The clinic supervisory system as experienced by nurse supervisors

Opsomming A lack of proper monitoring and supervision of clinics in the King W illiam’s Town Health District (Eastern Cape) was highlighted by members of the public in the local news­ paper, The Daily Dispatch, during 1999. A clinic audit con­ ducted by the Health Information Unit of the King William’s Town Health District further revealed the inadequacies of clinic supervision in this district. This article describes the qualitative study that was conducted with the aim of optimising clinic supervision in this health district. The study brought to light two issues that appear to be para­ mount in ensuring optimal clinic supervision. These are: • The importance of formal and informal preparation of clinic supervisors for the supervisory role • The support system that the clinic supervisors re­ quire to perform their duties effectively. The focus of this article will be on the discussion of the research findings as well as guidelines that were devel­ oped to optimise clinic supervision. Gedurende 1999 is die tekort aan effektiewe monitering en to esig in k lin ie k e in d ie K ing W illia m ’s Town Gesondheidsdistrik in die Daily Dispatch beklemtoon. ‘n A udit van som m ige klin ieke in die d istrik deur die Gesondheidsinformasie Eenheid, het die tekortkominge van die kliniek toesigen moniteringsisteem bevestig. Die artikel beskryf ‘n kwalitatiewe studie wat ondemeem is met die doel om die toesigsisteem in klinieke in genoemde distrik te optimaliseer. Die studie het die volgende twee punte wat van kardinale belang blyk om optimale toesig in klinieke te verseker, beklemtoon: • Die belangrikheid van formele en informele voorbereiding van kliniekbestuurders vir hul rol • Die ondersteuningsisteme wat die kliniekbestuur­ ders benodig om hul take effektief te voltooi. Die fokus van die artikel sal wees op die bespreking van navorsingsbevindinge en riglyne wat ontwikkel is om optimale toesig in klinieke te verseker. Introduction and background Three groups of supervisors are involved in the supervision of clinics in the King W illiam’s Town Health District. Their re­ sponsibilities are usually reflected in their job descriptions. The first level supervisor is the registered nurse in charge of a clinic. She/he is usually allocated to that clinic for a minimum period of 3 months. The second level supervisor is the area supervisor. She/he is a registered nurse with the rank of senior or chief professional nurse or nursing service manager and is stationed at a hospital. She/he is responsible for the supervi­ sion of a number of clinics. The supervisory functions of the first and second level supervisors are complementary and very similar, although the area supervisor is also expected to sup­ port the nurse in charge of the clinic in many ways, e.g. by updating her/him on changes and developments regarding policies and practices, assisting her/him with problem solving, facilitating the acquisition of the necessary skills and provid­ ing her/him with a written report after every visit. Such a report functions as feedback on the performance of the clinic staff and also highlights issues that need to be rectified in order to improve quality care. The third group of supervisors are programme managers or co­ ordinators from the District Health Office or Provincial Depart­ ment of Health. They are responsible for monitoring the imple­ mentation of their specific programmes, e.g. a programme man­ ager for mental health services would monitor mental health issues only when visiting a clinic. Each programme manager or provincial co-ordinator visits any clinic at any time to super vise her/his specific programme. This study focuses on the first level clinic supervisor, i.e. the registered nurse in charge of a clinic.


Abstract Opsomming
A lack o f proper monitoring and supervision o f clinics in the King W illiam 's Town Health District (Eastern Cape) was highlighted by members o f the public in the local news paper, The Daily Dispatch, during 1999.A clinic audit con ducted by the Health Information Unit of the King William's Town Health D istrict further revealed the inadequacies of clinic supervision in this district.This article describes the qualitative study that was conducted w ith the aim of optim ising clinic supervision in this health district.The study brought to light two issues that appear to be para mount in ensuring optimal clinic supervision.These are: • The importance o f formal and informal preparation o f clinic supervisors for the supervisory role • The support system that the clinic supervisors re quire to perform their duties effectively.The focus o f this article will be on the discussion o f the research findings as well as guidelines that were devel oped to optimise clinic supervision.
Gedurende 1999 is die tekort aan effektiewe monitering en to e sig in k lin ie k e in d ie K ing W illia m 's Tow n Gesondheidsdistrik in die Daily Dispatch beklemtoon.'n A udit van som m ige k lin iek e in die d istrik deur die Gesondheidsinformasie Eenheid, het die tekortkominge van die kliniek toesig-en m oniteringsisteem bevestig.Die artikel beskryf 'n kwalitatiewe studie wat ondemeem is met die doel om die toesigsisteem in klinieke in genoemde distrik te optimaliseer.Die studie het die volgende twee punte wat van kardinale belang blyk om optimale toesig in klinieke te verseker, beklemtoon: • Die belangrikheid van formele en informele voorbereiding van kliniekbestuurders vir hul rol

