Pilot project
Advanced Nurse Practitioner
at the primary level
roles distribution among primary health care providers in Ukraine
Agreed that part of the family phisician`s task may be delegated to the nurse
Support the idea of expanding the role of the nurse
managers
doctors
nurses
Our approach
Pilot project “Advanced Nurse Practitioner in Primary Health Care” improves the availability of healthcare services for patients and efficient use of resources in health care by strengthening the role of nurses. In particular, this includes the introduction of separate reception of patients by family doctors and nurses in the primary healthcare facilities and improvement of clinical and communicative competences of nurses.
The comprehensive report detailing the results of the pilot project "Advanced Nurse Practitioner in Primary Health Care" is available here.
At this page you will learn the details of implementation of the pilot project “Advanced Nurse Practitioner in Primary Health Care” in chronological order, studies and analytical work which preceded the pilot project and look behind the scenes of every project activity.
This page will be interesting for PHC teams, i.e. nurses and family doctors, as well as health managers who seek to develop quality and availability of services at their healthcare facilities.
We are happy that the information that we have collected for the page will become a convenient guide for you as we did not only describe a theoretical component of the project intervention, but also presented a collection of practical tools which you can use to implement similar initiatives for advancing the role of nurses at your primary healthcare facilities. View the programs of trainings in clinical and communicative skills development, examples of how to communicate with patients about reception of patients by an advanced nurse practitioner and many other things below!
The history of our pilot project began in 2021 when the team of the Ukrainian-Swiss project “Medical Education Development” prepared the policy brief “The Role of Nurses in Primary Health Care: Modern Models” . In this document we presented the reasoning and scope of advancing the role of nurses which is currently implemented in different European countries. We also explored the potential for introducing the advanced roles in PHC in Ukraine.
In addition, the project team conducted the representative study “Role Distribution Among Primary Healthcare Providers in Ukraine” whose results showed that medical doctors, as well as nurses and management representatives would like to give more power to the nurse as a service provider in primary care. In particular, 59% of managers and 45% of doctors agree that some of the family doctor’s duties can be delegated to a family nurse. Managers, medical doctors, and nurses also support the idea of expanding the role of the nurse (84%, 65%, and 52% respectively).
Thus, we determined one of the vectors to enhance the efficiency of healthcare services in PHC, and in April 2021, jointly with the Ministry of Health of Ukraine, selected 8 Ukrainian healthcare facilities out of 30 applicants to participate in the pilot project “Advanced Nurse Practitioner”.
Initial evaluation
In order to evaluate the potential and readiness of the pilot healthcare facilities for advancing the role of nurses our project team processed the application documents of the pilot healthcare facilities, made a brief on each of them, and developed and conducted a survey of 169 nurses working there. The survey results were presented in details by project experts Matviy Khrenov and Ivan Didyk during the Nursing Forum.
Below we are sharing the key findings and conclusions based on the survey results and visits to the pilot healthcare facilities during the first phase of the pilot project:
Time of patients` admission to the doctor according to the results of the questionnaire within the piot project:
time required to make an appointment
from 4 hours
1 day
2 days
3 days
4 days
till 5 days
waiting in line time
from 5 min.
till 2 hours
%
of respondents are satisfied with the nurse’s work, but the major concern is the low level of satisfaction with the level of salary.
%
of respondents feel independency working as a nurse and with regard to them making decisions. The nurses rated the amount of responsibility in their work at a high level, although they highlighted the low level of their involvement in the discussion of cases by doctors.
%
of respondents are motivated to work as a nurse. We registered a low level of opportunities for training and encouragement of proposals offered by the management, as well as ideas to improve health care.
%
of respondents noted that there is no separate reception of patients by nurses at the healthcare facilities. Only the Centre for Primary Health Care in Rivne has two rooms for pre-medical examination. That is where independent nursed work who are not members of the conditional ‘doctor-nurse’ team. They perform the following functions: collect patients’ complaints, do electrocardiography, measure blood pressure, pulse oximetry, visual acuity, height and weight, and perform a Ruthier test.
%
of respondents noted that nurses do not perform pre-medical surveys at any pilot healthcare facilities.
