enabling the performance of nurses in rural guatemala: the role of relationships alison hernández...
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Enabling the performance of nurses in rural Guatemala:
THE ROLE OF RELATIONSHIPS
Alison HernándezSupervisors: Miguel San Sebastián, Anna-Karin Hurtig, Kjerstin Dahlblom
“At the Heart of the Right to health lies an effective and
integrated Health system”
WHO Health System Building Blocks
“At the Heart of the Right to health lies an effective and
integrated Health system”
Hardware & Software
Wh
o is o
n t
he
FR
ON
T-LIN
ES
?
How to support PERFORMANCE in LOW
RESOURCE SETTINGS?
How to support PERFORMANCE in LOW
RESOURCE SETTINGS?
Health WorkerGuidelines New technology
Incentives
Resourc
es
Health system goals
Guidelines New
technology
Incentives
Resourc
es
Health system goals
Health Worker
Supervisor
Manager
Patient /Community
Organizational
processes
Population: 15 million
Multi-ethnic: 40%
indigenous 23 ethnic groups
Middle-Income Country – Highly
unequal
GUATEMALA
4 RN / 10,000
10 MD /10,000
18 AN/10,000
AUXILIARY NURSES
Largest group of health workers
Work in 3 levels of care – Front line in rural areas
1 year accredited training
ALTA VERAPAZ
Pop:1.1 million90% indigenous (Q’eqchi, Poqomchi’)
High levels of extreme poverty, maternal mortality
Health Region - 19 districts
MAIN OBJECTIVE
Examine the social environment of the practice of front-line auxiliary nurses (AN) in rural Guatemala in order to understand the role of software elements in enabling their performance and gain insight into how organizational support can be strengthened.
SPECIFIC OBJECTIVES
1. Understand the values orienting ANs and examine how they shaped their relationships in practice
2. Understand the values orienting supervisors and examine how they shaped their relationships with ANs
3. Examine ideas of health workers and managers on actions needed to support AN performance
AN
Values
Conditions
Values
Conditions
Supervisor
Manager
Patient /Community
Relationship
RelationshipSupervision
Obj. 2
AN practice Obj. 1
Organizational support
Obj. 3
STUDY 1: Methods
• Exploratory study of factors influencing performance
• Interviews with ANs in primary and secondary care
• Observations, interviews with community, supervisors
• Paper 1: Translating community connectedness to practice ISRN Nursing 2012
Values
Shared experience of needs: Preventable deaths of family members
“Be a person who serves others”“As ANs, we serve the people with the
greatest needs”
AN PRACTICE
Community connectedness
Nursing vocation
{
Conditions
Availability of incentives for community volunteers
Incompatible schedules with leaders
Shortages of medicines and supplies
Values
Community Connectedness
Nursing Vocation
AN PRACTICE
}
{ }Condition
s
IncentivesScheduleResources
Values
Community Connectedne
ss
Nursing Vocation
AN PRACTICE
Relationships
In community workShared interest in health of familiesUnderstanding of local situation Base for relationship with leaders
Attending patientsCope with constraints through more attention to patient relationshipListening to understand needs, gain trust
• Deepen understanding of how supervision functioned to support AN performance
• Multi-case study: Health post supervision
• Realist evaluation – Theory-driven
• Data collection protocol: Interviews with ANs, supervisors, community members, Document review
STUDY 2: Methods
• Case selection: Capture variation
• Data Envelopment Analysis of productivity data for 34 health posts, for years 2008 – 2010.
• Paper 2: Assessing the technical efficiency of health posts in rural Guatemala Global Health Action 2014
• 3 “strong” and 2 “weak” health posts
STUDY 2: Methods
• Analysis: Case reports, Cross-case analysis
• Paper 3: More than a checklist: A realist evaluation of supervision of mid-level health workers BMC Health Services Research 2014
STUDY 2: Methods
Values
Desired outcome: Achieve Ministry standards
View of AN: “Human tendency to neglect”
Desired outcome: Better care for patients
View of AN: “Human being with a hard job”
SUPERVISION
Managerial Control
Humanized Support
{ }
SUPERVISION
Conditions
Relationships
Monitoring criteria were base for relationshipCommunication and support offered focus on attaining standardsAN view: Full scope of work not recognized
Shared view of importance of work was base for relationshipAction guided by AN needs, focused on patient care issuesAN view: Efforts recognized and valued
Values
Managerial control
Humanized support
Standard-centered
People-centered
Standard-centered
People-centered
}
SUPERVISION
ConditionsRelationshipsValue
s
Managerial control
Humanized support
{Structure of routines: District meetings, Reports
Professional principles, Patient-oriented priorities
• Examine dynamics in health system actors views on how AN performance should be supported
• Concept mapping: Multi-step participatory process – visualize ideas and develop frameworks
STUDY 3: Methods
• Paper 4: Supporting the performance of nurses in rural Guatemala (manuscript)
STUDY 3: Methods
ORGANIZATIONAL SUPPORT
Cluster map: Actions grouped by theme
Actions focused on support for ANs, as well as managers and community
Dynamics in ratings
Organizational climate of support rated highest across groups
ORGANIZATIONAL SUPPORT
Interpretation with regional nurse managers
• Climate of support = Positive environment of working relationships +
Responsiveness to needs• Nature of
relationships across levels cross-cutting issue
• Well-being of ANs central to patient satisfaction – influenced by management
The role of software elements in enabling performance
Limitations of standard-centered approaches: Did not build up values that motivated ANs
Need for balance between attention to standards and attention to human dimensions of practice
CONCLUSIONS
How organizational support can be strengthened
Explicit focus on the developing the quality of the relationships across levels
Build on people-centered orientation: Attention to the well-being of the other and responsiveness to their needs
CONCLUSIONS
Implications for global nursing development
Local interdependence of nursing performance and health system environment is a global phenomenon
Enhanced understanding of patterns and dynamics of relationships and complex systems
Improving capacity of organizations to enable nurses’ performance and capacity of nurses to enable performance of paraprofessionals and caregivers
CONCLUSIONS
MUCHAS GRACIAS!