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How to cite this article:

Martínez-Trujillo N. Individual and institutional capacities for research in health systems and nursing services in Cuba. Rev Enferm Inst Mex Seguro Soc. 2017 Jan-Mar;25(1):65-70.

Individual and institutional capacities for research in health systems and nursing services in Cuba

Nelcy Martínez-Trujillo¹

¹Escuela Nacional de Salud Pública, Subdirección de investigaciones Departamento de Dirección en Salud. La Habana, Cuba

Approval of the project: Strategy for the development of research in nursing systems and health services. Approved in Convocatoria 2012 del Programa Ramal de Investigaciones en Sistemas y Servicios de Salud.  Consejo Científico, Escuela Nacional de Salud Pública de Cuba

Correspondence: Nelcy Martínez-Trujillo

Email: nelcynan@infomed.sld.cu

Received: March 3^rd 2016

Judged: August 4^th 2016

Accepted: October 10^th 2016

Abstract

Introduction: Research on health systems and health services allows the decision-making on the basis of well-founded evidence; however, this field of study has scarcely been addressed by nurses.

Objective: To describe the experience of implementing an educational strategy in professional nurses and managers to develop individual and institutional capacities in the execution of research in health systems and health services in Cuba.

Methodology: To implement the strategy, the referents of constructivism and action research were taken into account. Some workshops were set up for designing, monitoring and also for the participants to get familiar with the strategy. Their results were implemented in 13 research projects for decision-making in institutions and nursing services.

Conclusions: Individual and institutional capacities in participants for conducting research in health systems and health services were developed. The results support a new phase of sustainability of the strategy, which entails the projection of the strategy at a national level.

Keywords: Nursing; Health systems; Health services; Nursing research; Research support as topic; Cuba

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Introduction

Research on health policies and systems aims to obtain evidence for the definition of policies and continuous improvement of health systems. It studies how societies are organized to achieve their health goals and how the different social actors interact in the process of defining and implementing health policies.¹ This is an interdisciplinary field that involves economics, sociology, anthropology, political science, public health, and epidemiology. Taken together, these disciplines provide a comprehensive view of how health systems respond and adapt to policies, and how those policies influence or are influenced by health systems and determinants.²

The development and consolidation of this field of research requires initiatives that take into account their particularities. In this sense, the Alianza para las Investigaciones en Políticas y Sistemas de Salud  (AIPSS) establishes that the aspects to be taken into account are the connection of this type of study with the decision-making processes, the establishment of repositories that socialize methods and results of studies, increase in governments financial investment  in their realization and finally and very importantly, the development of capacities at the different levels: individual, institutional, and national.³

This type of research still does not reach its maximum potential by nursing professionals.^4,5 The research practice of these professionals generally focuses on studies related to health services, which explains the little development in this field towards generating policies or transformations at the health system level from the nursing perspective.

For the nursing profession, fundamentally linked to care, this field of research is a challenge in terms of understanding and application of its referents and the population perspective of problems that is necessary. In Cuba, this type of study is little approached by this professional group. This is due to multiple causes, such as a lack of knowledge about theoretical references and a lack of understanding about the contribution to care that can directly result from this type of research, which is the essence of this profession.⁶ Another aspect that must be considered is interdisciplinarity, seen as the basis for the synergy of referents that this field demands and which, is not part of the everyday nursing practice.⁷

The proposal issued by the AIPSS considers the applicable generalities. These recommendations, particularly for the nursing profession and its professionals, merit adaptations to the specificities of the profession.

The foregoing and the fact that there were no publications in the literature with this particular approach were the basis for the ability development strategy design for systems and services research by the nursing professionals in Cuba, which incorporated pedagogical referents and the field of research itself.^8,9

To this end, the objective of this document was to describe the experience of the implementation of an educational strategy in nursing professionals and managers to develop individual and institutional capacities in conducting research on health systems and services in Cuba.

Development

The context was 14 research institutes in the country's capital. These institutions were selected because they provide third care level and include investigation in an explicit way, both in their social aim and in the practice of their nursing professionals. 32 managers and 105 nursing professionals participated. In each institution, a team was created with researchers and nursing managers.

The variables of individual capacity and institutional capacity were defined. The first of these is the capacity that must be developed or strengthened in professionals involved in research on systems and health services. While institutional capacity must be developed or strengthened in centers or institutions where professionals are associated with conducting research in health systems and services.

The phases of diagnosis, development, evaluation, and monitoring of individual and institutional capacities that conform the strategy implementationand the scope of the expected objectives are detailed below. Also described are other aspects parallel to the process, which had an impact on the achievement of unexpected results. They are valuable elements for the same purpose. As such, this experience can serve as a reference to other contexts from which similar results are sought.

Capacity Diagnosis

• The objective of the diagnosis was to characterize the situation of research production in health systems and services performed by nursing professionals in the same context in which the experience was developed. Three actions were carried out:
• Analysis of statistics of research projects on policies, systems and health services that were carried out by nursing professionals in the period 1998-2007. The source of information was the national research program, which in Cuba manages the development of research with this approach. The results showed little annual production by nursing professionals and, therefore, the need to develop specific actions to promote research in health systems and services from a nursing perspective. Thus, the knowledge generated should support decision-making at the level of the health system and services.
• In a bibliometric study, the existence of articles published by nursing professionals in the health systems and services area was investigated. In this respect, few articles related to the research topic were found. In addition, they identified three major thematic topics about what nurses investigate and publish. The first of these has to do with patients' perceptions, beliefs, knowledge, and values, which is consistent with the disciplinary choice to provide appropriate and pertinent care to the social and cultural context in which they develop. The second topic is made up of studies on prevalence and incidence on health problems, which demonstrates the state of health of the population; the third consists of studies evaluating the competencies of the nursing professional.¹⁰
• Nursing professionals' knowledge on the subject of ISSS was explored in an expressedly designed questionnaire. The questionnaire was structured based on the following aspects: definition of ISSS, identification of lines of research, participation in projects, as well as dissemination and application of results for decision-making. From the results, the research team established three cut-off points for the level of knowledge: acceptable, moderately acceptable, and unacceptable (the author has this instrument, which is available by correspondence). The results revealed that the nurse practitioner does not know the aspects investigated in the questionnaire. Analysis of the variables related to participation in projects, dissemination, and application of results in decision-making allowed for the evaluation of, in addition, institutional capacities. There is insufficient familiarization with this field of research.