Introduction and background
Three groups o f supervisors are involved in the supervision of clinics in the King W illiam 's Town Health District.Their re sponsibilities are usually reflected in their jo b descriptions.The first level supervisor is the registered nurse in charge o f a clinic.She/he is usually allocated to that clinic for a minimum period o f 3 months.The second level supervisor is the area supervisor.She/he is a registered nurse with the rank o f senior or chief professional nurse or nursing service m anager and is stationed at a hospital.She/he is responsible for the supervi sion o f a num ber of clinics.The supervisory functions o f the first and second level supervisors are com plem entary and very similar, although the area supervisor is also expected to sup port the nurse in charge o f the clinic in many ways, e.g. by updating her/him on changes and developm ents regarding policies and practices, assisting her/him with problem solving, facilitating the acquisition o f the necessary skills and provid ing her/him with a written report after every visit.Such a report functions as feedback on the perform ance o f the clinic staff and also highlights issues that need to be rectified in order to improve quality care.
The third group of supervisors are programme managers or co ordinators from the District Health Office or Provincial Depart ment of Health.They are responsible for monitoring the imple mentation of their specific programmes, e.g. a programme man ager for mental health services would m onitor mental health issues only when visiting a clinic.Each programme manager or provincial co-ordinator visits any clinic at any time to super vise her/his specific programme.
This study focuses on the first level clinic supervisor, i.e. the registered nurse in charge o f a clinic.

Problem statement
The Eastern Cape Departm ent o f Health formulated policy guidelines to ensure that all residents have access to health services.Some of the values encapsulated in the policy guide lines include service excellence, respect and concern for all patients and clients.
It appeared that this com m itm ent by the Departm ent o f Health was not adhered to by the clinic staff in some o f the clinics in the King W illiam's Town Health District.Community members were being deprived o f access to health care.This was indi cated by the various complaints made by the public regarding a breakdown in services provided in the primary health care clinics in the King W illiam's Town Health District.Complaints 64 Curationis August 2003 included non-availability of drugs at these clinics shortly after they had been delivered, a shortage o f staff and delays in re pairing equipm ent like baumanometers.The public attributed this situation to a lack o f proper monitoring and supervision (Kene, 1998:8;Naki, 1998Naki, :2andM petile, 1998:6):6).
Com plaints were also received regarding unprofessional be haviour o f staff, e.g.reporting late for duty, unstaggered staff lunch breaks and pilfering medicines (Naki, 1999:2).The re sponsibility for monitoring these issues lies mainly with the nurse in charge o f a clinic as the first level supervisor.The inadequacy o f the clinic supervisory system was also high lighted by the findings o f an audit of clinics conducted by the Health Information Unit of the King W illiam 's Town Health District.The audit highlighted high levels o f absenteeism among nursing staff in the clinics of this district as a problem that needed to be addressed.The complaints forwarded by the public as well as the findings o f the audit created the im pression that nurses in charge o f clinics in the King W illiam's Town Health D istrict were not perform ing their supervisory function effectively.This prompted the researcher to question how first level clinic supervisors in the King W illiam 's Town Health D istrict experience their supervisory functions.

Aim and objectives of the study
The aim o f the study was to optimise supervision o f primary health care services in the King William's Town Health District.The objectives were threefold:

□
To explore and describe the experiences of first level clinic supervisors regarding their supervisory role; □ To elicit the viewpoints o f first level clinic supervisors about the strengths and weaknesses of the clinic su pervisory system currently in use;

D
To develop guidelines that will optimise the clinic su pervisory system used in the clinics in the King W illiam's Town Health District.

