6,322 miles from Atlanta is another Georgia, a country smaller than South Carolina, with half the population of the greater Chicago area, and has only 1.6 times the funding of Tufts University. 1,2 Despite its seemingly insignificant size and influence, Georgia has played a central role in regional politics for centuries as one of the only Christian, democratic countries (actually, the first) in the region, surrounded by Muslim, totalitarian nations. A former Soviet state located in the Caucus Mountains, Georgia is a developing country whose health care system is currently in a state of transition and reform. It is shown that low nurse staffing levels hinder the development of the health care system.
Nursing on a Global Level
The world has entered a critical period of human resources for health, and the scarcity of qualified nurses is amongst the most challenging obstacles to improving health care. 3 As indicated by Buchan and Aiken et al. in Solving nursing shortages: a common priority, 3 low nurse staffing levels are linked to multiple negative health outcomes, including: increased mortality rates, 4 adverse events after surgery5, increased incidence of violence against staff6, increased accident rates and patient injuries, 7 increased cross infection rates8, and frequent job burnout. 9
THE GEORGIAN HEALTH CARE SYSTEM
During the communist era in Georgia (1921-1991), the Soviet health care system, referred to as the Semashko model, was adopted. Characterized by universal, free health care, hierarchical facilities, and publicly funded institutions, the Semashko Health Care System was a highly centralized and efficient system that temporarily elevated the quality of health and health care in Georgia. Nevertheless, Georgia was not able to sustain the resource intensive system following the fall of the Soviet Union, especially considering its basis on hospital, in-patient medical care and lack of focus on primary care and preventive medicine. Public funding fell from $149 per capita to $.45 per capita in 1990. The 51-54.5% of the Georgian population living below the poverty line struggles financially, in part due to this expensive, corrupt payment system. 10 The results of a 2000 Tbilisi household survey conducted by the Curatio International Foundation indicate that the poorest households spend almost a quarter of their income on out of pocket health care expenses compared to only 15% by wealthier.11 Moreover, the struggling state of the Georgian health care system is reflected in the country’s poor national health status: life expectancy is low (73.1 years in Georgia compared to 78.5 in the E. U.), maternal mortality rates are high (40.3 per 100,000 in Georgia compared to 11 per 100,000 in the U. S.), and infectious diseases, especially tuberculosis, are still significant public health problems. 10
The health care system has undergone a series of reformations since independence from the Soviet Union. 1995 marked the introduction of a social health insurance program that made payroll taxes mandatory for the development of a state health fund (SHF); however, it was abolished in 2004. Thereafter, the Governmental Commission for Health and Social Reforms, the State Minister of Public Reforms, and the Ministry of Health, Labor, and Social Affairs (MoHLSA) developed “Main Directions in Health 2007-2009”, which outlines a three year health sector transformation. It focused on ensuring affordability, quality, accessibility, and efficiency of health services. It also introduced market-based principles to health care management; nearly 80% of hospitals were sold to the private sector in 2007 as a result. Despite these continued attempts at reformation, Georgia is hindered by lack of political will to prioritize health for national development and fund the health sector accordingly. 10
Nursing Practice and Nursing Education in Georgia
Nursing in countries in transition from a totalitarian government to a democracy, such as Georgia, is especially important to the quality of health care delivery. 10Despite this crucial role of nurses, the quality of nursing practice was negatively impacted by recent events in Georgia, including: the socioeconomic crises, civil war, increased unemployment, and intensive migration observed since the 1990’s.10 The quality of nursing practice was exacerbated by the relocation of 270,000 internally displaced persons (IDPs) following the recent civil wars in Abkhazia and South Ossetia; many hospitals were overtaken by IDPs following the conflicts. 13Furthermore, nursing departments are severely understaffed; the ratio of nurses to physicians in Georgia 0.9, which is significantly lower than that of more developed countries with more effective health care systems. ^10^