Development of individual abilities

With the application of the theoretical references of constructivism, three workshops were held in the institutions of participants (the author has the complete program, which is available by correspondence):

• Familiarization with the Investigación en Sistemas y Servicios de Salud (ISSS) methodology: in order for the nursing professionals to have a first approach with  ISSS, the sessions analyzed the aspects that characterize it. With a dynamic group activity about sharing, it was possible for professionals to identify, from their experiences, the advantages of their participation in decision-making. In the group sessions, based on the specificities of each institution, the topics that could be investigated were adapted and research teams were formed. The collective interaction and the exchange with the peers favored learning, which permitted an initial level of assimilation, as well as the approach of theoretical and methodological referents of this field of research (Figures 1 and 2).





Figures 1 and 2. The exchange between peers favored the assimilation of knowledge from the first moment



• Design of ISSS projects: the purpose of this workshop was for the participants to understand the structure of the methodological designs applicable to this field of research. The focus of the workshop was on the recovery of the participants' work experience and on the construction of research projects related to the design and approach of the problems identified in the nursing services. The collective work dynamics allowed for the main methodological variants to be analyzed, and for the selection of those that could be developed in a more feasible way. The participants were active subjects of the learning process and the design of the projects to approach each situation. The confrontation of ideas in the various work sessions culminated in the design proposal of the projects that they would develop.
• Follow-up of the ISSS projects: the objective was to create a community of practice for ISSS researchers, which implied analyzing the methodological and implementation aspects of the defined tasks. At each follow-up session, progress was assessed based on the partial results of the projects. This evaluation included publication and presentation at events. The participants confronted their results in order to collectively agree on proposals for improvement and strategies for solving the problems identified. Praxis was used for reflection and action and reality as a source of knowledge and creation. From experiences in the services, the proposals and forms of approach for the development of the action plans were shared. Although in each session the teacher (project investigator) provided general elements necessary to enter this field of research, it was the interaction of participants, as well as the construction from their experiences, were the fundamental factors in the achievement of the capacities in ISSS implementation in the nursing services (Figure 3).

Development of institutional capacities

At the institutional level, capacities were developed that helped to strengthen those achieved at the individual level. In that sense, the managers were connected in the topic definition process and included the topic of ISSS in the result presentation spaces. Among them were the conferences and the institutional events of nursing. This allowed us to share both favorable and unfavorable results. The challenges that emerged during its implementation and application were also socialized.

Access to the managers was possible due to the highest nursing director in the country's interest in the development of this type of study. Participation of the research team in the work spaces of the managers of these institutions was favored. This motivated them and achieved their cooperation. It is worth noting that the cooperation of managers for this type of study requires that the researcher be able to show their use of the managerial practice.

Monitoring individual and institutional capacities

Another of the abilities at the institutional level was the definition of criteria and indicators that, based on the specificities of each institution, allowed for the achievements to be monitored.

The experience developed its intervention stage in the period 2008-2011. Subsequently a period of implementation of the research and consolidation of the developed capacities began (2011-2015). In 2016 a new stage of proposals to generate the consolidation of the work carried out will begin.

Among the important actions to reach the results was the integration of managers and researchers throughout the process. This was a cornerstone in that the joint work of both parties is a fundamental premise for research in health policies and systems. Establishing the synergy of work between researchers and decision makers requires that both generate actions that mutually enhance what has been done from both perspectives. In the experience described, research alone would not have achieved the desired change, that is, a decision was not sufficient for the development of research, since it requires professionals with the necessary skills to achieve it. Only with the synergy of both perspectives was a sustainable outcome possible.¹¹

Conclusions

• The experience of the implementation of the program for the fulfillment of ISSS by nursing professionals in Cuba evidenced the need to generate new actions in order to consolidate what has already been done.
• The individual and institutional abilities developed by nursing professionals contributed to ISSS studies in the Cuban context.
• The familiarity of nursing professionals with the methodology and implementation of ISSS projects to address problems concerning nursing services are, among others, significant additional achievements.
• The publication of the results and their socialization through the presentation in professional events was another of the results that showed the scope of the anticipated capacities.
• Based on the results obtained, the foundations were laid for a new stage of sustainability of the strategy, which involves identification of new capacities, accomplishment of actions at these levels, and projection at the national level.
• The experience of the practice also generated the essential integration between researchers and decision-makers, fundamental for the achievement of more solid results. At the conclusion of the intervention and with knowledge acquired in the sessions, the design and implementation of 13 investigations that addressed problems of the nursing services was achieved. The research projects deal with quality issues in the dimensions of structure, process, and results of nursing care for patients with cerebrovascular, orthopedic, cardiovascular, ophthalmologic, and gastroenterological diseases. Another aspect of quality was the satisfaction of patients with care in endocrine diseases and satisfaction of nursing professionals working in nephrology services and the definition of functions of nursing staff for ophthalmology, oncopediatrics, hematology, and gastroenterology .

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