Background: The performance of front-line health workers is critical for improving the health of vulnerable populations. Performance is a complex behavior generated through interactions between health workers, the health system and communities served. In Guatemala, where front-line nurses serve rural communities with great health needs, a concept mapping study was carried out with actors from different levels of a regional health system to develop an integrated view on how performance can be supported in this setting.
Methods: The concept mapping process began with four sessions engaging a total of 93 regional and district managers, and primary and secondary care health workers in generating ideas on actions needed to support nurses’ performance. Ideas were consolidated into 30 action items, which were sorted by 12 managers and rated by a total of 135 managers and health workers from different levels. Maps depicting domains of action and dynamics in sub-groups’ interests were generated using a sequence of multivariate statistical analyses and were interpreted by regional managers.
Results: The combined input of regional health system actors provided a multi-faceted view of actions needed to support performance, which were organized in six domains, including: Communication and coordination, Tools to orient work, Organizational climate of support, Motivation through recognition, Professional development and Skills development. The nature of relationships across hierarchical levels was identified as a crosscutting theme. Pattern matching and go-zone maps depicted dynamics in the interests of sub-groups of actors, indicating directions for action based on areas of consensus and difference.
Conclusions: This study indicates that rural nurses’ performance is interconnected with the performance of other actors in the regional health system who require support, including managers and community-level collaborators. Organizational climate is critical for making rural nurses feel supported, and the nature of relationships across levels shapes the way actions to support performance are implemented and received. The participatory nature of the conceptmapping process enables regional health system actors to collaborate in co-production of context-specific knowledge needed to guide efforts to strengthen performance.
Health worker, nursing, performance, health services management, regional health system, concept mapping