First Nation Health Managers Needs Assessment and Situational Analysis
Preliminary Data Analysis Report for Focus Groups
1. PREAMBLE
This report provides one segment of the study entitled “First Nations Health Managers (FNHMs) Situational Analysis and Needs Assessment”. This portion of the study collected qualitative data through the use of focus group processes with ten groups held across Canada.
A focus group is typically a group of between 7 and 10 interacting individuals who possess common characteristics or experiences related to the subject of the research. Moderated by a facilitator, a group is engaged in discussion in a comfortable and safe environment which allows participants to share ideas, experiences and attitudes regarding the specific topic(s). The facilitator leads the process, acts as the listener and observer and records the proceedings. Careful and systematic analysis of the discussions seeks insights and themes that emerge as being important from the perspective and perceptions of the members of the groups.[1]
This document will:
· Describe the process used for the focus groups as well as any limitations to the methods
· Offer the findings from the 10 focus groups conducted across Canada
· Provide a summary of the findings
2. METHODS AND LIMITATIONS
Focus group processes can yield a wealth of rich data that is often considered more accessible to a reader, as it reflects the perceptions of participants in their own words rather than through statistical analysis. This type of qualitative research is a recognized technique for social scientific inquiry. Although in some ways ‘easier’ to conduct than other more complex research designs – which may include assuring random and statistically significant sample sizes – it still requires careful planning and conceptualization. To this end, a planning meeting was held during October 2007 in order to develop and fine-tune the nature of the questions that would be posed to the groups, as well as the process that would be used by the focus group facilitators.
The group targeted for the study were defined by the project parameters as follows: “A First Nation Health Manager - FNHM (i.e., CEO, health director, health coordinator, health manager, etc.) may be defined as the manager of a community health facility on-reserve (in a First Nation or Inuit/North of 60 community), including the management of health human resources, capital resources, financial resources, and health/social programs. The FNHM also provides leadership and direction around resource planning, change management, and health and social program delivery.”[2]
There was diversity among the participants, their service delivery systems and organizational infrastructure. That is, based on the group discussions, it appears that:
· Some of the participants work in health organizations that serve multiple communities
· Some provide direction to health organizations that serve a single community
· Some operate as Transferred Communities (currently referred to as Flexible Transfer Agreements), and receive multi-year funding from Health Canada, First Nations and Inuit Health Branch (FNIHB)
· Other communities operate under the auspices of other First Nation and Inuit Health (FNIH) Contribution Agreements (currently referred to as Set, Transitional and Flexible Agreements)
· In the Yukon and the NWT, health services have been devolved by the federal government to the Territorial governments; First Nations therefore negotiate funding and control of health services with the Territorial governments
· Some health organizations may also be involved with delivery of Child Welfare, Social Welfare and other social services
Translation service (English and French) is a key requirement for Québec communities. In the Yukon and NWT, most First Nations are considered to be ‘off reserve’. Based on the group transcripts, it also appears that not all participants were Health Managers/Directors as defined above.
It was hoped that approximately 80 FNHMs (8 individuals in 10 regions) across Canada would participate in these groups, but only approximately 40 individuals could attend. Two of the focus groups had 7 and 8 participants; in one instance a group was held with 1 participant (bad weather precluded other individual attendance); other groups included 3, 4 or 5 participants. Smaller group sizes (less than 5 people) can sometimes be considered a study limitation given that discussions can be restricted to only a few circumstances or experiences. Given the diversity among First Nations, small groups may not represent the diversity of experiences and perceptions that would be possible across the various provinces and territories, as well as the potential differences between communities that are considered urban, isolated and/or northern.
A flexible research design is used with focus groups, where it is usual to systematically select and personally invite potential informants to participate in the process. Along with the selection (as opposed to a random sample) of participants, it is noted that results from focus groups are intended to gather individuals’ insights and perceptions, and not data from which generalizations about an entire population can be inferred. The process for selecting focus group participants was as follows:
· Project team members from the First Nation Centre (FNC) were directed to contact identified regional representatives from the National First Nations Health Technicians Network (NFNHTN) in order to arrange focus groups[3]
· NFNHTN regional representatives were provided with background information on the project and suggested dates/locations for focus groups in their region
· NFNHTN regional representatives were asked to identify potential FNHMs from their region to participate in the focus groups
· Once provided with names, FNC staff contacted potential focus group participants to confirm attendance and arrange travel and accommodation
· Participants were reimbursed for all travel expenses and per diems
The focus group process included the following steps:
· The members of each group were provided a written description of the purpose of the study
· Participants were guaranteed anonymity
· All participants were asked to sign and submit a consent form which described the voluntary nature of their participation and the confidentiality of the proceedings
· All members were provided with an agenda that included the 6 questions for discussion
Group proceedings were digitally recorded and later transcribed verbatim by either the facilitator or a contracted ‘transcription service’. In one instance, the group members were provided a copy of their transcript (as per their request) to review and approve prior to it being submitted for further analysis. It is more usual for one facilitator to conduct all of the focus groups (for consistency of style and emphasis), transcribe and later analyze the results (to ensure the discussion nuances can be captured in the reporting of the results). In this instance, 3 different facilitators conducted the focus group processes. Although the latter fact could be viewed as a limitation to the study, it is noted that all facilitators were involved in the design of the questions and the group process, and all facilitators reviewed the transcripts from their groups to ensure accuracy.
