The perceptions of nurses in a district health system in KwaZulu-Natal of their supervision , self-esteem and job satisfaction

Background Supervision has been identified as a major issue in qual­ ity of care. Although increasing attention is being given to supervision in the District Health System, there have been no studies describing the current situation. This article describes a survey done in two health districts in KwaZulu-Natal involving 319 nurses from all types of government health care settings. Methods This was a quantitative descriptive study that described the current supervision, job satisfaction and self-esteem in two (2) health districts, that is the Ugu and the uThukela health districts. The three variables were described us­ ing a mailed questionnaire. A total 319 nurses partici­ pated in this study. Results The majority of the nurses (53%) felt that positive su­ pervision behaviours listed in a rating scale, occurred never or seldom. The average self-esteem score was very positive (83%), and the average job satisfaction score was 60%. Nurses were most satisfied with the factor reflecting “personal satisfaction about their contribu­ tion to the work” (72%) and the least satisfaction with the factor that has to do with “pay and prospects” (50%). While there was no relationship between any of the demographic variables and supervision, there was a low but significant relationship between supervision and job-satisfaction. A significant relationship was also found between the personal satisfaction factor of job satisfaction and self-esteem. Conclusion As nurses form the backbone of the health services, it is incumbent that health service managers safeguard the nursing workforce. Targeted strategies are neces­ sary to ensure retention of the nurses for the health care of the South African population. Title A survey of the perceptions of nurses in a district health system in South Africa of their supervision, self-es­ teem and job-satisfaction.


Background
Supervision has been identified as a major issue in quality of care.It has been identified as a priority by the Initiative for Sub-district Support (ISDS) (1998), the Centre for Health and Social Studies (CHESS) (Gwele and Makahnya, 2001), and the Eastern Cape Department of Health (2000).Al though increasing attention is being given to supervision in the District Health System, there has been no studies describing the current situation.Before this is done, that is outcome studies, it is impossible to get a clear picture of the problem, and plan interventions.
There seems to be two basic approaches to supervision, namely management supervision and consultative super vision.In management supervision, line managers super vise practice of the supervisee and have authority over them.Van Ooijen (2000, p. 26) points out that this type of supervision may be less effective in nursing, where it is seen as policing rather than supporting.Consultative su pervision is done by a person who has no managerial re sponsibility for the supervisee, with the sole objective of support development.This is less common in nursing, but is the model used in the professions of social work and counseling.
In a concept analysis of "clinical supervision", Lyth (2000, p.728) defined it as "a support mechanism for practicing professionals within which they can share clinical organi zational, developmental and emotional experiences with another professional in a secure, confidential environment in order to enhance knowledge and skills.This process will lead to an increasing awareness of other concepts includ ing accountability and reflective practice."This is a more consultant-friendly definition than the one by Butterworth (1992, p. 12) "an exchange between practicing profession als to enable the development of professional skills".These definitions lead one to expect distinct benefits for the serv ice as well as for the practitioner.
A descriptive study was therefore undertaken to describe and explore the current practice with regard to supervision in different service settings (primary health care clinics, district hospitals, and regional hospitals) in a District Health Service (DHS) as seen by nurses in those settings.In a study by Seccombe and Smith (1997) in the UK, the super visory relationships was central to job satisfaction.To ex plore the impact of supervision on the nurse, it was de cided to also explore the job satisfaction and self-esteem of nurses in these settings, and its relationship with supervi sion.

