Enabling the performance
of nurses in rural
Guatemala:
THE ROLE OF
RELATIONSHIPS
Alison Hernández
Supervisors: Miguel San Sebastián, Anna-Karin Hurtig, Kjerstin Dahlblom
“At the Heart of the Right to health
lies an effective and integrated
Health system”
“At the Heart of the Right to health
lies an effective and integrated
Health system”
WHO Health System Building Blocks
Hardware & Software
FRONT-LINES?
Who is on the
How to support PERFORMANCE
in LOW RESOURCE SETTINGS?
How to support PERFORMANCE
in LOW RESOURCE SETTINGS?
Health Worker
Guidelines
New technology
Health
system
goals
Organizational
processes
Manager
Supervisor
Health Worker
Health
system
goals
Guidelines
New technology
Patient /
Community
GUATEMALA
Population: 15 million
Multi-ethnic:
40% indigenous
23 ethnic groups
Middle-Income Country
– Highly unequal
AUXILIARY NURSES
Largest group of health workers
4 RN / 10,000
1 year accredited training
10 MD /10,000
18 AN/10,000
Work in 3 levels of
care – Front line
in rural areas
Pop:1.1 million
90% indigenous
(Q’eqchi,
Poqomchi’)
High levels of
extreme poverty,
maternal
mortality
Health Region 19 districts
ALTA VERAPAZ
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.
MAIN OBJECTIVE
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
SPECIFIC OBJECTIVES
Manager
Organizational
support
Obj. 3
Supervisor
Supervision
Obj. 2
Values
Conditions
Relationship
AN
Values
AN practice
Obj. 1
Conditions
Relationship
Patient /
Community
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
AN PRACTICE
Values
Community connectedness
Shared experience of needs:
Preventable deaths of family members
Nursing vocation
“Be a person who serves others”
“As ANs, we serve the people with the greatest needs”
AN PRACTICE
Values
Community
Connectedness
Conditions
Availability of incentives
for community volunteers
Incompatible schedules
with leaders
Nursing Vocation
Shortages of medicines
and supplies
AN PRACTICE
Relationships
Values
In community work
Shared interest in health of families
Community
Connectedness
Conditions
{}
Understanding of local situation
Base for relationship with leaders
Incentives
Schedule
Resources
Nursing Vocation
Attending patients
Cope with constraints through more attention
to patient relationship
Listening to understand needs, gain trust
STUDY 2: Methods
• 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
• 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
• 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
SUPERVISION
Values
Managerial Control
Desired outcome: Achieve Ministry standards
View of AN: “Human tendency to neglect”
Humanized Support
Desired outcome: Better care for patients
View of AN: “Human being with a hard job”
SUPERVISION
Relationships
Values
Managerial control
Standard-centered
{}
Conditions
Humanized support
Monitoring criteria were base for
relationship
Communication and support offered focus
on attaining standards
AN view: Full scope of work not recognized
People-centered
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
SUPERVISION
Relationships
Values
Conditions
Managerial control
{ }
Structure of
routines: District
meetings, Reports
Standard-centered
Professional
principles, Patientoriented priorities
Humanized support
People-centered
STUDY 3: Methods
• 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
• Paper 4: Supporting the
performance of nurses in
rural Guatemala
(manuscript)
STUDY 3: Methods
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
ORGANIZATIONAL SUPPORT
• 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
Interpretation with regional nurse managers
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
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
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
MUCHAS GRACIAS!
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