The health care system is controlled by the MoHLSA, and the current state of nursing education and its regulation does not demonstrate promise for improving the quality of clinical nursing practice. Relative to western standards, the quality of nursing education is very low, and little has changed in the structure of nursing education since the fall of the Soviet Union. Nurses are only educated in ‘nursing colleges’ that offer technical medical education; currently, no university level baccalaureate programs are offered in nursing. Nurses have the option to begin education after ninth grade, followed by three years of training, or after eleventh grade, followed by two years of training. Many nurses are simply medical students who begin working part time during medical school. There is no national competency examination or standard licensure for nurses; hence, determining the quality and legitimacy of resource limited nursing institutions and private nursing schools proves to be difficult. This absence of a systematic, federal regulation of the nursing profession explains the lack of public respect for nurses. Only recently was nursing recognized by Parliament as a separate profession, and the first national nursing organization, the Georgian Nursing Association (GNA), was created. 13 This lack of education regulation also correlates to lower quality of health care delivery and poorer patient health outcomes; it is shown that patient outcomes suffer if nurses are not educated and prepared to meet the modern challenges in healthcare. 13
Research on the relationship between patient outcomes and nurses’ level of education shows that in hospitals with higher proportions of nurses educated at the higher level, patients experience lower mortality rates. 14 Therefore, improving the quality of nursing in Georgia would correspond to decreased severity of health discrepancies, improved health care delivery, and improved health status.
REGISTRATION SYSTEM AS PREFACE FOR IMPROVING CLINICALCOMPETENCY OF NURSES
Partners for International Development (PfID), a non-governmental organization funded by the United States Agency for International Development (USAID), and the Georgian Nursing Association (GNA) are collaborating in the execution of a multidimensional health care reform initiative, which includes improving the quality of nursing in the Republic of Georgia. The development of a national nursing database registration system is one component of this program, and it will strengthen the nursing profession in several ways. Firstly, the nursing database will create national avenues of communication between nurses, health administrators, and governmental officials. Currently, the paper-based reporting structure for nurses is unreliable and results in discrepancies between different national data sources, as well as highly variable records of trends in nursing education. 10,15 Lack of reliable nursing workforce information also seriously impairs the development of effective workforce policy and the appropriate allocation of resources. 15 Hence, the conversion to an electronic, web-based system will provide accurate and easily accessible workforce data capable of influencing health policy in the MoHLSA.16 Secondly, the national registration system will accurately determine the number of nurses in the country, (which is currently unknown), as well as document their personal demographic information, educational history, and work experience. Knowing the level of training nurses have received will facilitate the development of education courses to meet specific needs and therefore help to fully utilize nursing resources. Developing such opportunities for higher nursing education will correlate to improved national health. Thirdly, the database system will help Georgian nursing to achieve its full potential; workforce data is a necessary prerequisite for the effective deployment of staff because it enables nursing managers to review patterns of activity and education. 16 PfID partners will consult with MoLHSA regarding development of a countrywide database for nursing including employment institution and positions of practicing nurses.
Developing a nursing database system in Georgia will facilitate the development of educational programs to address inadequacies in the training of nurses, which will strengthen the competency of nurses in a clinical setting and ultimately improve the quality of health care nationwide. Education programs for nurses have been developed through the Emory University Atlanta-Tbilisi Partnership, whose aim is “to build a lasting bridge between…academic communities, and to make a long-term impact on the quality of education, science and health in the Republic of Georgia”. 18 Through this partnership, courses in Nursing Triage, Infection Control, Pain Management, Intravenous Therapy, Physical Assessment, and other disciplines have been developed at several partner hospitals in Tbilisi, including: Iashvili Central Children’s Hospital, Gudushauri National Medical Center, National Center of TB and Lung Diseases, and the Central Clinical Hospital. These programs are proven to be effective; nursing students in 2006 demonstrated an increase in scores by 27.5% between mean initial and final test scores. The complete nursing workforce assessment and database development, and conversion of the paper-based reporting structure to an electronic, web-based model will require an estimated three years, $29,765.20 budget, and 25 person reporting structure to execute. Upon completion, the database system should focus the efforts and funding of USAID and PfID in targeting the deficiencies in clinical training of nurses to improve clinical efficiency and competency.