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Enabling the performance of nurses in rural Guatemala: the role of relationships
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
2014 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Att stödja sjuksköterskors arbetsprestation i landsbygdens Guatemala : Betydelsen av mänskliga relationer (Swedish)
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.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1672
Keyword [en]
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
Identifiers
URN: urn:nbn:se:umu:diva-95114ISBN: 978-91-7601-128-7 (print)OAI: oai:DiVA.org:umu-95114DiVA: diva2:757472
Public defence
2014-11-14, Sal 135, Allmänmedicin, Institutionen för folkhälsa och klinisk medicin, Norrlands universitetssjukhus, Umeå, 13:45 (English)
Opponent
Supervisors
Available from: 2014-10-24 Created: 2014-10-22 Last updated: 2015-04-29Bibliographically approved
List of papers
1. Translating community connectedness to practice: a qualitative study of midlevel health workers in rural Guatemala
Open this publication in new window or tab >>Translating community connectedness to practice: a qualitative study of midlevel health workers in rural Guatemala
2012 (English)In: ISRN Nursing, ISSN 2090-5483, E-ISSN 2090-5491, Vol. 2012, 648769- p.Article in journal (Refereed) Published
Abstract [en]

Background. The performance of midlevel health workers is a critical lever for strengthening health systems and redressing inequalities in underserved areas. Auxiliary nurses form the largest cadre of health workers in Guatemala. In rural settings, they provide essential services to vulnerable communities, and thus have great potential to address priority health needs. This paper examines auxiliary nurses' motivation and satisfaction, and the coping strategies they use to respond to challenges they confront in their practice.

Methods. Semistructured interviews were conducted with 14 auxiliary nurses delivering health services in Alta Verapaz, Guatemala.

Results. Community connectedness was central to motivation in this rural Guatemalan setting. Participants were from rural communities and conveyed a sense of connection to the people they were serving through shared culture and their own experiences of health needs. Satisfaction was derived through recognition from the community and a sense of valuing their work. Auxiliary nurses described challenges commonly faced in low-resource settings. Findings indicated they were actively confronting these challenges through their own initiative.

Conclusions. Strategies to support the performance of midlevel health workers should focus on mechanisms to make training accessible to rural residents, support problem-solving in practice, and emphasize building relationships with communities served.

National Category
Nursing Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-66628 (URN)10.5402/2012/648769 (DOI)23097715 (PubMedID)
Available from: 2013-03-18 Created: 2013-02-26 Last updated: 2017-12-06Bibliographically approved
2. Assessing the technical efficiency of health posts in rural Guatemala: a data envelopment analysis
Open this publication in new window or tab >>Assessing the technical efficiency of health posts in rural Guatemala: a data envelopment analysis
2014 (English)In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 7, 23190- p.Article in journal (Refereed) Published
Abstract [en]

Introduction : Strengthening health service delivery to the rural poor is an important means of redressing inequities. Meso-level managers can help enhance efficiency in the utilization of existing resources through the application of practical tools to analyze routinely collected data reflecting inputs and outputs. This study aimed to assess the efficiency and change in productivity of health posts over two years in a rural department of Guatemala.

Methods : Data envelopment analysis was used to measure health posts' technical efficiency and productivity change for 2008 and 2009. Input/output data were collected from the regional health office of Alta Verapaz for 34 health posts from the 19 districts comprising the health region.

Results : Technical efficiency varied widely across health posts, with mean scores of 0.78 (SD=0.24) and 0.75 (SD=0.21) in 2008 and 2009, respectively. Overall, productivity increased by 4%, though 47% of health posts experienced a decline in productivity. Results were combined on a bivariate plot to identify health posts at the high and low extremes of efficiency, which should be followed up to determine how and why their production processes are operating differently.

Conclusions : Assessing efficiency using the data that are available at the meso-level can serve as a first step in strengthening performance. Further work is required to support managers in the routine application of efficiency analysis and putting the results to use in guiding efforts to improve service delivery and increase utilization.

Place, publisher, year, edition, pages
Umeå: Umeå University, Centre for Global Health Research, 2014
Keyword
data envelopment analysis; efficiency; Malmquist; primary health care; health services management; Guatemala
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-85680 (URN)10.3402/gha.v7.23190 (DOI)000329933800001 ()24461356 (PubMedID)
Available from: 2014-02-10 Created: 2014-02-10 Last updated: 2017-12-06Bibliographically approved
3. More than a checklist: a realist evaluation of supervision of mid-level health workers in rural Guatemala
Open this publication in new window or tab >>More than a checklist: a realist evaluation of supervision of mid-level health workers in rural Guatemala
2014 (English)In: BMC Health Services Research, ISSN 1472-6963, E-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
Keyword
Mid-level health worker, Supervision, Performance, Motivation, Realist evaluation, Guatemala
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-87000 (URN)10.1186/1472-6963-14-112 (DOI)000332617800002 ()24602196 (PubMedID)
Available from: 2014-03-17 Created: 2014-03-17 Last updated: 2017-12-05Bibliographically approved
4. Supporting the performance of rural nurses: a concept mapping study with regional health system actors in Guatemala
Open this publication in new window or tab >>Supporting the performance of rural nurses: a concept mapping study with regional health system actors in Guatemala
(English)Manuscript (preprint) (Other academic)
Abstract [en]

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.

Keyword
Health worker, nursing, performance, health services management, regional health system, concept mapping
National Category
Public Health, Global Health, Social Medicine and Epidemiology Nursing
Research subject
Public health
Identifiers
urn:nbn:se:umu:diva-95112 (URN)
Available from: 2014-10-22 Created: 2014-10-22 Last updated: 2015-04-29Bibliographically approved

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