Research method
The study was conducted in two phases: PHASE 1: Entailed exploration and description o f the ex periences o f nurses in charge o f the clinics re garding their supervisory role and the clinic su pervisory system currently used.
PHASE 2: Described the guidelines that will assist nurse supervisors in their supervisory role and optimise the clinic supervisory system.The guidelines were based on the findings of Phase 1 as well as on a literature control.

Research population
The research population consisted o f registered nurses in charge o f clinics in the King W illiam 's Town Health District.
The criteria for inclusion in the sample were as follows: The participant must: • Have worked as a registered nurse in charge o f a par ticular clinic for at least one year; • Be able to communicate in English; • Be willing to participate.

Sampling procedure
Purposive sampling (Holloway & Wheeler, 1998:75) was used to select the participants who would best address the research objectives.

Data collection
Unstructured interviews were held with seven first level clinic supervisors who met the selection criteria.The researcher felt that the data was saturated after seven interviews, as the same story-line seemed to appear from subsequent interviews.The interviews were tape-recorded and then transcribed verbatim.Field notes relating to the appearance of the clinic, non-verbal communication and the researcher's experience o f the inter view were kept, as well as a record of events.Ethical principles, as described by Polit & Hungler (1997:130-138) were maintained throughout the study.

Data analysis
The database in this study consisted o f transcribed interviews and field notes.In analysing the data, cognitive strategies that were used included inductive reasoning, synthesis, bracket ing and intuition (De Vos, 1998:336-337).
Categories or themes were identified by using Tesch's method o f descriptive analysis (Creswell, 1994: 155).The raw data was sent to an independent coder with experience in qualitative research.A consensus discussion o f the findings was held with the independent coder to identify the themes and sub themes.

Research findings and discussions
All participants in this study were black females who had rel evant experience, i.e. being in charge o f clinics.The duration of the participants' em ploym ent as nurses in charge o f clinics ranged from two to ten years.One o f the participants was in charge of an urban clinic while six were in charge o f rural clin ics.Three participants in the study had post-basic qualifica tions in nursing management.
Table 1 : Identified themes and sub-them es relating to the clinic supervisory system as experienced by nurses in charge of clinics.Community participation in health matters gave support to the clinic supervisors A pilot study was also conducted to identify problems that might be encountered during the first phase.
Following a consensus discussion between the independent coder and the researcher, three main themes emerged from the participants' accounts o f their experiences.□ The first theme highlighted the inability o f the first level clinic supervisors to perform the supervisory function efficiently and effectively □ The second theme revealed that the first level clinic supervisors experienced their role as stressful □ The third theme addressed the support needs o f clinic supervisors The themes and their sub-themes are depicted in Table 1.
The supervisory role of the first level supervisor is briefly de scribed before the discussion o f the themes and sub-themes.This role can be described as: □ Setting goals for her/his clinic in consultation with the clinic staff and the district managem ent team; □ Assisting clinic staff in meeting those goals; □ Ensuring the clinic is well staffed and well equipped; □ Identifying training needs, facilitating the training and; □ M onitoring the quality o f service delivery.
Them e 1 : Clinic supervisors experienced an inability to perform the supervisory function efficiently and effectively The inability to perform the supervisory functions was per ceived by the participants as em anating from the role confu sion they experienced in the performance of their tasks, inad equate preparation for the supervisory role, a lack of resources and a lack of autonomy.
Sub-them e: The nursing supervisors experienced role confusion related to their supervisory function.
The participants said they had to perform supervisory func tions as part o f their duties.They explained that they were required to supervise all categories o f clinic staff including nursing staff, the general assistants and gardeners.This en tailed seeing to it that staff reported for duty punctually and went off duty at the correct time, m otivating staff to work pro ductively, identifying staff training needs and making the nec essary arrangements for the provision of the relevant training.
The participants also reported that they were required to su pervise the provision of supplies to ensure an effective serv ice.This involved acquiring and controlling medicines, order ing and repairing equipment and ordering and controlling sur gical stock.Added to theii managerial duties they also had to execute nursing duties like assessing patients, prescribing medication, dressing wounds and counselling.

