Results of Nursing Training Reforms: Estimating the Scope of Results of Nursing Training Reforms: Estimating the Scope of Nursing Practice Nursing Practice

Background : With the adoption of the Astana Declaration on primary health care, modern approaches are being introduced in the Republic of Kazakhstan. The created national foundations of the nursing management system in Kazakhstan are a visible manifestation of a new organizational culture. In connection with the large-scale reform of nursing and the creation of a new position of nurses that meets modern social challenges and international requirements, the role of nurses in healthcare has increased signi ﬁ cantly. In this study, we measured the actual scope of nursing practice among nurses in the medical organizations in the Republic of Kazakhstan. Methods : We performed a cross-sectional descriptive quanti ﬁ cation study using electronic questionnaire on the actual scope of nursing practice in the Kazakh and Russian languages. The study group consisted of 146 registered nurses working in state organizations of the Republic of Kazakhstan. Results : Nurses from primary care organizations have demonstrated the high complexity of ful ﬁ lling the scope of nursing practice. There were minor differences in the performance of simple nursing tasks depending on the level of education. Nurses with postgraduate training and bachelor ' s education were signi ﬁ cantly more likely to practice high complexity of actual scope of nursing practice than nurses with a college diploma. Conclusion : The overall mean of the actual volume of the nursing practice is 5.09. The actual scope of nursing practice of high complexity was performed more often by primary care nurses (5.65). Nursing education reform in Kazakhstan is demonstrating positive results.


Introduction
W ith the adoption of the Astana Declaration on Primary Health Care (PHC), modern approaches to primary care are being introduced in the Republic of Kazakhstan [1].The nursing process brings a new understanding of the role of a nurse in practical healthcare in Kazakhstan [2].Increasing attention is paid to good nursing practice in the provision of primary health care, early diagnosis and, most importantly, prevention of diseases and complications that are impossible without the active use of nursing staff, their knowledge, and skills [3].
Nowadays, the primary care nurse is actively involved in disease management, teaching patients and their relatives how to perform simple manipulations, and to competently provide emergency first aid, etc. [4,5].
The comprehensive plan for the development of nursing in the Republic of Kazakhstan included the reform of healthcare organization structures based on parallel and equal management structures, where nurses and doctors could work independently while being part of a single system [1,6].A new generation nurse now participates in the development of management decisions to improve the efficiency of a medical organization and independently conducts scientific research.Based on the results of these studies, nursing specialists are able to implement new activities on their own and also have the opportunity to train nursing personnel by the nurses themselves [7,8].
The Republic of Kazakhstan has undertaken ambitious reforms in its education and healthcare systems.Since 2015, the goal has been to improve the efficiency of the public health system and government regulation [9,10].Due to the large-scale reform of nursing care and the creation of a new position of nurses that meet modern social challenges and international requirements, the role of nurses in healthcare has significantly increased [11].
Nursing education at all levels e vocational and higher education e has been reformed in line with European requirements for medical education and established master and doctoral programs.New educational programs include courses in nursing management and support a new generation of common thinking, as well as a deeper shared understanding of the role of nurses and their power in service management [12].
In 2018, Kazakhstan hosted the graduation of the country's first applied bachelor's of nursing [13].Educational programs of 6e8 qualification levels are being implemented, where academic bachelors, masters, and, PhD nurses receive training.Thus, today, health care organizations employ nurses who have been trained on the basis of general secondary education for 10 months in college and college graduates with a full cycle of technical and vocational education (college diploma -CD), applied and academic bachelors of nursing (BSN) and Masters of Science (Postgraduate).
In 2018, a pilot project introduced a new nursing service model in healthcare organizations of the Republic of Kazakhstan to improve nursing education and the nursing process in accordance with good international nurse-run clinics [14].Within the framework of the project, the staff of the patronage service of the PHC organization was trained, and curators were trained to monitor the effectiveness of the work of the patronage service [15].In the process of joint development of new nursing management structures in pilot healthcare organizations in Kazakhstan, changes in legislation were made, and nurses have the prospect of occupying new, more independent positions at all levels in healthcare organizations.Internal standards of operating procedures have been developed for extended and delegated functions of nurses of different levels of education [16].
Nowadays, there are no tools that assess the scope of nursing practice including their level of complexity of the activities performed.As a result of an extensive literature research and the study of competencies that correspond international requirements, we have chosen the questionnaire «The actual volume of nursing practice» (ASCOP) to assess the results of the latest reform in Kazakhstan.This tool developed by D'Amour D. et al. [17] is used to measure the extent to which nurses apply the breadth of their professional practice and it can be used as an instrument to measure systemic change and determine the effectiveness of reforms, such as in Kazakhstan.The objective of this study is to gain some insight into the practice of nursing in public health services in the Republic of Kazakhstan through measuring the actual scope of nursing practice among nurses in the medical organizations in the country.