Based on the results, our project team, together with the external consultants, planned the implementation and key activities of the pilot project with regard to broader involvement of nurses into the process of health care provision.
Below is the chronology of the pilot project implementation and topics and content of activities we have implemented.
Nursing Forum
The Nursing Forum became a powerful platform for networking within the medical community. Thanks to the efforts and willingness to develop of nursing community leaders, as well as doctors and managers, the forum became the platform for deep and meaningful discussions about the most important issues related to quality, accessibility and efficiency of medical care. Such events make an important contribution to strengthening the role of nurses as medical care providers, especially in PHC. Find the Forum program at the link. Дивіться відео з форуму:- The Role of a Nurse in the Patient’s Life, Anastasiia Leukhina
- Presentation of the concept “Advanced Nurse Practitioner: Model Piloting”, Matviy Khrenov, Ivan Didyk
- Presentation of the results of the study “Distribution of Roles Among Doctors and Nurses in PHC”, Daryna Bohdan, Mladena Kachurets
- Session “Stethoscopes for Nurses”, Iryna Voloshyna
- Presentation of the direction “Nursing” from AFMU, Iryna Voloshyna, Vadym Vus
- Peer Groups as CPD for Nurses, Nataliia Osadchuk
- Panel discussion about CPD for Nurses, Svitlana Dudnyk, Natalia Ruzhylo, Vadym Vus, Oleksandra Palahitska and Iryna Voloshyna
Feedback from the Forum participants:
“It’s a great pleasure to see that we, nurses, are finally heard a little”.
“I wish to have more interesting projects specifically for nurses because this is really inspiring, stimulating, uniting the nursing work, and teaching to work in a team! There are more and more of us who want to change a rotten system and change the quality of nursing for better. I believe that we can do it together”.
“Here one can express their dissatisfaction, proposals, thoughts without any problems... It’s a pleasure to have the colleagues who are able to hear!!!”
“I’d like to have more events like this; it unites, detects the problems of nursing and allows to address the urgent issues”.
Intensive educational course for nurses
Intensive educational course for nurses in Zhytomyr One of the findings of the mentioned study “Distribution of Roles Among Doctors and Nurses in PHC in Ukraine” was the lack of competences required for the nurse’s work in PHC teams due to the imbalance of theoretical and practical parts in their education, as well as obsolescence of methods and formats of the nurse’s education. The study showed that at that time there was a number of skills required for the advanced role but nurses did not possess them: resuscitation measures, ECG interpreting, otoscopy and ophthalmoscopy techniques, methodology of testing using rapid tests, etc. As the key to successful expansion of the role of nurses is ensuring conformity of their competences to functions that were planned to be vested on them, during the intensive course the nurses of the pilot healthcare facilities attended a series of trainings and master classes in clinical and communicative skilled which had been prepared by the trainers of the Academy of Family Medicine of Ukraine: ISBAR, a tool for communication in a medical team; clinical tasks in immunization and “red flags”; how to involve a patient into the treatment process; how to work in a team, and many other things. View the photos from the intensive educational course hereFeedback from the event participants:
“Thank you for the event! I can now feel that I’m important and that my profession is important as such fantastic speakers and trainers spent their time and shared their knowledge with me”.
“It was very valuable to hear about the extended powers for nurses and tools for implementation of this project in PHC in Ukraine. It’s cool to try to implement it in practice”.
“A year ago in the frame of the Project we only thought about how to strengthen nursing in PHC in Ukraine, and today we already see the inspired nurses who will start receiving patients separately as soon as in October. New skills and knowledge offer unprecedented opportunities — for this we are here. We believe that the pilot project “Advance Nurse Practitioner in Primary Health Care” will create a landscape of opportunities for Ukrainian PHC professionals. We hope that as soon as in 2022 we will share our experience and positive feedback from patients”.