"... I 'm consulting, m edication, dressings, I 'm doing every thing. "
They were also involved with the community.This entailed home visits, organizing training o f village health workers and clinic committees, providing health education in the clinic, in homes and in schools, assisting in establishing and im plem ent ing community health projects, assisting with training of stu dent nurses allocated to the clinics and liaising with profes sionals in other disciplines to prom ote the health status of people in the community.
All participants in this study reported that they were unable to perform their supervisory duties as efficiently and effectively as expected.It became apparent during the interviews that the supervisors' time was devoted to direct patient care duties like patient consultations, prescribing medication and counselling clients rather than to supervision.The supervisors therefore felt that their supervisory duties were often neglected.This inability to perform supervisory duties was verbalized by one participant:

"It is a lack o f identity as a su pervisor because subordinates see you checking p a tie n ts' b lood pressure, testing urine, you know, checking vital signs. It is ju s t you fe e l that as a su per visor, i t ' s ju s t a lip service in the sense that you d o n 't do what you are saying. You d o n 't im plem ent it as a supervisor".
The statements made by the participants in this study indicate that the supervisory function was the least performed function by nurse supervisors.It was also noted that the supervisory function was not always reflected in the job description of the nurse in charge o f the clinic and in two clinics job descriptions were not available.
Sub-them e: Nursing supervisors felt inadequately prepared for the supervisory role Sub-them e: A lack of resources interfered with the effective m anagem ent of the clinic.
All participants in the study indicated that inadequate re sources especially personnel, transport, time, equipment and infrastructural resources hindered the efficient performance of the supervisory function.A shortage o f staff forced nurses in charge of the clinics to devote most of their time on direct patient care duties and to pay less attention to supervisory duties.The participants in the study tended to express that they were unable to perform their supervisory duties because of time constraints.This was verbalized by one respondent:

Checking the work perform an ce o f yo u r subordinates, identifying th eir stren gths a n d w eaknesses, the know ledge an d skills that they have, the know ledge an d skills that they lack -you don't have tim e to do it. "
The participants also identified a lack of transport in order to facilitate effective execution of their supervisory functions as a problem.One o f the roles that supervisors said they were expected to play was to oversee all health activities in the com munities and do home visits.This requires transport, as some villages are quite distant from the clinic.Certain supervisors resorted to using their own cars to fetch m edications or to attend workshops.The participants also stated that a shortage o f stock, equip ment and infrastructural resources made supervision difficult.The shortage ranged from medical supplies and surgical stock to equipment, telephones and radiophones.This shortage was said to be interfering with the successful perform ance o f the supervisory role.

Sub-them e: A lack of autonom y made supervising difficult
A lack of autonomy was perceived by the participants as inter fering with decision-making and also as underm ining the au thority o f the supervisors.Participants indicated that although they were given the responsibility o f being in charge o f the clinics, this was not coupled with authority to make independ ent decisions.They stated that they were expected to consult the area supervisors or community nursing service managers even for issues perceived by them as trivial.
Theme 2 : Clinic supervisors experienced stress at being in charge of clinics The majority of clinic supervisors who participated in this study experienced the supervisory role as evoking mild to moderate stress.Only one participant experienced the supervisory role as very, very stressful to the extent of causing mental exhaus tion.
Sub-them e: The complex and challenging nature of the supervisory role evoked stress The nurses in charge o f clinics experienced their supervisory role as complex and challenging.This caused them to experi-ence elevated levels o f stress.Two factors, namely a heavy workload and limited resources were experienced as the main stressors resulting in the complex and challenging nature of the supervisory role.
Another factor that was perceived as contributing to the stress ful nature of the supervisory role was functioning within a challenging system characterized by staff shortages, a lack of transport as well as a lack o f equipment, surgical stock and drugs.
Various methods have been suggested for the effective elim i nation o f stress.One method is for managers to match the personal characteristics of their employees to the culture of the organization in such a way that the 'right people are placed in the right places'.Some studies in the field o f nursing have also established that adequate resource allocation can consid erably reduce the impact o f stress, particularly when the work load o f personnel is affected (Lundh, 1999:950).