Design
А cross-sectional descriptive quantification was performed in this study.The study group included nurses working in state organizations (one hospital and five polyclinics) of the Republic of Kazakhstan.

Participants
A public link to the electronic questionnaire was sent by SMS via phone numbers of chief nurses in the 32 medical organizations in different regions of Kazakhstan for further distribution to participants.Out of the 152 responses that we received, only 146 were eligible for data analysis.All respondents were informed about the study, including a description of the project and the purpose of the study, the voluntary nature of participation, the anonymity of all organizations and respondents, the contact details of the researcher, and that the analysis would be carried out by the researcher himself.The data collection period was from JulyeSeptember 2022.

Instrument
An electronic version of the actual scope of nursing practice questionnaire (ASCOP) was used [17].We obtained permission to use and translate the tool into Kazakh and Russian from the original author, Dr. D'Amour [17], via email correspondence.The questionnaire was translated from English by qualified translators and tested on a focus group with 35 nurses working in Almaty city hospital #5.Internal consistency and validity check demonstrated an alpha coefficient of 0.88 for all 26 points.
The only published tool that measures the volume of nursing practice and reflects the core competencies of nurses is the Actual Scope of Nursing Practice questionnaire.Nurses completed the ASCOP themselves containing 26 items.The amount of practice was assessed on a six-point Likert scale ranging from never to always.Each competency in the questionnaire was assigned a complexity level from one to three.Every level represented activities of varying complexity, ranging from assessing the patient's condition, assessing the specific information and educational needs of the patient, and ending with participation in the development, implementation and updating of patient care programs; ensuring the continuity of treatment and coordination of the actions of the interprofessional team.

Statistical analysis
The obtained data were performed using statistical methods (SPSS software v.24.0).A descriptive analysis of participant characteristics was collected based on frequencies, percentages, means, and standard deviation results.The presentation of the data went through two stages.The characteristics of the participants and the corresponding total ASCOP score for each group were determined.Descriptive analysis was followed by a t-test, and analysis of variance ANOVA (KruskaleWallis test).The mean values of the ASCOP scale parameters, standard deviations, and their correlation with the educational level of the participants and the current position of the nurse were followed.

Ethical approval
The study was approved by the Local Ethics Committee (IRB-A391 from 24.03.2022) of Al-Farabi Kazakh National University, Almaty, Kazakhstan.

Results
In general, the overall ASCOP score for each dimension varied.The mean ASCOP score for each parameter ranged from 4.18 to 5.74 (overall mean ¼ 5.09).Significant differences were found in the total ASCOP score for socio demographic characteristics, as shown in Table 1.The age of the participants was between 19 and 58 years old (M ¼ 38.1, SD ¼ 8.6), and 100% of participants were women.The nurses had been working for an average of 14 years (Me ¼ 11, SD ¼ 7.6).
More than half of the respondents (63%) worked as regular nurses, 26% as senior nurses and 11% as chief nurses.A regular nurse refers to the senior nurse at the unit or department level, and a senior nurse refers to the chief of nursing staff at the level of the entire organization.
Tables 1 and in assessing the level of ASCOP, it is interesting that nurses aged 25e44 years showed higher levels (M ¼ 5.37, SD ¼ 1.10) than their younger (M ¼ 5.07, SD ¼ 1.7) or older counterparts (M ¼ 5.24, SD ¼ 1.09).Nurses that most commonly worked in a primary care organization practiced the highest level of ASCOP N ¼ 92 (63%) (M ¼ 5.57, SD ¼ 0.75) compared to hospital nurses (M ¼ 5.06, SD ¼ 1.03), p < 0.001.Nurses with 6e10 years and 11e15 years of experience had higher ASCOP scores (M ¼ 5.21, SD ¼ 1.08 and M ¼ 5.21, SD ¼ 1.12) than those with less than 6 years of experience and more than 16 years of experience.The position also showed an impact on the level of ASCOP, chief nurses demonstrated the level 5.60 (SD ¼ 1.01).Similarly, nurses with a master's degree had higher levels of ASCOP (M ¼ 5.14, SD ¼ 1.02) than a vocational college graduate nurse (M ¼ 4.61, SD ¼ 1.05), p ¼ 0.003.
Table 2 shows that for all types of competencies, a high level was demonstrated by nurses with a master's degree and nurses from polyclinic organizations.This is especially evident in the competence of the nursing process and clinical decision-making with elements of assessment and care planning: the level of masters M ¼ 5.11 (SD ¼ 1.11) is higher than in the others, p < 0.001.Teaching and coaching outpatient nurses had the highest competencies: M ¼ 5.17 (SD ¼ 1.34) than in other organizations, p ¼ 0.210.These differences are not statistically significant.Practice levels of ASCOP difficulty among study participants (Table 3) showed interesting results.Low complexity tasks did not differ significantly from the point of view of the place of work, p ¼ 0.23.Moreover, low-complexity tasks were more often practiced nursing bachelor graduates and masters than nurses with a college degree, p ¼ 0.003.On the other hand, high complexity ASCOP differed significantly between graduate and graduate nurses p ¼ 0.010.ASCOP of high complexity was performed more often by primary care nurses 5.65 (1.13), p 0.001.

