A comparative analysis of the changes in nursing practice


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Short communication A comparative analysis of the changes in nursing practice related to health sector reform in five countries of the Americas Edilma B.…
Short communication A comparative analysis of the changes in nursing practice related to health sector reform in five countries of the Americas Edilma B. Guevara1 and Elnora P. Mendias1 ABSTRACT Objective. To identify changes in nursing practice and the nursing-practice environment that have occurred with implementation of health sector reform in five countries in the Americas. Methods. An exploratory study of selected settings in Argentina, Brazil, Colombia, Mex- ico, and the United States of America was conducted between 1997 and 1999 to collect narra- tive data from 125 professional nurses about their perceptions of nursing practice and changes in work environments. Descriptions of characteristics and trends in nursing practice in the study sites were also obtained. Results. Reorganization of health services has occurred in all five of the countries, respond- ing to health sector reform initiatives and affecting nursing practice in each country. Respon- dents from all five countries mentioned an emphasis on private enterprise, changes in payment systems for patients and providers, redistributions in the nursing workforce, changes in the personnel mix and nursing-practice functions, work shifting from the hospital to the commu- nity, and greater emphasis on cost control and prevention in practice settings. Conclusions. The study provides initial information about current nursing issues that have arisen as a result of health care reform initiatives. Regardless of differences in service models or phases of health sector reform implementation, in all the countries the participating nurses identified many common themes, trends, and changes in nursing practice. The driving forces for change and their intensity have been different in the five countries. Nurses maintain their core values despite increased work stress and greater patient care needs in all the coun- tries as well as economic crises in the Latin American countries. Key words Health care reform, nursing, hospitals, health manpower, delivery of health care. Improvements in the health status tion health status influences the devel- This perspective has served as the of a population are affected by social opment of maximum human capacity basis for market-driven health sector and economic factors and by develop- and productivity. Therefore, the provi- reform. However, this philosophical ment in areas such as urbanization, sion of health services may be consid- shift and its focus on market concerns employment, nutrition, education, and ered an investment in human capital has resulted in limited consideration environment (1). Moreover, popula- and a crucial factor for countries’ be- of other aspects such as the needs for a coming and remaining competitive in socio-environmental framework for 1 The University of Texas Medical Branch, School of a global economy, according to a con- analyzing health status and for hu- Nursing, Galveston, Texas, United States of Amer- ference paper by Barillas.2 manistic approaches to empowering ica. Send correspondence to: Edilma B. Guevara, University of Texas Medical Branch, School of both health care providers and health- Nursing, 301 University Boulevard, Galveston, 2 Barillas E. Health care reform: global economic system clients. Texas 77555-1029, United States of America; tele- and social trends [conference paper]. The Third phone: (409) 772-5029; fax: (409) 772-5864; e-mail: Millennium Conference, 16 May 1996, Galveston, Health sector reform, in various eguevara@utmb.edu Texas. forms, has affected all aspects of health Rev Panam Salud Publica/Pan Am J Public Health 12(5), 2002 347 care delivery: objectives, administra- ticipating countries. Additional data addition, health service reorganization tion, organization, outcome measure- on external factors (country character- was characterized using the health ment, and payment systems. Nursing istics) and internal factors (site charac- care reform indicators in the Barillas personnel and nursing services have teristics) were used to assess the com- conference paper mentioned earlier. been considered the target and means parability of the study sites. both for cost containment and for After study approval by the Institu- quality improvement (2). Nursing per- tional Research Board at the Univer- Data analysis sonnel comprise a large percentage of sity of Texas Medical Branch and insti- health care personnel, and changes in tutional review committees at each The research team in each country health care organization have altered participating institution, researchers was responsible for the analysis of nurses’ practice and work environ- used a purposive sample approach to its own data, using the standardized ments. Nurses have had limited partic- obtain a sample of at least 10 profes- protocol. Data analysis techniques ipation in the decision-making on the sional nurses working at participating included content analysis, constant reorganization of their services. Thus, institutions in each country. (Purpo- comparison, and unitization and cate- it is vital to obtain more information sive sampling is commonly used in gorization of emerging themes as a about how health sector changes are qualitative research and involves se- means to define category labels and influencing nursing practice, decision- lecting subjects considered typical of generate each country’s definition of making, and regulatory mechanisms. the study population (12)). After ob- nursing practice. Although much has been written taining informed consent, researchers According to Lincoln and Guba (13), about health care reform, little is interviewed participating nurses in evaluation of the trustworthiness of known about how nurses’ practice and depth at least once to obtain narrative qualitative findings may be conducted work environment have changed since data on their perceptions of nurses’ using four indicators: credibility, the reorganization of health care sys- practice and work environments as transferability, dependability, and tems in the 1990s. One urgent need is well as descriptions of nursing-prac- confirmability. Credibility was ad- the identification of relevant concepts tice characteristics and trends. Inter- dressed through peer debriefings in and variables related to current nurs- views took place in private in the facil- two ways: 1) frequent researcher con- ing practice and work environments, ities where the nurses were working. sultations with the project’s principal