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More than a checklist: a realist evaluation of supervision of mid-level health workers in rural Guatemala
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.ORCID iD: 0000-0001-7087-1467
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.ORCID iD: 0000-0002-8052-479X
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.ORCID iD: 0000-0001-7234-3510
2014 (English)In: BMC Health Services Research, ISSN 1472-6963, Vol. 14, no 1, 112- p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Mid-level health workers (MLHWs) form the front-line of service delivery in many low- and middle-income countries. Supervision is a critical institutional intervention linking their work to the health system, and it consists of activities intended to support health workers' motivation and enable them to perform. However its impact depends not only on the frequency of these activities but also how they are carried out and received. This study aims to deepen understanding of the mechanisms through which supervision activities support the performance of auxiliary nurses, a cadre of MLHWs, in rural Guatemala.

METHODS: A multiple case study was conducted to examine the operation of supervision of five health posts using a realist evaluation approach. A program theory was formulated describing local understanding of how supervision activities are intended to work. Data was collected through interviews and document review to test the theory. Analysis focused on comparison of activities, outcomes, mechanisms and the influence of context across cases, leading to revision of the program theory.

RESULTS: The supervisor's orientation was identified as the main mechanism contributing to variation observed in activities and their outcomes. Managerial control was the dominant orientation, reflecting the influence of standardized performance criteria and institutional culture. Humanized support was present in one case where the auxiliary nurse was motivated by the sense that the full scope of her work was valued. This orientation reflected the supervisor's integration of her professional identity as a nurse.

CONCLUSIONS: The nature of the support health workers received was shaped by supervisors' orientation, and in this study, nursing principles were central to humanized support. Efforts to strengthen the support that supervision provides to MLHWs should promote professional ethos as a means of developing shared performance goals and orient supervisors to a more holistic view of the health worker and their work.

Place, publisher, year, edition, pages
BioMed Central, 2014. Vol. 14, no 1, 112- p.
Keyword [en]
Mid-level health worker, Supervision, Performance, Motivation, Realist evaluation, Guatemala
National Category
Public Health, Global Health, Social Medicine and Epidemiology
URN: urn:nbn:se:umu:diva-87000DOI: 10.1186/1472-6963-14-112ISI: 000332617800002PubMedID: 24602196OAI: diva2:705625
Available from: 2014-03-17 Created: 2014-03-17 Last updated: 2015-04-29Bibliographically approved
In thesis
1. Enabling the performance of nurses in rural Guatemala: the role of relationships
Open this publication in new window or tab >>Enabling the performance of nurses in rural Guatemala: the role of relationships
2014 (English)Doctoral thesis, comprehensive summary (Other academic)
Alternative title[sv]
Att stödja sjuksköterskors arbetsprestation i landsbygdens Guatemala : Betydelsen av mänskliga relationer
Abstract [en]

Background: Enhancing the performance of front-line health workers serving vulnerable populations is crucial for redressing inequities. Traditional approaches have focused on introducing technical solutions, such as guidelines and incentives, to modify performance outcomes. Recognition of the complex social nature of health system function draws attention to the intangible software elements that shape performance, including the values, ideas, interests, and norms that guide human behavior and interactions. Insight into the operation of software elements can provide a base for people-focused solutions to support health workers and enable them to confront constraints in low resource settings. This study examines the social environment of the practice of front-line auxiliary nurses (AN) in rural Guatemala, in order to understand the role of health system software elements in enabling their performance and to gain insight into how organizational support can be strengthened through locally-relevant actions.

Methods: A mixed methods approach provided a multi-level view of the AN practice environment, situated in the regional health system of the rural department of Alta Verapaz. Interviews with ANs and observations of practice were conducted to understand the values orienting them and how these shaped their relationships with patients and communities. A theory-driven case study of AN supervision was conducted in selected health posts to understand the values orienting supervisors in their role and examine how these shaped their relationships with ANs. The participatory method of concept mapping was used to examine the views of health workers, district and regional managers on actions to strengthen organizational support for the performance of ANs.

Results: The values of nursing vocation and community connectedness were prominent in ANs’ interpretations of their work. In relationships, nursing principles oriented them to be attentive to understanding patient needs, and a shared ethnic identity and personal experience of local needs served as a base for engaging with local leaders in community work. The dominant orientation of supervisors in their role was managerial control, and it provided limited support. It contributed to standard-centered relationships with ANs focused on fulfillment of ministry criteria. Supervision oriented by a holistic understanding of ANs’ needs and the goal of improving patient care was more successful in enabling AN motivation. This relationship was characterized as people-centered, based in a shared interpretation of the value of work with patients and the responsive support provided to ANs’ problems. “Organizational climate of support across levels”, where working relationships are characterized by respectful treatment, attention to psycho-social well-being and responsiveness to needs, was identified by health-system actors as a top priority for improving performance.

Conclusions: To enable performance, there needs to be a balance between attention to standards and attention to the human dimensions of health worker practice. The dominant approach to supervision did not recognize or build on AN values. Supervision and management should be oriented by a more holistic view of the ANs’ work and their needs, in order to promote a people-centered approach to working relationships. Locally relevant action to strengthen district and regional management’s support for AN performance should focus on operationalizing performance goals that go beyond standards to encompass care that responds to patient and community needs.

Place, publisher, year, edition, pages
Umeå: Umeå universitet, 2014. 101 p.
Umeå University medical dissertations, ISSN 0346-6612 ; 1672
Health workers, nurses, performance, health services management, health systems research, people-centered health systems, work environment, Guatemala
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health
urn:nbn:se:umu:diva-95114 (URN)978-91-7601-128-7 (ISBN)
Public defence
2014-11-14, Sal 135, Allmänmedicin, Institutionen för folkhälsa och klinisk medicin, Norrlands universitetssjukhus, Umeå, 13:45 (English)
Available from: 2014-10-24 Created: 2014-10-22 Last updated: 2015-04-29Bibliographically approved

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