Discussion
Effective nursing management requires a good understanding of cultural issues and competencies associated with change processes.An essential component of successful change in nursing education is understanding the importance of assessing cultural influences and having adequate cultural competencies to guide the change process.D'Amour D. et al. [17] showed that the average score for the actual volume of the nursing process as a whole is 3.47, indicating that nurses' practice less than their optimal volume.A cross-sectional survey of 178 registered nurses in Canada illustrated an overall mean score of 4.8 [4], indicating that registered nurses in interprofessional primary care teams are almost involved in activities.
In a similar study of Khalid A. Aljohani et al. [7] in Saudi Arabia, where 928 nurses participated, the overall mean score was 4.59.Postgraduate nurses were found to be significantly more likely to practice high complexity actual volume than graduate nurses.This is the first study that examines the level of competence of nurses in Kazakhstan.Several studies [18] in various areas of development of nursing showed that more than 95% of undergraduate nurses wanted to have a highly qualified mentor with a higher nursing education.The results of the study [19] in Aktobe city (Kazakhstan) showed high professional satisfaction of nurses, despite low satisfaction with wages and conditions for its implementation.
Kazakhstan improves its nursing service model for the effectiveness of nursing service management in organizations of practical health care based on the revision of the role of nursing staff in the treatment and diagnostic process.
In our study, we encountered difficulties in reaching a large number of nurses, despite the fact that the survey was conducted online and sent to 32 medical organizations in different regions of Kazakhstan.We suppose that these are characteristics of mid-level healthcare workers who are accustomed to receiving directives from their supervisors.The results of this study cannot be generalized, and further research is needed with the involvement of the leaders of medical organizations themselves in order to ensure the maximum number of nurses participate from different regions for a clear understanding of the entire nursing process.
There are certain problems due to the lack of direct payments for nursing services, which negatively affects the quality of nursing services, reduces the motivation of administration and staff to develop the proper level of nursing services, increases the professional burnout of nurses, reduces nurses' satisfaction with the working environment and increases staff turnover, which further increases the cost of medical organizations.The low staffing and high workload of nurses, especially bachelor degree qualified nurses, also offsets the benefits from increased nursing hours by bachelor's degree.Bachelor's level nurses usually have difficulty if their workload is more than 8 patients.

Conclusions
The ASCOP Nursing Guidelines are important for preparing nurses with good nursing practice.This study showed that there are a number of differences in nursing practice, however, the place of work and the level of education affect the duties of nurses.
Nurses in primary care organizations have shown a high degree of difficulty in completing the dimension of nursing practice.The overall mean of the actual volume of the nursing practice is 5.09.ASCOP of high complexity was performed more often by primary care nurses (5.65).There were minor differences in the performance of simple nursing tasks depending on the level of education.Nurses with graduate and bachelor's degrees (BSN) practiced high complexity ASCOPs significantly more often than nurses with a college diploma (CD).

Table 1 .
Characteristics of the participants and the corresponding total score ASCOP.

Table 2 .
Average (SD) score on the ASCOP scale parameters depending on the education of the nurse and the place of work (N ¼ 146).

Table 3 .
Mean (SD) score on ASCOP complexity level by nurse education and place of work (N ¼ 146).
a KruskaleWallis test.