Sub-them e: The attitude of colleagues caused the supervisors to experience distress
Participants in this study tended to express concern about the attitudes o f both area supervisors and subordinates, which were perceived as stressful.Area supervisors, or community matrons as they are sometimes called, were perceived as evok ing stress due to the way they conducted supervision when visiting the clinics.The participants alleged that supervision was conducted like a policing or a faultfinding exercise.Only two participants m entioned experiencing stress as a re sult of the attitude o f their subordinates.Supervisors reported the difficulty they experienced in maintaining discipline amongst subordinates as the subordinates stated that they had a dem o cratic right to do as they pleased.Supervisors also stated that they did not experience sufficient support from their managers in dealing with subordinates who displayed a negative atti tude.
Sub-them e: The rotation allocation system caused supervisors to experience distress The system of allocating clinic staff to one clinic for a specific period and then relocating her/him to another clinic or back to the hospital responsible for reallocation, was experienced as stressful by the participants in this study.This practice was said to be very dem anding for the supervisor, as she/he had to keep on orienting new staff m embers to the clinic.

Them e 3: Support needs of clinic supervisors
Clinic visits by area supervisors, staff developm ent activities including in-service education opportunities, workshops, meet ings and community participation in health matters were activi ties in the present supervisory system identified by the su pervisors as sources o f support.

Sub-them e: Visits of area supervisors as experienced by clinic supervisors
Area supervisors were perceived as providing valuable sup port to the nurses in charge o f clinics through their visits to the clinic.The nature o f the support provided through clinic visits included updating clinic staff with information on changes in the health care delivery system, giving feedback on how clinic staff were performing their duties, giving assistance with problem-solving and conflict resolution and providing information on available continuing education opportunities.The concept of conducting supervisory visits in order to pro vide the required support is strongly supported by Strasser (1998:3).Strasser suggests a need to provide onsite support when new programmes or practices are introduced, as well as ways to ensure effective use o f clinic visits.She maintains that clinic visits have to be scheduled in a rational way, objectives for each visit determined, a checklist used, records of the visits kept and timely feedback be provided to the clinic staff.One participant highlighted the fact that although she valued the area supervisor's visits, clinic visits were done in a hurried m anner that did not give her sufficient time to discuss her problems with the area supervisor or to obtain the necessary support.This problem em anated from the fact that in order to visit the clinic, the area supervisor had to share transport with the community doctor and whilst the doctor saw patients, the area supervisor conducted supervision.Visits were hurried in order that the supervisor did not miss the transport back to the hospital.

Sub-them e: S ta ff developm ent activities helped clinic supervisors to cope with new situations and challenges
Participants experienced the opportunity to attend in-service education opportunities, workshops, seminars, short courses and meetings as a strong source o f support.Participants stated that they felt refreshed, updated and confident after attending these continuing education activities.Some participants had undertaken formal post registration courses in Community Nursing Science, Nursing Adm inistration and Primary Health Care Nursing Science in order to empower themselves.Others had attended, or were attending, in-service education lectures or courses.The monthly meetings that were held with area supervisors and other peers were also experienced as valuable since they afforded time to share problems encountered in the clinics and to realize that other supervisors were experiencing similar prob lems.Planning can be done jointly and the best solutions for identified problems sought.
Sub-them e: Com m unity participation in health m atters gave support to the clinic supervisors Some o f the participants stated that they were influential in organizing community members like village health workers, and setting up clinic com m ittees to participate in health matters where these had not existed before.Participants also men tioned links that they had established with individuals from other fields or sectors to assist in addressing health problems.The supportive value of community participation did not only ease the work o f clinic supervisors but also made it enjoyable.

Guidelines to optimise the supervisory role of the first level clinic supervisor
The following guidelines are based on the identified needs following analysis o f the themes and the literature review.
These guidelines have been generated to prepare and equip the first level supervisors for their supervisory responsibilities and to optimise clinic supervision.

