Enabling the performance of nurses in rural Guatemala: THE ROLE OF RELATIONSHIPS Alison Hernández Supervisors: Miguel San Sebastián, Anna-Karin Hurtig,

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!