Community Engagement

Undergraduate reform: Nursing students

Swiss TPH and the Institute of Nursing Science in Basel worked together to build the skills of nurse tutors to teach key competencies, to revise the curricula for nurse students, and to set up clinical skills bases at the nursing colleges. The latter work focuses on two colleges, in Dushanbe and Kulob. At these colleges, nursing and midwifery programs follow a common curriculum in the first three years, after which the students enrol in their respective specialty training for their fourth and final year. The work that was done to build nurse tutor capacity was carried out by nurse practitioners to foster greater prestige and recognition of the role of the family nurse.

Proven results

To assess nursing students’ perceptions of their learning environment, the Dundee Ready Education Environment Measure (DREEM) instrument was applied as a baseline in two nursing colleges in 2015. The DREEM is a well-established tool for measuring the subjective educational environment in medical education programs. It consists of a 50-statement questionnaire with the possibility to respond along a five-point Likert-scale ranging from 0 to 4 (strongly disagree 0, disagree 1, unsure 2, agree 3, strongly agree 4). Based upon the findings of the baseline study, steps were taken to refresh the curriculum, improve the clinical skills lab, build the didactical skills of tutors, and bring more nurses into teaching to help establish a positive role model for nursing students. The DREEM was re-applied in late 2018 to assess the change in perceptions over time. The results show that between 2015 and 2018, the perception of the learning environment improved with a significant increase of the mean total DREEM score and a significant improvement for all sub-scores over time. These scores are indicative of a positive evolution, so it is generally recommended to maintain the current strategic direction. However, there are still areas of concern which include that more efficient use could be made of the Clinical Skills Labs and that the teaching style still remains too teacher-centred. Many students suffer from high levels of stress. Therefore, adequate monitoring systems, support structures and counselling should be developed.

Dushanbe DREEM Scores Kulob

2015 n=297 2018 n=315 60%

precentage of max. score 90% 2015 n=332 2018 n=294

31.2 34.7 Studentʼ perception of learning 32.1 35.4

27.5 32.0 Studentʼ perception of teachers 28.0 32.1

22.6 25.0 Studentʼ academic self-perception 23.7 26.8

32.0 35.7 Studentʼ perception of atmosphere 32.8 37.2

18.4 19.5 Studentʼ social self-perception 18.3 19.7

131.8 146.9 Total Score 134.9 151.2 “Being in the clinical environment sets necessary conditions for us to learn what it is like to be a nurse and how nurses can indeed help people even in desperate situations. Being next to real nurses and patients is a completely different experience compared to standard learning practices at the nursing college.”

Jahonoro Asrorova

Nursing Student, Dushanbe, Tajikistan

Medical Education Reform: Tutorship in Family Nursing in Tajikistan

Postgraduate reform

MEP has facilitated the establishment of a 2-year postgraduate training for family doctors at the Post Graduate Medical Institute PGMI. The course is comprised of 20% theory and 80% practice and takes place in policlinics and rural health centres. It is delivered by trained and certified family doctors (clinical tutors) under the supervision of the PGMI. The ordinators (residents) are integrated into the team with growing responsibility over the course of the two years.

Proven results

An evaluation of the 2-year postgraduate training used Multiple Choice Questions (MCQs), and measured clinical skills, attitudes and behaviour through an OSCE with different stations to assess history taking, examination, interpretation of lab results and communication skills.

Postgraduate Education Achievements

The two-year specialty training was completed by 143 ordinators in the timeframe 2013-2019, with 138 of them deployed by the Ministry of Health to work as family doctors in rural districts.

Local health administrators are very pleased to have these well trained young family doctors in their PHC facilities. In some districts, they have been the first to join the PHC workforce in over 10 years.

Family doctors’ 2-year postgraduate specialty training in Tajikistan

Three groups were compared – Ordinators entering the specialty training; Ordinators completing the specialty training (newly graduated family doctors); as well as Interns completing the traditional, unstructured 1 year work experience which is all that is otherwise available in Tajikistan for the training of family doctors.