Develop a clear job description
Jo b descriptions are useful for a number of purposes like giv ing an employee a clear picture o f her/his responsibilities, as sisting in the evaluation o f job performance, assisting in the orientation o f new employees to their jobs, forecasting train ing needs and showing the proper channels o f communication (Booyens, 1998:232-233).Strasser (1998:23) alludes to the fact that one of the difficulties experienced by participants in the position of clinic supervisor is the lack of a clear job description resulting in more time being spent on non-supervisory tasks.It is important to determine how the scope o f responsibilities o f a clinic supervisor differs from that o f a programme manager and programme co-ordinator, and how the expectations for, and responsibilities of, co ordinators and program m e managers com plem ent or overlap one another.The job description should indicate the supervi sory duties o f the nurse in charge o f a clinic as a first level supervisor regarding utilization or allocation of resources such as the budget, staff, availability of water, electricity, equipment and supplies like drugs, cleaning materials, stationery and main tenance of the clinic building.The job description should also indicate how the first level clinic supervisor is expected to in teract with the communities, organizations and the govern ment departm ents that support service provision.

Set selection criteria for the position of first level supervisor
The criteria for appointm ent as a supervisor should be defined and these criteria m ust include relevant experience, qualifica tions, knowledge base and personal attributes.The supervi sor should have some experience in supervision and have con solidated that experience, although the length o f experience or seniority does not necessarily correlate with effective supervi sion (Fowler, 1995:36).The supervisor should demonstrate knowledge and skills in the area that she/he is supervising.One measure of this may be the successful completion o f a formally recognized relevant course, e.g. a Diploma in Nursing Management (Fowler, 1995:36).

Delegate responsibility and authority
The current situation o f clinic supervision as experienced by first level supervisors is that they are given the responsibility o f being in charge o f a clinic without the associated authority.They perceive this situation as weakening their confidence and ability to supervise and dim inishing their power to exer cise control over their subordinates.They interpret their posi tion as tantam ount to being a contact person.Delegation of responsibility and authority will assist in rem oving over-reli ance on area managers who in most cases visit the clinic once a month, or sometimes never due to transport problems.The first level supervisors need to be given an opportunity to de velop their problem-solving and decision-making skills.It is important however that they are equipped with the necessary knowledge and skills to perform these tasks competently.

Develop an orientation programme for clinic supervisors
The orientation programme should at least address the job requirem ents and jo b expectations, the daily, weekly and monthly duties, the physical layout o f the nursing unit and com munication channels and structures.Formal introduction of the newly appointed supervisor to the clinic staff, clinic committee and the community members is essential in order to foster acceptance and to ease the functioning o f the clinic supervisor.
There should also be proper transfer o f authority from the per son vacating the post to the new registered nurse who will take charge o f the clinic.

Formal preparation for the supervisory role
Although needs will vary from district to district, clinic super visors should at least have strong skills in primary clinical care, health promotion, good interpersonal skills as well as the abil ity to supervise and mentor (Strasser, 1998:2).A prospective clinic supervisor can act as understudy to an experienced clinic supervisor for a fixed period of time in order to learn the reali ties o f the job and to build confidence.Attendance at staff development opportunities should be implemented in a struc tured manner guided by training needs.

Provision of support
The necessary supervisory tools and resources that will facili tate the supervisor's functioning and increase the effective ness o f clinic supervision should be provided in order to sup port the first level supervisors.The relevant supervisory tools with which the nurse in charge o f a clinic should be provided are supervisory checklists, a handbook for clinic managers outlining clinic functions and policies, perform ance appraisal tools and treatment guides and protocols.Providing resources such as transport, staff, equipm ent and means o f com m unica tion, will improve the supervisor's ability to function in her/his role and promote clinic supervision.

Designing a long-term clinic rotation plan
Clinic supervisors and their subordinates need prior notifica tion regarding their allocation to another clinic or back to the hospital.It is therefore recom m ended that a long-term clinic rotation plan be designed.The plan must be sufficiently flex ible to take special requests into account and it should be reviewed annually.This move will minimize stress caused by a need to continually orientate and arrange training for new staff.
Disorganization of family life and the interruption of projects that have been initiated by the supervisor and clinic staff will be averted if rotation is done in a well-planned and proactive manner.

