Alison Hernández

105 Pages·2014·4.45 MB·English

09036_Oms_AlisonHernandez_9,68_C.pdf
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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
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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.
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