Literature review Supervision
A number of articles describing research projects around supervision were found.Sloan (1999) described a qualita tive study in which the experience of supervision of regis tered nurses working in a mental health setting was de scribed.Individual questionnaires and one focus group interview was used.He found that although supervision was generally helpful, supervisees had trouble with not being able to choose a supervisor, and by the supervisor also being the manager, and keeping written records of in teractions.Clinical supervision time was spent on clinical business, emotional support and professional development, with the process strongly resembling Proctor's three func tion model.This model was also used in a study by Bowles and Young (1999), in which a positive correlation was found between experience of supervisors and reported benefits, with benefits spread almost equally between the three func tions (formative, restorative and normative).
White, Butterworth, Bishop, Carson, Jeacock and Clements (1998) also described clinical supervision from the perspec tive of supervisors interviewed individually.They did su pervision individually or in groups, and saw supervisees fort-nightly or monthly.They dealt with practice, organiza tion, management, education, training and personal devel opment.They were convinced that supervision improved practice and strengthened relationships with work col leagues.However, they were concerned about the lack of time for supervision, and the lack of training for this aspect of their jobs.
Closer to home Kim, Tavrow, Malianga, Simba, Phiri and Gumbo (2000) explored the supervision process in Zimba bwe.They surveyed the supervision practice of sixteen (16) supervisors in eleven ( 11) districts by non-participant observation, using an observation schedule, as well as in terviews and record reviews.Establishing rapport and giv ing feedback were the strengths of the supervisors.Weak nesses included not promoting participation, not discuss ing service standards, not assisting with problem-solving, and did not take a longer or more comprehensive view of problems.There was a lack of continuity between visits, and checklists used showed a range of limitations.A study by Troskie (1994), which surveyed the expressed needs of registered nurses for additional management training, su pervision scored the lowest, together with orientation of staff.Registered nurses therefore did not feel that they needed additional training in this aspect.

Job satisfaction
Job satisfaction is a pleasurable or positive emotional state resulting from the appraisal of one's job experiences.Job satisfaction results from the perception that one's job ful fils or allows the fulfillment of one's own important job values (Locke, in Tovey and Adams, 1999, p. 152).This was measured using the Measure of Job Satisfaction (MJS), an instrument developed by Traynor and Wade (1993).
Job satisfaction is a heavily researched topic, not only in nursing (Tovey and Adams, 1999;Price, 2002), but also in medicine (Beasley, Kern, Howard and Kolodner, 1999).It has been pointed out that initially job satisfaction studies focused on the influence of job satisfaction on productiv ity, while later studies has recognized it as a quality of life issue pertaining to the welfare of workers (Westaway, Wessie, Viljoen, Booysen and Wolmarans, 1996).Job satis faction has been successfully linked with strike action, ab senteeism and turnover (Westaway et al, 1999).
Conceptually, job satisfaction is also discussed in the mo tivation theories such as Maslow and Hertzberg, since these theories address the antecedents to job satisfaction (Tovey and Adams, 1999).This was the approach followed by Fertig (1998) in a study of staff motivation done in the Uthukela District.He found salary, opportunities to learn, achieve ments, recognition by the community and taking part in decision-making to be most motivating to the respondents.
From the literature it is clear that job satisfaction is influ enced by multiple factors (Kaplan, Boshoff and Kellerman, 1991).The categories used in different instruments devel oped to measure this concept, therefore also differs widely.Beasley et al (1999) found six facets (work with supervisees, colleague relations, resources, patient care, pay and pro motion).Tovey and Adams (1999) researched the compo nents to establish an empirical framework for such research.They identified the following topics from their data: job content, resource issues, professional concerns, profes-

Self esteem
Self -esteem is the belief about ones own worth, which al lows for confi dent handling of life's problems, as measured by Rosenberg's Self-esteem Scale.Westaway et al (1996), pointed out that initially job satisfaction stud ies focused on the influence of job satisfaction on produc tivity, while later studies recognized it as a quality of life issue pertaining to the welfare of workers and these au thors have also found a positive relationship between self esteem and job satisfaction.

Research Design
This was a descriptive study to describe the current su pervision in two (2) health districts, as well as the job satis faction and self-esteem of nurses in these two districts.All three variables, that is, supervision, job satisfaction and self-esteem were described using a mailed questionnaire.

Setting
The two districts involved are Ugu and Uthukela.These two districts were chosen because two different interven tions around supervision were planned for these districts, and doing a baseline survey would allow for evaluation of the interventions.Both districts are seen as relatively typi cal rural districts in terms of their population and service spread.The two districts are briefly described in Table 1.