Group Description

Ordinators-1st year (N=20) Graduated medical students newly entering the 2-yr specialty programme

MCQ Sample OSCE Sample

N=20 N=20

Interns (N=22)

Ordinator Family Doctors (N=26) Newly graduated family doctors that underwent the 1-year internship (unstructured work experience)

Newly graduated family doctors who just completed the 2-yr specialty programme N=8 N=6

N=26 N=24 Compared to the other 2 groups, the Ordinator-Family Doctors achieved statistically significantly better scores in the OSCE test (61%, representing 84 out of 139 possible marks), with the Ordinators-1st year gaining the next highest results and the Interns performing worst of all. In fact, no statistical difference could be observed between Interns and Ordinators-1st year for either MCQs or OSCE; this indicates a lack of professional progress of the Interns during their one-year work experience.

Final scores (OSCE)

% correct answers mean values

100 Continuous Professional Development

The traditional form of Continuous Professional Development (CPD) is based on one or two months of theoretical courses that are taken every five years. These courses are primarily taught at an institution in the capital Dushanbe, but also in some other cities (Khuchand, Kulob, Khorog). They enable doctors to reach a higher level of income and focus on knowledge rather than competencies.

50

0 61%

47%

Ordinator Family Doctors Ordinators- 1st year

45%

Interns

Based on this positive evaluation a case for investing in the 2 year training of family doctors was generated. The slightly higher costs of the 2 year course are more than off-set by the resulting benefit of having better educated family doctors providing higher quality care. This indicates the value for money given by these Swiss investments. “Medical Education needs to be innovative to meet the needs of practical medicine. Continuous education needs to be introduced as a new learning tool for acting family doctors in Tajikistan. Initiatives such as peer groups helps family doctors keep up with new developments in medicine and enhance their clinical skills.”

Qodirjon Kholbekov

Peer group facilitator, Tursunzoda, Tajikistan

Peer groups

The concept of peer groups has been introduced as a potentially cost-effective CPD option. These are groups of family doctors and/or nurses, usually from the same or neighbouring districts that meet on a regular basis to discuss clinical topics and find solutions to problems faced in everyday practice. A facilitator is chosen by each peer group on a rolling basis to help coordinate meetings. A 2017 study found that family doctors in districts with peer groups were more involved in CPD activities and perceived the flexible choices of the content and timing of CPD meetings and types of CPD events positively. Conversely, family doctors from districts without peer groups complained about the lack of sufficient exposure to clinical updates and limited topic choices.

Peer Groups as a strategy for continuing medical education in Tajikistan

Credit-based system of CPD

To build a system of CPD that meets the World Federation for Medical Education standards and applies to modern adult learning theory, a transparent, nationwide credit-based CPD system for all specialties will be needed. The on-going MoHSP-led pilot in one district is a positive step in this direction. Additionally, in the long term, the role of professional associations needs to be strengthened and an independent agency of accreditation established to assure the quality of CPD provided by teaching institutions. With support from MEP, the Tajik Association of Family Medicine has joined the World Organisation of Family Doctors (WONCA). On the occasion of the last Family Doctor Day the activities organised in Dushanbe by the Ministry of Health and Social Protection with the Tajik State Medical University were included in the WONCA news roundup.

Impact of Medical Education Reform on the people of Tajikistan

As the percentage of people living in rural areas is rising at a faster rate than in urban areas, providing healthcare to the rural population remains an immense challenge. Through the strengthening of primary healthcare and the building of a workforce of well-trained doctors and nurses, the MEP contributes to the improvement of health outcomes in Tajikistan and acts as a model for other countries working towards achieving UHC through medical education. “I have a long-term history with this health center. The reason which makes me come back to same health center is the attitude of health professionals and quality of care one can observe in this facility.”

Female patient and her grandson

Dushanbe, Tajikistan