as an initial step in the description of Researchers used a standardized pro- investigator and 2) two researchers’ the nature, extent, and magnitude of tocol to apply a structured interview meetings. Transferability or generaliz- these changes. In addition, there is a guide. The interview guide included ability of findings was achieved by need to develop cross-cultural instru- questions related to 11 areas, including identifying rich segments of data com- ments to study current nursing issues. participants’ perceptions about defini- mon to all the countries and establish- To address these needs, an exploratory tions of nursing practice and the social ing inter-country agreements about qualitative study was designed to ob- value of nursing, nursing functions themes. Dependability (stability of tain a current cross-cultural view of and roles, recent changes in nursing findings) and confirmability (neutral- nursing in selected health settings in practice and the practice of other ity) were achieved by using an audit five countries of the Americas and to health care workers, reasons for recent trail. To ensure consistency of method- provide information about current changes, the effect of those changes on ology and confirmability of narrative trends in nursing practice, education, nursing practice and patient care, data, a sample of transcripts (trans- and regulation. This paper presents a nursing decision-making, and the fu- lated into English) was reviewed by an cross-country summary of findings ture of nursing. Interviews were au- expert in qualitative data analysis. reported by researchers in each of the diotaped, then transcribed verbatim. five participating countries: Argentina, Naturalistic inquiry methodology Brazil, Colombia, Mexico, and the (13) was used to collect and analyze RESULTS United States of America. The study the narrative data in each country. The framework (3, 4) and the individual goal of naturalistic inquiry is not to Study population country studies (5–11) have been pub- generalize findings but to present a lished elsewhere. view of the phenomenon as perceived The study population included a by participants and researchers. total of 125 practicing professional Goins’ Paradigm of Dynamic Inter- nurses as well as other health profes- MATERIALS AND METHODS action (3) was used as the framework sionals, who were interviewed at se- to characterize the study sites’ internal lected institutions. Included here are This multicenter study used a quali- environment (money, manpower, ma- results from 20 nurses from Córdoba, tative approach to identify changes in terials, facilities, and equipment) and Argentina; 42 from Ribeirão Preto, nursing practice and the nursing-prac- external environment (social, techno- Brazil; 10 from Antioquia, Colombia; tice environment since implementa- logical, economic, ethical, political, 20 from the state of Mexico, Mexico, tion of health sector reform in the par- legal, and environmental aspects). In and 16 from the state of Nuevo León, 348 Guevara and Mendias • Changes in nursing practice related to health sector reform in five countries of the Americas Mexico; and 17 from the state of Texas, maintained. Varying degrees of tech- specific basic package but has imple- United States. The researchers in each nology were found in public hospitals, mented a number of health programs country described the characteristics ranging from state-of-the-art technol- with similarities to basic packages, in of the nurses whom they interviewed. ogy in the United States to limited that comparable services and popula- technology in the other four countries. tions are identified.3 The trend in all Private facilities were well equipped, the countries was to encourage pre- Structural characteristics including with equipment for high- ventive and health promotion services. tech procedures. Targeted populations in all the coun- Structural characteristics are sum- tries have included the indigent and marized using Goins’ Paradigm of Dy- uninsured. Women and children have namic Interaction (3), which includes Reorganization of health services been considered high-risk groups in such institutional resources as man- Argentina (5), Brazil (14), Colombia (7), power, money, materials, facilities, Health services had been reorga- Mexico (15), and the United States.3 and equipment. Researchers in all the nized in all five countries in response to The elderly have been targeted in countries had difficulty obtaining spe- health care reform initiatives. Those re- Brazil (6), Colombia (14), Mexico (15), cific information about financial and form initiatives are summarized below, and the United States (16). Specific ser- material resources at the study sites. A using Barillas’ health care reform indi- vices have been targeted to indigenous mix of private and public funding ex- cators, which include decentralization, groups in Brazil (17), Mexico (15), and isted in all the study sites. In all five self-initiatives, changes in private and the United States (18). countries, federal, state, and municipal public funding, basic health packages, In summary, the study sites ap- governments funded public hospitals and target populations (4). peared to differ in the characteristics of and clinics. Private services used insur- Decentralization has occurred in all the populations served and the extent ance, prepaid, or fee-for-services plans. five countries, with a shifting of con- of health care reorganization. These Reflecting regional trends, with the trol from federal to state and local lev- facts were considered in interpreting exception of the United States, most of els (5–11). and comparing the study findings. the study sites had a low percentage of Self-initiatives are efforts directed nurses as compared to nurse auxil- toward increasing management capa- iaries or nurse’s aides. The proportion bility and decision-making at the state Changes in nursing practice of nurses with a baccalaureate degree, and local levels (4). Self-initiatives fo- which requires four to five years of cusing heavily on institutional financ- The study’s data analysis included full-time university education, was ing have been a by-product of compe- identifying major thematic areas re- low in all the countries except the tition between the public and private lated to changing nursing work en- United States. In the four Latin Ameri- sectors in efforts to control costs or vironments and responsibilities. Even can countries, public institutions re- to subsidize health services for the though the characteristics varied ported a higher percentage of bac- underserved. In all the countries, self- among the study sites, we identified calaureate-prepared nurses than did management