Conducting annual review of the training needs of first level supervisors
Supervisors themselves require periodic training and updates to remain abreast of the many rapid changes in health care, e.g. the changing health policies, changing professional legisla tion and advances in health technology.The value of in-service training in these circumstances cannot be overemphasized.Some of the topics that can be included in an in-service educa tion programme for clinic nurses are: Limitations of the study □ Due to the rural nature of the King W illiam's Town dis trict, more rural than urban clinics were represented in the study.□ Cultural and gender representation could not be achieved as was initially planned by the researcher be cause none of the clinics were supervised by male reg istered nurses.The only white female clinic supervisor who could have participated in the study withdrew on the day of the interview because of an urgent assign ment.□ Clinics that were furthest from the provincial and dis trict offices and from the supervising hospitals were not represented, as they were not accessible to the re searcher due to the conditions of the roads.

□
The study was conducted at a time when rearrange ment of clinic supervision was being considered.

Recommendations
The recommendations are made with specific reference to nurs ing practice, nursing education and nursing research

Nursing practice
The position of the nurse in charge of a clinic as first level supervisor needs to be upgraded to that of a senior or chief professional nurse depending on the size of the clinic.This will place her/him at the same level as her/his counterparts in a hospital ward or unit.The first level clinic supervisor should be relieved of other duties such as direct patient care duties, in order that she/he can monitor, evaluate and oversee all activi ties in her/his clinic with the guidance of the supervisory check lists and handbooks for managers that are presently used by area supervisors.This recognition of status for the first level supervisor will increase her/his authority and confidence and enable her/him to exercise more direct control over her/his sub ordinates.This will prevent her/him from contributing to the problems in the clinic.Optimal supervision will be achieved by shifting the focus to direct energies into equipping the nurse in charge of a clinic with supervisory skills rather than concentrating on the area supervisors as is current practice.The present over-reliance on "strangers" who visit the clinic once a month can result in a dependency situation and abuse of area supervisors.Some problems, such as those relating to staff discipline, are some times postponed for the attention o f the area supervisor when she/he visits the clinic without making an earnest effort to resolve them.An investment in the nurses in charge of the clinics and a re-evaluation o f their role to allow them to func tion optimally is clearly needed.

Nursing education
The research results revealed the supportive value o f staff development programmes.A needs analysis should be con ducted annually in all clinics and the information channelled to the In-Service Education Committee.A policy should be for mulated recommending that each clinic supervisor attend at least two continuing education activities per year.The present clinic supervisory manuals and checklists have to be reviewed to determine their relevance to the current health care situa tion.

Nursing research
This study has revealed that staff development activities like in-service education and workshops are experienced as sup portive by clinic supervisors, but further research is needed to evaluate the impact of such continuing education activities on client or customer satisfaction.

Conclusions of the study
The results of the interviews, as well as the field notes, high lighted the fact that clinic supervisors experienced an inability to perform their supervisory function effectively and efficiently.A lack o f resources and autonomy, role confusion and inad equate preparation for the supervisory role were cited as un dermining the capacity o f first level clinic supervisors to per form their supervisory duties.These were the weaknesses that need to be addressed or improved in the present clinic supervi sory system.The supervisors also perceived their supervisory role as stressful but felt supported by those area supervisors who used clinic visits constructively.Participants also sug gested that attending in-service education programmes, work shops and meetings offered further beneficial support.Com munity members and community health structures like clinic committees were also perceived as providing the first level clinic supervisors with necessary support.The supportive el ements or activities were perceived as the main strengths of the present clinic supervisory system.The guidelines that were designed are to assess and address the support needs of su pervisors o f clinics.
Participants tended to feel that they were not adequately pre pared for the supervisory role prior to placement in a supervi sory position.No orientation on what and how to supervise was given.No arrangements were made for proper handing over from the person currently in charge of the clinic prior to placement in a clinic.This point of view is emphasized byDimond (1998:394)who advises that training must be provided for supervisors to ensure that they are well prepared for this role, as it cannot be assumed that supervision skills are innate.
Strasser (1998:2)supports the need for preparation for the su pervisory role and recommends that the training needs o f the clinic supervisors be determined.She warns about the danger °f assum ing that supervisors automatically have clinic and managerial expertise.She maintains that there is a need to establish the type o f orientation required by, or provided to, new supervisors in a district and the way of addressing ongo ing educational needs of supervisors.