1. Enabling the performance of nurses in rural Guatemala: THE ROLE OF RELATIONSHIPS Alison Hernández Supervisors: Miguel San Sebastián, Anna-Karin Hurtig, Kjerstin Dahlblom

2. “At the Heart of the Right to health lies an effective and integrated Health system”

3. WHO Health System Building Blocks “At the Heart of the Right to health lies an effective and integrated Health system”

4. Hardware & Software

5. Who is on the FRONT-LINES?

6. How to support PERFORMANCE in LOW RESOURCE SETTINGS ?

7. Health Worker Guidelines New technology Incentives Resources Health system goals

8. Guidelines New technology Incentives Resources Health system goals Health Worker Supervisor Manager Patient / Community Organizational processes

9. Population: 15 million Multi-ethnic: 40% indigenous 23 ethnic groups Middle-Income Country – Highly unequal GUATEMALA

10. AUXILIARY NURSES Largest group of health workers Work in 3 levels of care – Front line in rural areas 1 year accredited training

11. ALTA VERAPAZ Pop:1.1 million 90% indigenous (Q’eqchi, Poqomchi’) High levels of extreme poverty, maternal mortality Health Region - 19 districts

12. MAIN OBJECTIVE Examine the social environment of the practice of front-line auxiliary nurses (AN) in rural Guatemala in order to understand the role of software elements in enabling their performance and gain insight into how organizational support can be strengthened.

13. SPECIFIC OBJECTIVES 1. Understand the values orienting ANs and examine how they shaped their relationships in practice 2. Understand the values orienting supervisors and examine how they shaped their relationships with ANs 3. Examine ideas of health workers and managers on actions needed to support AN performance

14. AN Values Conditions Values Conditions Supervisor Manager Patient / Community Relationship Supervision Obj. 2 AN practice Obj. 1 Organizational support Obj. 3

15. STUDY 1: Methods Exploratory study of factors influencing performance Interviews with ANs in primary and secondary care Observations, interviews with community, supervisors Paper 1: Translating community connectedness to practice ISRN Nursing 2012

16. Values Shared experience of needs: Preventable deaths of family members “Be a person who serves others” “As ANs, we serve the people with the greatest needs” AN PRACTICE Community connectedness Nursing vocation

17. { Conditions Availability of incentives for community volunteers Incompatible schedules with leaders Shortages of medicines and supplies Values Community Connectedness Nursing Vocation AN PRACTICE }

18. { }{ } Conditions Incentives Schedule Resources Values Community Connectedness Nursing Vocation AN PRACTICE Relationships In community work Shared interest in health of families Understanding of local situation Base for relationship with leaders Attending patients Cope with constraints through more attention to patient relationship Listening to understand needs, gain trust

19. Deepen understanding of how supervision functioned to support AN performance Multi-case study: Health post supervision Realist evaluation – Theory-driven Data collection protocol: Interviews with ANs, supervisors, community members, Document review STUDY 2: Methods

20. Case selection: Capture variation Data Envelopment Analysis of productivity data for 34 health posts, for years 2008 – 2010. Paper 2: Assessing the technical efficiency of health posts in rural Guatemala Global Health Action 2014 3 “strong” and 2 “weak” health posts STUDY 2: Methods

21. Analysis: Case reports, Cross-case analysis Paper 3: More than a checklist: A realist evaluation of supervision of mid-level health workers BMC Health Services Research 2014 STUDY 2: Methods

22. Values Desired outcome: Achieve Ministry standards View of AN: “Human tendency to neglect” Desired outcome: Better care for patients View of AN: “Human being with a hard job” SUPERVISION Managerial Control Humanized Support

23. { }{ } SUPERVISION Conditions Relationships Monitoring criteria were base for relationship Communication and support offered focus on attaining standards AN view: Full scope of work not recognized Shared view of importance of work was base for relationship Action guided by AN needs, focused on patient care issues AN view: Efforts recognized and valued Values Managerial control Humanized support Standard-centered People-centered

24. Standard-centered People-centered } SUPERVISION Conditions Relationships Values Managerial control Humanized support { Structure of routines: District meetings, Reports Professional principles, Patient- oriented priorities

25. Examine dynamics in health system actors views on how AN performance should be supported Concept mapping: Multi-step participatory process – visualize ideas and develop frameworks STUDY 3: Methods Paper 4: Supporting the performance of nurses in rural Guatemala (manuscript)

26. STUDY 3: Methods

27. ORGANIZATIONAL SUPPORT Cluster map: Actions grouped by theme Actions focused on support for ANs, as well as managers and community Dynamics in ratings Organizational climate of support rated highest across groups

28. ORGANIZATIONAL SUPPORT Interpretation with regional nurse managers Climate of support = Positive environment of working relationships + Responsiveness to needs Nature of relationships across levels cross-cutting issue Well-being of ANs central to patient satisfaction – influenced by management

29. The role of software elements in enabling performance Limitations of standard-centered approaches: Did not build up values that motivated ANs Need for balance between attention to standards and attention to human dimensions of practice CONCLUSIONS

30. How organizational support can be strengthened Explicit focus on the developing the quality of the relationships across levels Build on people-centered orientation: Attention to the well-being of the other and responsiveness to their needs CONCLUSIONS

31. Implications for global nursing development Local interdependence of nursing performance and health system environment is a global phenomenon Enhanced understanding of patterns and dynamics of relationships and complex systems  Improving capacity of organizations to enable nurses’ performance and capacity of nurses to enable performance of paraprofessionals and caregivers CONCLUSIONS

32. MUCHAS GRACIAS!