has allowed public several common categories of recent private facilities. One reported trend health institutions to charge for health changes in nursing practice. was a decreasing number of nursing care services that they provide to the personnel. Another trend was short- members of private health care plans More work in less time with fewer term contracting of nursing personnel or of other plans. staff. Some nurses mentioned a de- to work in specific programs or proj- A mix of private and public funding crease in the nursing workforce, differ- ects, instead of hiring them for stable for health care existed in all the study ent duties, extended use of auxiliary full-time positions. Salaries had been sites, with private financing exceeding personnel, or reductions in other job diminished or frozen in Argentina and public financing. The level of private positions that impact nursing tasks. Colombia. financing ranged from 53% in Mexico Specific comments included: “There is Although there were some varia- (8) to 70% in Colombia (7). an immense accumulation of work,” tions and some missing data across the Basic health packages are selected “There is more pressure on everybody countries, in comparing private and health services that are designated to do more with less,” and “There public settings, the study found that as the minimal health services for a seems to be less time and less staff. My public sites were more likely than pri- targeted population. The four Latin workload is greatly increased, and vate sites to report insufficient materi- American countries had identified there is no one to help me.” als and supplies. The renovation and basic packages, which usually in- maintenance of public hospitals varied cluded preventive health and health within all the countries, but it tended promotion services for vulnerable to have decreased in all the countries populations such as women and chil- 3 Goins PN. US STEEPLE framework. Paper pre- sented at Pan American Health Organization Re- except the United States. Private sites dren, the elderly, and the poor (5–10). searcher Group, University of Texas Medical were reported to be adequate and well The United States has not designated a Branch, March 1998, Galveston, Texas. Rev Panam Salud Publica/Pan Am J Public Health 12(5), 2002 349 More paperwork. Nurses reported ing education and to be up to date in all work, administrative duties, and fewer having to do large amounts of paper- theoretical and practice aspects; [every- nursing personnel. work as well as performing responsi- thing is] an innovation.” In Mexico the themes included bilities once assigned to others. One decreased time for care, heavy work- nurse commented, “No one has picked Clients who are more informed, edu- loads, low salaries, increased respon- up any of my responsibilities.” An- cated, and demanding. Nurses ex- sibilities, too few nurses to meet in- other nurse said, “We have picked up pressed the need to be more knowl- creased service demands, increased more of what different people used to edgeable about disease processes and paperwork, and more technology. do.” In addition, the amount of paper- about sophisticated technology, to re- The themes in the United States in- work requested from the clients has spond to both market demands and cluded doing more with less, heavy complicated the health care system, in- population characteristics. One nurse paperwork, more time spent manag- cluding the delivery of nursing care. said: “People are starting to under- ing and less time spent providing di- stand their values and needs. They are rect care, more time directing the work Less direct patient care. Nurses men- more demanding. He [the patient] of unskilled staff, insufficient supplies, tioned increased workloads affecting knows what he wants and can get. and managed care. Nurses indicated their practice, including reduced time More access to information is making that managed care dictated reim- for direct patient care despite in- an internal revolution.” bursable services, which increased creased patient acuity. For example, nurses’ time spent in completing pa- one nurse said, “Now we have fewer perwork and in documenting clients’ nurses to take care of an increasing Changes in the nursing work health needs, which were needed to number of patients who are coming in environment ensure reimbursement. Also, restric- worse conditions, poorer, and with tions on reimbursement for supplies more serious deterioration in their per- Dominant themes in each of the and equipment affected client care. sonal appearance and nutrition.” countries. The study identified domi- nant themes in work environment More administrative duties. Nurses changes in each country. Common categories of factors cited increased administrative respon- In Argentina these themes included affecting nursing work environments sibilities. “There is a big change,” one increased workloads, decreased job nurse said, “and responsibility has in- security, insufficient supplies, low The study also identified common creased. You have to supervise several salaries, increased demand for techno- categories of factors affecting nursing workers now.” The need for self- logical knowledge, and the need for work environment across the countries. financing also affects nursing and nurses to hold two jobs in order to nurses’ administrative duties. One support their families. Insufficient resources. Nurses men- nurse reported, “We have to imple- Themes in Brazil included redirec- tioned insufficient resources for ade- ment a billing system for the commu- tion of resources, supplies, and tech- quate patient services. One nurse said: nity activities in order to obtain finan- nology from hospital to ambulatory “Materials are much scarcer. They de- cial resources.” care; the need for a more cohesive mand a series of things, but the ele- workforce, in which interaction and ments are not provided to accomplish Increased demand for technological communication among various disci- them. The only thing that this creates knowledge. Nurses in all five countries plines are facilitated; increased service is chaos within personnel of the entire felt a demand for knowledge based on demands, with greater client needs health team.” Another nurse said: technological advances and new work and fewer nursing personnel available “Sometimes we do not have anything settings, as well as administrative ex- to meet those needs; increased work- to work with. There are no disposable pectations for continuing professional loads; job dissatisfaction among hospi- materials, clothing, medicines, but growth. Some nurses mentioned the tal nurses; low salaries; the need to the
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