09036_Oms_AlisonHernandez_9,68_C.pdf A lis o n H e r n á n d e Enabling the performance of nurses in rural Guatemala: z E THE ROLE OF n a RELATIONSHIPS b lin g t h e p e r Alison Hernández f o r m a n c e o f n u r s e s in r u r a l G u a t e m a la : T h e r o le o f r e la t io n s h ip s U m e å U Department of Public Health and Clinical Medicine ISBN: 978-91-7601-032-7 n Department of Public Health and Clinical Medicine Epidemiology and Global Health ISSN: 0346-6612 iv e Epidemiology and Global Health Umeå University, SE-901 87 Umeå, Sweden New series nr: 1639 rs Umeå University 2014 www.umu.se/phmed/epidemi it y UmeåUniversityMedicalDissertations NewSeriesNo1672 ISSN0346-6612 ISBN978-91-7601-128-7 Enabling the performance of nurses in rural Guatemala: The role of relationships Alison Hernández DepartmentofPublicHealthandClinicalMedicine EpidemiologyandGlobalHealth UmeåUniveristy SE-90187,Umeå,Sweden NewSeriesNo1672 ISSN0346-6612 ISBN978-91-7601-128-7 Electronicversionavailableathttp://umu.diva-portal.org ResponsiblepublisherunderSwedishlaw: theDeanoftheMedicalFaculty ThisworkisprotectedbytheSwedishCopyrightLegislation(Act1960:729) Copyright(cid:13)c 2014AlisonHernández CoverphotographybyMagnusVollset TypesetbyFranciscoHernández-RodríguezwithLATEX PrintedbyPrint&Media Umeå,Sweden2014 “Injusticeanywhereisathreattojusticeeverywhere. Wearecaughtinan inescapablenetworkofmutuality,tiedinasinglegarmentofdestiny. Whateveraffectsonedirectly,affectsallindirectly.” MartinLutherKingJr.,LetterfromBirminghamJail,1963 Contents Abstract 7 Original papers 9 Prologue 11 Introduction 13 Strengtheninghealthsystems . . . . . . . . . . . . . . . . . . . . . . . . . 13 Healthworkforce: Theroleofmid-levelhealthworkers . . . . . . . . . . 14 Howtoimproveperformanceinlowresourcesettings? . . . . . . . . . . 15 HealthSystemsResearch: understandinghealthsystemsassocialsystems 18 Healthworkerperformance: outcomeandprocess . . . . . . . . . . . . . 20 Background 23 HealthsystemsinLatinAmerica . . . . . . . . . . . . . . . . . . . . . . . 23 HealthworkforceinLatinAmerica . . . . . . . . . . . . . . . . . . . . . . 24 HealthsysteminGuatemala . . . . . . . . . . . . . . . . . . . . . . . . . . 25 HealthworkforceinGuatemala . . . . . . . . . . . . . . . . . . . . . . . . 26 Regionalprioritiesforstrengtheninghealthsystemsandtheworkforce . 28 Objectives 33 Conceptual framework 35 Study context 37 Studysetting: AltaVerapaz . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Organizationoftheregionalhealthsystem . . . . . . . . . . . . . . . . . 37 Methodology 41 Methodologicalorientation . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Researchdesign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 5 Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Ethicalconsiderations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Results 55 Section1: Auxiliarynursesinpractice . . . . . . . . . . . . . . . . . . . . 55 Section2: Supervisorsinpractice . . . . . . . . . . . . . . . . . . . . . . . 62 Section3. Organizationalsupportforperformance . . . . . . . . . . . . . 68 Discussion 73 Valuesorientingauxiliarynursestolocalneeds . . . . . . . . . . . . . . . 73 Limitationsofstandard-centeredsupervision . . . . . . . . . . . . . . . . 73 Potentialofpeople-centeredsupervision: Buildingonprofessionalvalues 74 Localpriorityforsupportingperformance: Strengthenorganizational relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 People-centeredorientationtorelationships: Criticalresourcefor enablingperformance . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Methodologicalconsiderations . . . . . . . . . . . . . . . . . . . . . . . . 