The transcribed proceedings were forwarded electronically to one of the facilitators for analysis. The analysis of the group responses was conducted manually by this facilitator who made every attempt to ensure that all voices and that the general themes were summarized and represented in this document. The process to analyze the findings included a systematic reading and re-reading of 192 pages of transcripts. Although the major categories were pre-determined by the questions posed during the focus groups, further coding and sorting for general themes and repeating patterns, as well as for unique perceptions and descriptive phrases, was undertaken.
3. FINDINGS
This section of the report will provide the findings and thematic analysis of the focus group responses. The questions posed during the focus groups will act as section ‘headings’, followed by the prompts that the facilitators used (if necessary) to clarify the purpose of the question and the nature of the desired information.
Approximately 40 individuals participated in 10 focus groups held across Canada between December 2007 and January 2008. Participant quotes or paraphrased remarks (appearing in quotations marks) will be used to highlight general themes and responses from the groups, but these will be provided anonymously to ensure that the identity of individuals can be protected.
As noted earlier, the diversity among First Nation communities and the participants of this study must be acknowledged. There are regional differences, and given small group numbers and the underlying nature of focus group processes, it is difficult to offer statements that can be generalized to all Health Directors across the country. The FNHM survey, which was implemented shortly after the focus group phase, will have a sufficient sample size to allow for inferences and/or conclusive statements regarding the needs and circumstances of FNHMs across Canada.
i. What initially attracted you to the job of Health Director/Health Manager?
Prompts:
· Consistent with educational background
· Consistent with previous work experience
· Personal interest, wanted to help community
It would be safe to assert that the focus group participants have a passion for health and a desire to have a positive impact on the health of the community in which they work: “I’m First Nation and want to help my people”; “I’m very passionate about my people…their needs need to be recognized…and being able to give a voice to that… I can sit at a table and lend credibility to what I am saying [because of my background education and experience]... this is so significant for me”; “I can I’ve made a difference, I’ve had some influence on our young people, I’ve left a legacy and so I’m happy”.
It is noted that 10 of the 40 participants had a nursing background. Twelve other individuals indicated that they had worked previously in other front line and administrative positions in the health field, (e.g., clerical, Community Health Representative (CHR), day care worker etc.), before they moved into a management position. Seven individuals reported having a social service background (e.g., social work, early childhood training).
Only 4 participants had returned to school to obtain formal Health Administration training.
Some participants sought out their current jobs by applying for a vacant position, while a larger number (7) were ‘encouraged’ to accept the position: “I would have never applied had I seen a posting…I was asked to step in to clean up the organization…this position is so elusive, the whole thing is so different than I thought it would be”; “I started in one position and it evolved into being the Health Director…this was put on your desk and that was put on your desk and then the next thing you know you’re doing is the Health Director’s job”.
A connection with their community, culture and language was another reported reason to be attracted to health for 7 participants. One participant indicated: “My Mom was in health and “when I was young I used to be dropped off at the health centre. I got off the bus and waited for my Mom. I thought it was such as happy place and my Mom was a real role model for me. I looked at all sorts of health career options and thought the Director position was the one that would have the most overall impact on the health of the community”.
ii. What surprised you? Were there any aspects of your job that you did not expect, or did not feel prepared for?
Prompts:
· Expectations vs. reality
· Challenges
Once again the diversity of the various communities is acknowledged, as well as the regional structural differences for the delivery of health care and health related services.[4]
Broad perspective for Health Delivery
Health as a service is ‘huge’, and there are broad expectations to address all of the health-related needs of a community. In some instances, Health Directors received descriptions of their job expectations, but it is felt that a job description can not fully delineate the scope of the services: “I received a two page job description but they forgot to give me the manual that goes with that 2-pager”; “We really have to be everything for everybody… for example mould is a health issues but the responsibility for mould in houses belongs to the band housing department but we still need to work and sometimes fight with them to get the problem fixed”.
Orientation to the Job
Participants identified that orientations to the job, the organization and to the funding body expectations were lacking or negligible. It appears that most Health Directors learn to perform their duties ‘on the job’ with little to no support or training: “My orientation included giving me the key to the centre and to my office.”
Workload and Expectations
In general, participants agreed and highlighted that the Health Director position is more than a ‘9-5 job’: “this is a 24/7 thing” and “your home phone number is public”. Many felt that the workload and high expectation to meet all needs (from the funding body, the community/clients, leadership etc.) can produce significant stress; as one participant put it, “I’m just happy to keep my head above water”.
The reporting requirements (primarily to Health Canada), and the fact that these requirements are constantly changing, appears to be an issue that was not anticipated by many participants: “I didn’t expect all the demands...what struck me... is Health Canada and how much writing, reading, the work plans, the activity reports measured again the work plan and even the budget stuff”. Some identified an issue with “short-term turn-around demands and/or notification” in relation to attending meetings, conferences and/or submitting proposals. Another issue or surprise identified by some participants was the expectation to attend meetings not just at the local level (in their community and organization) but also at the regional and national levels: “If I’m going to all these meetings then I’m not in my office doing the work”; “It’s almost like the system is set up for failure…we lack so many resources and it’s like they (government) are sending us off on the little rat races to keep us busy and confused”.
Human Resources
Some participants identified a general lack of human resources (and thus money) to deliver services, while other suggested that a lack of training for staff impacts on the ability to get the ‘job done’ effectively. One participant highlighted ‘nursing’ as an issue, especially the Monday to Friday rotation: “On weekends we have no medical, if anything happens we medivac out our patients”. Some noted that they may have not been adequately prepared to deal with all of the human resource issues, including such issues as grievances, concerns for liability, union negotiations and staff turnover.