Sample
There are 1668 nurses in Ugu Health District, and 1250 in Uthukela Health District.In the Uthukela health district, the three (3) hospitals were selected, and in the Ugu health district, three (3) hospitals and in both districts six (6) clin ics were randomly selected.All the nurses on duty on the day of a visit from the field worker were given a question naire to complete.A total of 248 nurses from Ugu district and only 71 from Uthukela district responded (319).Phone calls to the services in the Uthukela district lead to only a few more questionnaires being returned.This represents a 15% return in Ugu, and a 6% return in Uthukela.
Table 2 sets out the work settings of the sample.In the population in this district 17% of nurses work in PHC set tings, 60% in district hospitals, and 23% in regional hospi tals.In the sample the percentages were 17%, 29% and 44% respectively.Regional hospitals were therefore over repre sented in the sample at the expense of district hospitals.In terms of category of nurses, nursing auxiliaries make up 22% of the population in the district, enrolled nurses 25%, registered nurses 41% and supervisors 2%.In the sample 22% were nursing Auxiliaries, 25% Enrolled Nurses, 39% Registered Nurses and 10% supervisors.The sample there fore seems to reflect the categories in the district quite ac curately.
Only twenty-three (23) of the respondents were men (7%), and the average age was 38 years (SD 12), with the ma jority (34%) falling between 31 and 40 years, and a large number also between 41 and 50 years (28%).On average the respondents had years of nursing experience, with an even spread from 1-5 years upwards to 20 years and more.

Data collection
Questionnaires were delivered by hand to all sampled services in the two districts.A letter explaining the re search and asking the respondent to participate accom panied the questionnaires.A stamped, self-addressed envelope was attached to send the reply to the research ers at the University.The following data collection instruments were used: Description o f current supervision: A questionnaire was developed based on the observation schedule used in the Zimbabwe study (Kim et al, 2000).Twelve items described the supervision activities and respondents were asked to rate these for frequency, and one general item requested respondents to rate their satisfaction with supervision.This instrument was developed without reference to the differ ent models of supervision, in an effort not to have an in strument biased towards a specific model of supervision.
Self-esteem: The Rosenberg Self-Esteem Scale (RSE) was used to measure self-esteem.This is a 10 item 4-point scale with a coefficient alpha of 0,78 in both American and South African studies (in Westaway et al, 1996).
Job satisfaction: The Measure of Job Satisfaction (MJS) was developed and tested in the UK.It has shown an inter nal consistency of 0,88 on Cronbach alpha, and an inter rater reliability of 0,86 on average.It showed a 0,83 correla tion with another measure of job satisfaction (criterion va lidity) and was able to discriminate between different groups of nurses (Traynor and Wade, 1993).It has 38 Likert scale items (very satisfied to very dissatisfied) on a five-point scale.
Ethical clearance for the research was obtained from the University, the Provincial Department of Health and the Directors of the two health districts.The voluntary com pletion and mailing of the questionnaires by respondents were accepted as voluntary participation.

Analyses
Internal consistency of all the instruments was calculated using the Cronbach Alpha Correlation Coefficient.Frequen cies, means, standard deviations were then calculated.The significance of differences between the two health districts was calculated using the Pearson Chi-Square test.

The current practice with regard to supervision
Since this is the first time this scale was used, a Cronbach Alpha Correlation Coefficient was calculated, and was found to be 0,8996.The inter-item variance was 0,05, the standard deviation 10,7 and the mean 31 out of a total pos sible score of 48.A factor analysis was done, and this showed that items 1 and 12 had the lowest correlation with the rest of the items (both 0.4).It also showed only one factor with significant loadings from all items, except 13.
The responses of the 318 nurses in the sample are summa rized in table three.On average, 53% of nurses rate the positive behaviours listed in the scale as occurring never or sometimes (see column 5).The percentage is in the 60% for two items (Give me feedback about my own perform ance, Discuss next visit or supervision session).On the item asking about their general satisfaction with supervi sion, 72% indicate dissatisfaction.
Nurses were also asked to identify their supervisor(s).On average the nurses identified 5 (4.8) people as their super visors, and in many cases nurses from the same setting would name different supervisors.
Using the Spearman Rank Correlation no significant corre lation was found between any of the demographic factors,

Frequency
Figure 1 Scores on the Self-esteem scale

Self-esteem of nurses
The internal consistency of this scale was tested using a Cronbach Alpha Coefficient, and was found to be 0,65.The average Self-esteem Score of the nurses was 33 out of a possible total of 40, and a SD of 4,35.Only three scored below 20, as illustrated in figure 1.To explore whether su pervision influence self-esteem, a Chi-Square test was per formed and no association was found (r=0.287,df=2, p=0.866) (41 %).On factor one, personal satisfaction, only 13% are dissatisfied, and 25% are very satisfied.The average scores on the factors were as follows: factor 1 = 3.7, factor 2 = 2.8, factor 3 = 3.4, factor 4 = 2.3 and factor 5 = 2.4.
To find out whether supervision influences job satisfac tion, a Chi Square correlation was calculated between these two sets of data.A low but significant relationship was found (r=39.852,d.f.= 9, p<0.000), and the Phi value for symmetric measures showed that this was a positive rela tionship.The relationship between self-esteem and job sat isfaction was also explored by doing a Chi-square test, and no relationship was found (r=4.225,df=6, p=0.646).