Informing patients about a separate reception by nurses
The patients’ attitude to nurses is largely affected by the previous experience of accessibility of GPs and specialty physicians. Especially in large cities, patients got used to having easy access to GPs and specialty physicians and share a stereotype about low competence of nurses and quality of their services. That’s why an important component of the pilot project was communication of the advanced role of nurses to patients. For this purpose the project team developed a series of individual posters displaying nurses of every pilot healthcare facility. The patients’ trust to advanced nurse practitioners is a vital success factor for their roles. Some studies show the patients’ trust to advanced nurse practitioners at the level of 95% (Griffiths et al., 2018). Thus, the patients of the pilot healthcare facilities were able to learn from the posters what the advanced nurse practitioner is and why it’s worth turning to them. We introduced patients to the skills and qualification of nurses, and after the positive experience of interaction with nurses we hope that the level of trust to nurses has become higher. We believe in the importance of the human-centred approach in health care and are sure that this format of communication with patients is important to be implemented at the healthcare facilities.Capacity development of PHC teams: online trainings for healthcare facilities
From the results of the initial survey we understood that the majority of PHC teams had been working in a purely hierarchical mode where a doctor decided everything and a nurse was responsible for execution of his/her orders. Therefore, under the new conditions there was a risk that they would repeat the practices which had been established long ago and were also usual for patients. The implementation of the advance role of nurses at the level of PHC facilities is a complicated and multi-vector process that requires a lot of will and effort of all the members of PHC teams, both clinical and managerial. Trust and interaction in the team are some of the priorities and necessary conditions for the successful implementation of the advanced role of nurses (Hutchinson et al., 2018). Therefore, we took into account this very topic and the topic of teamwork when planning educational activities for nurses, doctors and management teams of the pilot healthcare facilities. View the programs of the trainings for different target audiences below:- while working with management teams we helped the teams of pilot healthcare facilities to build the systems of material and non-material motivation, develop the indicators to measure the quality of nurse’s work, and form a customer-oriented approach;
- we conducted a series of online consultancies with health managers to audit the patient route, points of interaction with a facility at the stages of appointment and receiving a service, and identify all the processes that require changes;
- we conducted the webinars for the representatives of reception offices and contact centres in effective communication where the participants learnt the general rules of building a quality telephone conversation at a healthcare facility, jointly developed and processed the algorithm of patient appointment with advanced nurse practitioners, created a template of typical telephone requests and patients’ objections, and looked into the tools of effective communication with patients;
- trainings in communicative skills for nurses were important as nurses need a composition of knowledge in clinical work and interpersonal communication. Effective communication skills are an important element of nursing in all the areas of activity: prevention, treatment, therapy, rehabilitation, education, and health promotion. During the webinar in communicative skills nurses learnt the peculiarities of independent reception of patients, communication with a patient at all stages of interaction, secrets and tools of effective communication, as well as crisis communication;
- for doctors we conducted the webinar in effective communication and teamwork with regards to the separate reception and delegation of functions to nurses. The doctors worked on the changes which would take place with the introduction of the new medical service “consultancy of the advanced nurse practitioner”;
- trainings for nurses with a practicing psychologist were focused on motivation and setting goals for personal development of nurses.
Development of team competencies at the forefront: online trainings for pilot institutions
Trainings for healthcare facilities: medical care during the war With the beginning of the russia’s full-scale invasion of Ukraine the direction of the project’s educational activities changed in line with the new reality and challenges which PHC providers faced. Thus, nurses and doctors learnt the specifics of providing medical care during the war, new approaches to care for patients, in particular, remote consulting and working with stress.- Series of trainings in remote consulting during the war The first stage of the training was related to the specifics of remote consulting of patients with different requests. Nurses and doctors of the pilot healthcare facilities learnt to consult patients with diabetes, COPD and asthma, acute stress, arterial hypertension, and learnt the peculiarities of the algorithm of the telephone and online consultation.
- Peculiarities of medical care under stressful factors The second part of the course in medical care during the war was dedicated to trainings with a practicing psychologist. During these trainings PHC teams of the pilot facilities learnt about the nature of stress, common reactions to stress, and mastered the tools that allow helping both oneself and patients with acute stress reactions.
