r ia n aid programs, major gains have been achieved. New programs offering childbirth education have been introduced, as have clinical training programs to upgrade the quality of clinical care offered to women and families.

206 JOGNN Volume 2 7, Number 2

I'artnerships: Learning From Each Other

International experiences offer numerous oppor- tunities for growth and development. After the demise of the Soviet structure, numerous humanitarian efforts were sponsored by the U.S. government and by private organizations. One such program, the American Inter- national Health Alliance, created hospital-to-hospital partnerships that established exchange programs for health care providers of the United States and the newly independent states of the former Soviet Union. These ex- periences offered the opportunity for each to learn and to benefit from an expanded view of health care in the global setting. From their U.S. partners, nurses of the newly independent states learned of the arduous efforts to reform nursing practice in the United States during the last century. They learned of current thinking in nursing practice models, nursing curriculum, and gov- ernance. They were surprised to observe the highly com- plex skills used by nurses and were impressed to see the technology used and the environments in which nurses conduct their work. They also observed the similarities all nurses face in addressing the issues and challenges of providing health care with ever-shrinking resources and creating a vision for the future.

Maternal-child health, as only one focus of the partnership, was an area of great importance. Part- nerships addressed clinical care needs through educa- tion, role modeling, mentoring, and general support. Within the partnerships, work with city officials, health ministers, hospital directors, physicians, and nurses was undertaken. All received the same message: value the family unit as it approaches childbearing; design programs that enhance the experience; create clinically safe methods; and incorporate the family unit, the community, and providers to achieve the best outcomes. It was found that with a positive, suppor- tive approach, readiness to incorporate new thinking was improved. In summary, Table 1 outlines the major areas of focus for improvements in maternal-child health that were addressed in one of many partner- ships to improve such health care in the newly inde- pendent states of the former Soviet Union.

From their partners from these newly indepen- dent states, the U.S. nurses learned of incredible te- nacity, through attempts to define professionalism against all odds. The U.S. nurses learned of unique abilities to create helping and healing environments with little resources. Together, the two groups of nurses learned of more similarities than differences, and together they learned that more can be achieved through partnerships than in isolation.

As we move to a global economy in business, we must be prepared to create international health care system linkages to serve the growing international em-

TABLE 1 Programs Designed to lmpmve Maternal/ Child Health in the Commonwealth of Independent States

1. Nursing and midwifey cum'cuhm enhancements to address the psychosocial and educational needs of childbearing families, nursing processes, and access to knowledge sources.

2. Medical school curriculum enhancements to upgrade knowledge of clinical techniques and to expand access to knowledge sources.

3. Continuing education programs on all aspects o f maternal child health conducted through modeled interdisciplina y collaboration.

4. Consultations with the health ministty to improve the birthing experience for women by altering regulations to humanize the environment and to consider issues of access and choice.

national, regional, and local levels to energize advocacy activities on behalf of nurses and the populations they senre.

define appropriate management and leadership models to support the enormous changes required in the system.

7. Collaboration with hospital administrators to alter regulations about the care process and environment, attendants at birth, and infection control policies.

implementation: childbirth education, community outreach and education, and clinical care, including prenatal evaluation sewices, infant resuscitation, maternal risk assessment, and higb- risk pregnancy management.

I-

5. Collaboration with nursing leadership at the

6. Collaboration with nursing administrators to

8. Consultation about program design and

ployee base. Future initiatives aimed a t partnerships and transfer of technology and knowledge will ex- pand. Although our differences currently can be de- scribed as extreme, the gaps will shrink a t a rapid pace, and our futures will grow more similar. Learning from each other will enhance the benefit worldwide society may derive from a skilled and well-managed nursing work force.

KEFER1:NCE.S

Bernal, H., Church, O., Arevian, M., & Schensul, S. (1995). Community health nursing in a former Soviet Union Re- public: A case study of change in Armenia. Nursing Out- look, 43, 78-8 %.

Bellamy, D. (1997). The state of the world's children. New York: Oxford University Press. 80-81.

Davis, C. (1989). In M. Field & R. Saltman (Eds.), The inter-

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national handhok of health care systems (p. 323). New York: Greenwood.

Picard, C., 8: Perfiljeva, G. ( I 99.5). Nursing: Visions and re- alities. Nursing 6 Health Care: Perspectrzles on Com- munity, I(,,, 126-130.

Rowland, D., 8: Telyukov, V. (1991). Soviet health care from two perspectives. Health Affairs, 10. 71-86.

Ryan, M. (1978). The organization of Soviet medical care. London: Basil Blackwell.

Smith, L. S. (1994). Nursing in Russia: Impact of recent po- litical changes. In J. McCloskey and H. Grace (Eds.), Current issues in nursing (pp. 595-602). St. Louis: Mosby.

Lauren Arnold is a senior manager for Ernst & Young in Phil- adelphia, PA.

Irina Bakbtariiia is dean of the Post Graduate Nursing School of Hospital 122 in St. Petenburg, Russia. Ann Marie Brooks is the vice president of Patient Care in Saudi Arabia. Sharon Coulter is the vice president of Patient Care Services of Via Health in Rochester, NY. Laura Hurt is the director of Medical Surgical Nursing at Grady Memorial HospitaVHealth System in Atlanta, GA. Cynthia Lewis is a program analyst for American lirterna- tional Health Alliance in Washington, D.C. Sharon Weinstein is the director o f the Ofice of International Affairs of Premier, Inc., in Westchester, IL. Jane Younger is the senior vice president and chief operating officer of Clark Memorial Hospital in Jeffersonville, IN. Address for correspondence: Lauren Arnold, RN, PhD, 40 Carter Lane, Elkins Park, PA 1902 7.

For information about earning continuing education credit using this and other Clinical Issues articles, call AWHONN, 800-673- 8499, extension 1623.

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