Job-satisfaction of nurses
The average job satisfaction score of the nurses was 113.56 out of a possible total score of 190 (60%), with a higher score indicating greater satisfaction with supervision.The average score can also be stated as 2,6 with a SD of 0.7, as was done by Traynor and Wade (1993).This score falls between dissatisfied (2) and neutral (3) (or 76 and 114), but is very close to a neutral score.The SD is 26.6, which is within one category, and still does not move the majority of nurses to the "very dissatisfied" or the "satisfied" catego ries.A toral of 41% of the respondents falls in the two lowest categories (very dissatisfied and dissatisfied).
The scale consists of five (5) factors, and in Table 4 the dissatisfaction rating of respondents on each factor is sum marized.There are three (3) factors on which the dissatis faction scores are high.These are factor 5 -Satisfaction with Training (52%), factor 4 -Satisfaction with pay and prospects (50%), and factor 2 -Satisfaction with workload

Discussion
It would seem that there is a general feeling of dissatisfac tion amongst nurses with the supervision they receive (72%).More than half (52%) of respondents saw positive supervision behaviours as happening never or only some times.In view of the poor correlation of the items on rap port and involving clients, these two items should perhaps be deleted from the scale.It is interesting that the factor on the Measure of Job Satisfaction (MJS) which deals with feeling supported (factor 3) did not show such a negative picture, with only 20% indicating dissatisfaction.When one looks at the individual items in this factor, however, it would seem that it is support coming from peers that is rated high in items such as "contact with colleagues" or "value placed on my work by colleagues".
The results contrast with the Zimbabwe study, where the rapport and feedback were strengths, and the solving of problems a weakness.Planning ahead for other supervi-  Although there is no significant relationship between self esteem and job satisfaction, there is a positive relationship between the high scores on factor I of the MJS (Personal satisfaction) and high scores on the self-esteem measure.
The high levels of personal satisfaction and the high self esteem might serve to disguise the dissatisfaction in many other areas.
It is difficult to compare the average job satisfaction of this group of nurses with other South African samples, since the three (3) available studies (current, Kaplan et al, 1991, andWestaway et al, 1996) used different measuring instru ments.However, Westaway et al (1996) found nurses to be the least satisfied with promotion and pay, and the most satisfied with supervision and co-workers.This is a similar finding to this study.Respondents in this study are nega tive about three out of the four factors, which all has to do with negotiable job benefits.
When comparing the average scores of the different factors with the scores on these factors obtained by district nurses in the UK (T ray n o r and Wade, 1993), scores for factors 1 to 3 were remarkably simi lar (see table 5).However, when it came to the last two factors, the SA nurses scored much lower.Traynor and Wade compared six different groups of nurses with each other, and none of these groups scored as low as the SA nurses on the last two factors.This leads one to take the dissatisfaction in these areas more seriously, since it does not seem to be common to all nurses.In 1991 Kaplan et al's study compared the score of nurses in South Africa with that of other health professions, and found that it was not only the lowest, but that it was significantly lower than the other professions.It would therefore seem that these as pects need some attention.Whilst district management cannot address pay, which is negotiated nationally, they can address career development and training.

Conclusion
Nurses form the backbone of the health services in South Africa, especially in rural areas, where doctors and all other health professionals are a scarce resource.Attracting nurses to rural government services and keeping them there in the face of international recruitment is also becoming increas ingly difficult.It is therefore incumbent on health service managers to safeguard the nursing workforce.This study points to particular problems that need to be addressed; the quality of supervision, the training opportunities and pay and prospects.Although it is safe to say that no group is ever satisfied with its pay, the comparison with other professions and with nurses internationally shows that this problem is real for South African nurses.Targeted strate gies are necessary to ensure the retention of nurses for the health care of the South African population.