- Trainings in tactical medicine and triage for civilians The third component of the educational course in medical care during the war was the training in tactical medicine for doctors and nurses of the pilot healthcare facilities. The training consisted of two parts: a theoretical online part and practical offline part with practicing skills in every individual facility. The trainings program was based on the MARCH (Massive hemorrhage-Airways-Respiration-Circulation-Hypothermia). Nurses and doctors practiced the skills of applying different types of tourniquets, inserting a nasopharyngeal tube, applying an occlusive dressing, decompressing thoracic spine, applying a splint, making a dressing, as well as analysed situational tasks in triage.
Feedback:
“It’s important that we did not abandon the initiative “Advanced Nurse Practitioner in Primary Health Care” with the beginning of the russia’s military aggression. Our nurses continue working with patients, consult and complete questionnaires because diseases haven’t disappeared. Today communication with every patient takes nurses more time than before, there’s a great need for psychological support of patients, especially the elderly ones. Frequent air raid alerts made us prefer working with patients by phone as safety is above all”. Viktoria Pokoievchuk
“The topics of trainings fully meet the current needs of nurses who can immediately apply the received knowledge and skills in their professional activities. From the feedback we can see that the employees of our pilot facilities are satisfied and are eager to study further”. Ivan Didyk
Освітній інтенсив для команд ПМД
We conducted the intensive educational course for PHC teams in Lviv in October 2022. During the event we focused on working with nurses, doctors and managers since it has been proven that team work reduces medical errors, increases patient safety and decreases mortality rates among patients (Royal College of Physicians, 2017). During the trainings the participants developed clinical and communication skills. The facilities shared the results of implementation of the advanced role of nurses and analysed success and obstacles in the pilot project implementation. Watch the recording of the panel discussion “Experience of distribution of roles in PHC: qualification or trust” with participation of Viktoriia Pokoievchuk, Vadym Vus, Daryna Bohdan, Kateryna Huriienko and Nataliia Palii. View the photos from the intensive course for PHC teams here.Feedback from the participants:
“Personally, I liked the format, there was plenty of new information, and I was also really inspired by trainings and workshops in practicing clinical skills. I’d love to continue studying in this way!”
“Thank you for helping us, nurses, to gain confidence and trust”.
“Our meetings are always inspiring and guide us to self-develop and lead the way”.
“Nurses have overcome their fears, become more confident in consulting patients, speaking at conferences, and sharing their experience with colleagues. Doctors have also begun to trust their nurses more because they see that they are constantly learning and improving their competences”.
Study tour for PHC teams to Croatia
The final educational activity in 2022 was the study tour for PHC teams of the pilot facilities to Croatia. During the tour the participants explored the peculiarities of providing primary health care services in Croatia, distribution of roles in the PHC teams in Croatia; analysed interaction between a nurse and GP at the primary healthcare facilities with different categories of patients and in different services; gained insight into the approaches used to ensure the quality of services, planning, and provision of CPD for nurses and doctors. The study tour lasted for three days and a half, and the managers of the pilot healthcare facilities, nurses, doctors, peer group facilitators, representatives of the Ministry of Health of Ukraine and National Health Service of Ukraine participated in it. We had selected the study tour participants based on their motivation letters. The event program included the visits to the Croatian PHC facilities of different sizes and forms of ownership, public institutions, where the participants learnt the approaches to organizing primary health care in Croatia and explored the role of nurses in this process. See the tour program here. View the photos fromday 1, day 2 and 3, and day 4. Watch the video “PHC in Croatia: experience and insights of the study tour”Feedback from the study tour participants:
“I became sure once again that the teams of people working together are behind global systemic changes. But, of course, changes should also be local for this process to be bilateral. And the availability of huge resources is not mandatory when the system is built based on the principle “care for every citizen”. Anastasiia Hibeskul, Kryvyi Rih .
“I think nurses should be given more purely medical tasks. During all possible events it is necessary to communicate to doctors that nurses are valuable as medical professionals in the team and not as office employees who fill out medical paperwork”. Natalia Osadchuk, Chernivtsi
Trainings in development of clinical competences for nurses of pilot primary healthcare facilities
In January-April 2023 every pilot facility selected three most relevant trainings in clinical skills for their teams:- Basic otoscopy skills.
