Building a Professional Mexican Nursing Workforce A Case Study

							Building a Professional
Mexican Nursing Workforce:
A Case Study
  Allison Squires, PhD, RN
  Research Fellow
  Center for Health Outcomes & Policy Research
  University of Pennsylvania
  Philadelphia, PA, USA
                                          A presentation for the
                 12th World Congress on Public Health
                                                Istanbul, Turkey
                                                   April 28, 2009
The Nursing Role
   A formally educated person who
       Monitors patients for critical changes in their
        condition and ensures their safety during
        hospitalization
       Implements medical treatments, based on available
        resources
       Manages a complex system of care delivery and the
        complex nature of family dynamics during wellness
        and illness
       Helps prevent hospitalization by facilitating the
        health of a community
Overview of the Problem
   Global nursing shortage, especially of
    professionally educated personnel; extent
    varies by country
   Research demonstrates that nursing
    professionals educated at the post-high school
    level produce the best patient outcomes (See
    studies by L.H. Aiken, E. Lake, S. Clarke, P. Beurhaus, etc.)
   Few to no studies that examine the process of
    producing professional nursing personnel or the
    development process
Overview of the Problem
   Nurses organize under a professional model
   Organization of nursing affects health system
    outcomes
   Intersection of relationships between internal
    and external variables relevant to nursing not
    well understood
       Creates problems for producing nurses at the
        country level
The Study
   A qualitative case study of the
    professionalization of Mexican nursing between
    1980 and 2005
   Purpose: To identify the themes and variables
    involved in professional nursing workforce
    development.
   General thematic analysis & data synthesis of:
       48 interviews with Mexican nurses from four regions of the
        country
       410 documents from government and non-government sources
        served as primary and secondary sources
Mexico
Nursing in Mexico
   Formally organized around          Nursing education from
    1905                                auxiliary to doctoral level
   Centralized department and         Primarily draws candidates
    state level representation in       from families of low
    the ministry of health              socioeconomic status or the
   A pre-migration State even          middle class
    though a major free trade          Nurse-to-population ratio
    agreement exists and                   2.3/1,000 (national average)
    incentives for nurses to               1.3 to 3.1 (range between
    migrate abound                          states)
The Results
   Eight themes significantly affected the
    professionalization of Mexican nursing (a.k.a. nursing
    human resources development)
       Historical
       International Influences
       Economic
       Political
       Unions
       Sociocultural
       Workplace
       Intraprofessional dynamics
Significant Factors

                  Colonialism
                  20th century health
                   system design &
 HISTORICAL        founding
                  Women’s history
                  Nursing’s historical
                   image
Significant Factors

                     Globalization
                     International
  International       Institutions
    Influences       International
                      Exchanges
                     English language
                      “requirement”
Significant Factors
                   Instability
                   Trade Agreements
                   Migration
                   Economic security
 Economic           provided by becoming a
                    nurse
                   Difficult to obtain full-time
                    work with benefits
Significant Factors

                 Influence of the State
                 Political participation
                  of nurses
  Political      Legislation/
                  Regulation
                 Corruption
Significant Factors


                   Positive
    Unions         Negative
                   Repression
Significant Factors

     Sociocultural                                     “Being female”
                                                       Female role models




                                           GENDER
                                                       Machismo
 EDUCATION                                             Male-female dynamics
  SYSTEM         HEALTHCARE                            Men in Nursing
                                                       “Nature of nurses”
    CLASS          SYSTEM
                                                       Personal relationships
                                                       Self actualization
DISCRIMINATION                INFLUENCE
                                                       Single motherhood
                 RELIGION      OF FAMILY               Balancing work and
                                                        family
                                                       Responding to social
                                                        changes & adaptive
                                                        processes
Significant Factors
                  Administration/ Management
                   practices
                  Decentralization/ health
                   system reforms
                  Institutional Variation
                  Working multiple jobs
                  Institutional nursing roles
 Workplace        Quality of Care
                  Relationships
                  Salaries
                  Supply Management
                  Work/Practice Environment
Significant Factors
                            Autonomy
                            Career path/advancement
                            Culture of nursing
                            Development processes
                            Professional education
                            Ethics
                            Visions of the future
   Intraprofessional        Image (public/internal)
     Development            Knowledge development
       Dynamics             Leadership
         a.k.a              Licensure/credentialing*
 “Professionalization”      Professional organization*
                            Reasons for becoming a nurse
                            Research
                            Rewards
                            Roles
                            Shortage
                            Specialization
                            Standards (education & practice)*
 Nursing Human Resources
Development: It’s Complicated
Defining A System
     “A group of independent but interrelated
      elements comprising a unified whole; a
      complex of method or rules governing
      behavior; a procedure or process for
      obtaining an objective; [or] an organized
      structure for arranging or classifying”
(Definition downloaded from http://wordnet.princeton.edu/perl/webwn?s=system, July 20, 2007)
The Nursing System (NS)
   A country-level system that produces and
    develops professional nursing human resources
   Exists separately from healthcare system, but is
    an integral part of it
   The NS has several products that benefit the
    country on multiple levels, but most likely
    through social and healthcare system
    outcomes, as well as professional infrastructure
    development
                                                    Int’l
                                                 Influences



                                     Economic                 Political
Profession-based outcomes




                                                                              Health System Outcomes
                                                  Unions


                            Intraprofessional
                              Development                         Workplace
                                Dynamics




                                           Sociocultural

                                                HISTORICAL
Enhancing Infrastructure Through
Better Outcomes
   Profession-Based Outcomes
        # of educated females and females
        completing high school degrees
        quality of professionals
        recruitment into the profession
        career mobility
        economic security
       Research/knowledge production
Enhancing Infrastructure Through
Better Outcomes
   Health System Outcomes
        Quality of hospital and primary care
        Patient satisfaction
        Job satisfaction of nurses
            Retention
       In the long term, costs decrease because
        patient outcomes improve, complications
        rates decrease, and retention improves
Example: Applying the Model
   Can a combination of        State level analysis (31
    socioeconomic                Mexican states)
    development,                Variables
                                    Median Income
    professional
                                    Average years of
    infrastructure, and              education
    health system                   Average # of children per
    indicators predict the           female
                                    Total # of nursing schools
    nurse-to-population
                                    Ratio of public to private
    ratio?                           healthcare facilties
Results          (Squires & Beltrán Sánchez, 2009, Accepted, under revision)


    Robust regression: p<0.000; adjusted r2=.7

    Variables                                     Coef. p-value
    Median income                                 0.001         0.582
    Average education                             0.600         0.000
    Children per family                           0.104         0.662
    Total nursing schools                        -0.004         0.410
    Ratio Private to Public
       Facilities                                -1.685         0.001
Policy Implications for Professional
Infrastructure Development
   Investments in education, from elementary to university
    level, indirectly help develop nursing human resources.
   The types of workplaces available for nursing
    employment will affect recruitment, retention, and
    migration, but not always in the way we traditionally
    think.
   Creating ways for nurses to become solid middle class
    members of society may help reduce migration.
Thank You! Gracias! Mercí! Obrigada!


                     Questions?
                     Comments

                    Contact Information
                      (til August 2009):
                    Allison Squires, PhD,
                               RN
                   asq@nursing.upenn.edu