Building a Professional Mexican Nursing Workforce A Case Study

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					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
       Implements medical treatments, based on available
       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
   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
   General thematic analysis & data synthesis of:
       48 interviews with Mexican nurses from four regions of the
       410 documents from government and non-government sources
        served as primary and secondary sources
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
Significant Factors

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

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

                   Positive
    Unions         Negative
                   Repression
Significant Factors

     Sociocultural                                     “Being female”
                                                       Female role models

                                                       Machismo
 EDUCATION                                             Male-female dynamics
  SYSTEM         HEALTHCARE                            Men in Nursing
                                                       “Nature of nurses”
    CLASS          SYSTEM
                                                       Personal relationships
                                                       Self actualization
                                                       Single motherhood
                 RELIGION      OF FAMILY               Balancing work and
                                                       Responding to social
                                                        changes & adaptive
Significant Factors
                  Administration/ Management
                  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, 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

                                     Economic                 Political
Profession-based outcomes

                                                                              Health System Outcomes

                              Development                         Workplace


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
                                    Average years of
    infrastructure, and              education
    health system                   Average # of children per
    indicators predict the           female
                                    Total # of nursing schools
                                    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
   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,