- Working with objections and helping at grief.
- Practicing the skills of examination of children under one year. Check list of a healthy child.
- Screening of mental disorders and basic counselling skills.
- Fundamentals of ECG recording and interpretation.
Feedback from the participants:
“We often have different trainings at our facility. But for the first time I had faced the situation that while making the list of participants it was so difficult to decide whom to select. Thus, new knowledge, practical skills which were thoroughly practiced by every participant, positive emotions and a very friendly atmosphere in communication with partners is an amazing result of three trainings which ended last week.
Our nurses feel more and more confident as they improve their knowledge level during such modern formats of professional trainings and are proud to say that these trainings are held specifically in the nursing development project. It definitely commands more and more respect to the role of nurses among doctors”. Valentyna Duka, Rivne
Our partners
The pilot project “Advanced Nurse Practitioner in Primary Health Care” was implemented with support of professional trainers and speakers; thanks to their expertise it became possible to achieve all the successful results listed above. We are grateful to:
Matviy Khrenov
co-founder of the Ukrainian Health Centre (UHC)
Ivan Didyk
medical Director of the "Vidnovlennya" Medical Center
Iryna Voloshyna
family doctor, member of the board of the Academy of Family Medicine of Ukraine NGO
Ihor Zastavnyi
family doctor, co-founder and member of the board of the Academy of Family Medicine of Ukraine NGO, co-owner and doctor at the network of family outpatient clinics “VULYK”
Volodymyr Shlionskyi
family doctor, the Academy of Family Medicine of Ukraine NGO
Vadym Vus
general practitioner, trainer of the Academy of Family Medicine of Ukraine, trainer of doctors' competencies in projects of the Ministry of Health, WHO, UN Development Program, USAID
Olena Vus
nurse, primary health care center in Karpylivka village
Mychailo Wynnyckyj
vice President for science and training, Associate Professor at the Sociology Department at the National University of Kyiv Mohyla Academy
Dmytro Huliayev
head of publishing, research, and education projects at the Ukrainian Anti-Stroke Association NGO
Fedir Lapiy
doctor, paediatric infectious disease specialist, Head of the National Technical Expert Group on Immunoprophylaxis
Anastasiia Khodan
family doctor, national MhGAP trainer, member of the board of the Academy of Family Medicine of Ukraine NGO, co-founder of the family outpatient clinic “VULYK”
Inga Bayer
expert in external and internal communication, former head of external communication and speaker at the NHSU
Ivan Kondratenko
general practitioner of the highest qualification category, instructor in pre-medical care for adults and children
Olena Kondratenko
family doctor, Medical Center "Medical Practice for Family"
Oleksandr Pavlishevskyi
family doctor, trainer at the Academy of Family Medicine of Ukraine
Anastasiia Leukhina
founder of Horizontal NGO, author of A Non-Scary Book
Iuliia Volodina
general practitioner, Head of Medical Leaders NGO
Iryna Fryz
practicing psychologist, Associate Professor, Department of General, Developmental and Educational Psychology, Zhytomyr Ivan Franko State University
Khrystyna Stroiich
family doctor, the Academy of Family Medicine of Ukraine
Anna Kyrynychna
general practitioner, trainer in pre-medical care and tactical medicine
Taiisa Kanevska
deputy Head at Scientific and Practical Centre “UNIT” NGO, senior instructor at the training centre UNIT (first aid and special training)
Liudmyla Rakovska
paediatrician, founder of two medical centres “HELP kids+”, Associate Professor at the Department of Paediatrics No 2 of V.N. Karazin Kharkiv National Medical University
Natalia Tunik
family doctor, Director of the Novotroitsk Primary Health Care Center
Ivan Kutchak
family doctor, the Academy of Family Medicine of Ukraine
Anastasiia Spasibo
family doctor, founder of Ridni Medical Centre
Kateryna Bliashyk
family doctor, the Academy of Family Medicine of Ukraine
Oksana Petrynych
family doctor, Assistant Professor of the Family Medicine Department, Bukovinian State Medical University, trainer at the Academy of Family Medicine of Ukraine