77 Conclusions 83 ImplicationsforenablingtheperformanceofnursesinruralGuatemala 83 Summaryofcontribution. . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Acknowledgments 87 References 91 Abstract Background: Enhancingtheperformanceoffront-linehealthworkersservingvulnerablepopu- lationsiscrucialforredressinginequities. Traditionalapproacheshavefocused on introducing technical solutions, such as guidelines and incentives, to mod- ify performance outcomes. Recognition of the complex social nature of health systemfunctiondrawsattentiontotheintangiblesoftwareelementsthatshape performance,includingthevalues,ideas,interests,andnormsthatguidehuman behavior and interactions. Insight into the operation of software elements can provideabaseforpeople-focusedsolutionstosupporthealthworkersandenable themtoconfrontconstraintsinlowresourcesettings. Thisstudyexaminesthe social environment of the practice of front-line auxiliary nurses (AN) in rural Guatemala,inordertounderstandtheroleofhealthsystemsoftwareelementsin enablingtheirperformanceandtogaininsightintohoworganizationalsupport canbestrengthenedthroughlocally-relevantactions. Methods: Amixedmethodsapproachprovidedamulti-levelviewoftheANpracticeenvi- ronment,situatedintheregionalhealthsystemoftheruraldepartmentofAlta Verapaz. InterviewswithANsandobservationsofpracticewereconductedto understandthevaluesorientingthemandhowtheseshapedtheirrelationships withpatientsandcommunities. Atheory-drivencasestudyofANsupervision wasconductedinselectedhealthpoststounderstandthevaluesorientingsupervi- sorsintheirroleandexaminehowtheseshapedtheirrelationshipswithANs. The participatorymethodofconceptmappingwasusedtoexaminetheviewsofhealth workers,districtandregionalmanagersonactionstostrengthenorganizational supportfortheperformanceofANs. Results: Thevaluesofnursingvocationandcommunityconnectednesswereprominentin ANs’interpretationsoftheirwork. Inrelationships,nursingprinciplesoriented 7 ABSTRACT themtobeattentivetounderstandingpatientneeds,andasharedethnicidentity andpersonalexperienceoflocalneedsservedasabaseforengagingwithlocal leaders in community work. The dominant orientation of supervisors in their rolewasmanagerialcontrol,anditprovidedlimitedsupport. Itcontributedto standard-centeredrelationshipswithANsfocusedonfulfillmentofministrycrite- ria. SupervisionorientedbyaholisticunderstandingofANs’needsandthegoal ofimprovingpatientcarewasmoresuccessfulinenablingANmotivation. This relationshipwascharacterizedaspeople-centered,basedinasharedinterpreta- tionofthevalueofworkwithpatientsandtheresponsivesupportprovidedto ANs’problems. “Organizationalclimateofsupportacrosslevels”,whereworking relationshipsarecharacterizedbyrespectfultreatment,attentiontopsycho-social well-beingandresponsivenesstoneeds,wasidentifiedbyhealth-systemactorsas atoppriorityforimprovingperformance. Conclusions: Toenableperformance,thereneedstobeabalancebetweenattentiontostandards andattentiontothehumandimensionsofhealthworkerpractice. Thedominant approachtosupervisiondidnotrecognizeorbuildonANvalues.Supervisionand managementshouldbeorientedbyamoreholisticviewoftheANs’workandtheir needs,inordertopromoteapeople-centeredapproachtoworkingrelationships. Locallyrelevantactiontostrengthendistrictandregionalmanagement’ssupport forANperformanceshouldfocusonoperationalizingperformancegoalsthatgo beyond standards to encompass care that responds to patient and community needs. Keywords. Healthworkers,nurses,performance,healthservicesmanagement, health systems research, people-centered health systems, work environment, Guatemala. 8