The role of clinic supervisors in clinical supervision in primary health care services in KwaZulu-Natal

The role of clinic supervisors in clinical supervision in primary health care services in KwaZulu-Natal Authors: PH Nkosi, BA Cur, UNISA 1 C Horwood, MPH, University of KwaZulu-Natal 1 K Vermaak, MSocSci (Research Psychology), University of Natal 1 C Cosser, DLITT ET PHIL, UNISA 1 L Haskins, M. Tech Nursing (TN), Durban Institute of Technology 1 1. Centre for Rural Health, University of KwaZulu-Natal, South Africa Corresponding Author: Phumla Nkosi Centre for Rural Health University of KwaZulu-Natal Private Bag 7, Congella 4013 Durban South Africa E-mail: nkosip6@ukzn.ac.za Telephone: +27 31 2601569 Fax: +27 31 2601585

The role of clinic supervisors in clinical supervision in primary health care services in KwaZulu-Natal Abstract: Introduction In South Africa, primary health care (PHC) services are provided by professional nurses, who are often left on their own, with very little or no support at all. To provide quality services, clinic nurses need to have regular skills assessment and development. Supervision has been shown to improve performance of health workers. Clinical supervision is regarded as one of the most important support systems for effective, high quality health care services. To fulfil this role, supervisors need to be trained and also be supported with resources, including time, so that their activities go beyond administrative activities. An investigation of the role of clinic supervisors was conducted as part of a study undertaken to evaluate referral and support systems between clinics and district hospitals in 3 districts, namely uthungulu, Umkhanyakude and Zululand. Methods A descriptive study was conducted, involving 58 randomly selected PHC clinics, and the 22 district hospital-based clinic supervisors responsible for these clinics. The 58 clinics were visited between July and September 2007, during which clinic managers were interviewed and records of supervisory visits reviewed. During the same period, the 22 clinic supervisors were interviewed and their supervision records reviewed. 2

Results The majority of supervisors had been trained in clinic supervision and had a PHC diploma. Most supervisors felt that the supervision course had equipped them with the skills and tools to do their job well. While 64% of clinics reported having monthly supervisory visits, only 38% recorded having been visited in the past month. Almost a third (32%) of the supervisors said they had missed more than one visit in the past 6 months due to transport problems. However, most supervisors said they missed visits due to other commitments, such as attending meetings. Most activities of the supervisors revolved around administrative issues, with clinic managers reporting main activities during supervisors visits as general supervision and support (43%); with management reviews reported by 16%. In the previous month, only 22% of the clinics had an in-depth programme review; no clinic had records or reports of quality of clinical care reviews. 22% of the clinics reported phoning the supervisor when they needed clinical advice, whereas most telephonic contact was reported to be for discussion of administrative issues (74%). Conclusion Clinic supervisors have a limited or no role in clinical supervision; their focus is mainly on administrative matters. Current guidelines on clinic supervision do not emphasize observation of patient management. The role of supervisors in clinical supervision can be improved by development of relevant guidelines and checklists, and by being provided with resources and time to do supervision. Key words: Supervision; clinical supervision; clinical skills; quality assessment; patient care; case management 3

Introduction and literature There is a huge burden of disease and death in developing countries like South Africa, even though interventions are available to prevent these deaths. There is a growing imperative to improve coverage of key health interventions if the millennium development goals are to be met (Bryce et al, 2005, p.69). However poor performance of health workers frequently leads to a failure to implement available guidelines (Bryce et al, 2005, p.69). It has often been assumed that the solution to poor health worker performance is more and improved training. However, determinants of health worker practice are more complex and correct knowledge often does not lead to correct practice (Rowe et al, 2005, p.1026). Supervision has been shown to improve health worker performance, and to improve the transfer of new knowledge into practice (Pariyo et al, 2005, p.i58). Chaudhary et al ( 2005, p.735) also point out that frequent and regular visits are important in helping health workers adopt, and practise newly acquired skills. In South Africa, like in other developing countries, primary health care services are provided by professional nurses or clinic nurses. Though clinic nurses are usually provided with management protocols, they are often left on their own, with poor, or no support and supervision (Reid, 2002, p.1). In order to provide quality services, clinic nurses need to have regular skills assessment and development. It has been suggested that clinic supervisors can help improve quality of care in clinics by providing both administrative and technical support to service providers (MSH, 2006, p.i). Furthermore, some authors see the primary aim of supervision as that of providing advisory support and training to health professionals, while administrative control is viewed as of secondary importance (Görgen et al, 2004, p.72). The modern approach to supervision puts emphasis on quality improvement; clinical supervision is regarded as one of most important support systems for effective, high 4

quality health care services (Tavrow et al, 2002, p. 57). Clinical supervision entails assessment of skills, where the supervisor observes patient care, identifies gaps in knowledge and/ or skills, and takes action to improve skills and performance of health care providers. Directly observed practice is beneficial to the health care providers as instant feedback is received (Smith, 1996, p.16). Most clinic-based managers often lack skills and authority to manage and address service delivery challenges; hence the importance of regular supervisory visits by sub-district based, or external clinic supervisors (Marquez et al, 2002, p.1). External supervisors are an important link between health workers in remote areas and the health system (Rowe et al, 2005, p.1030). There are major challenges to supervision, including supervisors lack of skills, lack of useful assessment tools, and lack of transport, and supervisors are often burdened with administrative duties. Supervisors are often not supported by their superiors, who may prioritise other activities over supervisory visits (Rowe et al, 2005, p.1030). Supervision, therefore, needs to be improved, so that supervisors are able to contribute to quality improvement. To achieve this, supervisors need to be trained in supportive supervision so that the clinic supervisor is given skills to act as a facilitator, trainer and coach (Marquez et al, 2002, p.24). Supervisors also require support from their superiors, and resources to increase the time they spend with health workers (Rowe et al, 2005, p. 1030). Benefits of training of clinic supervisors It has been recognized that clinic supervisors need to be trained in order for them to play a meaningful role. Strasser (1998, p.2) suggested that supervisors undergo periodic training and updates in order to keep abreast with changes. Reid (2002, p.1) also alludes to the importance of training of supervisors. In his paper, Training programme for Rural Primary Care Nurse Practitioners in South Africa, Reid (2002, p.1) 5

points to the fact that, in South Africa, the role of support and supervision of PHC workers was given to professional nurses who were not adequately trained for the job. The article describes a programme that was designed to support and develop PHC coordinators in Pietermaritzburg district (now Umgungundlovu) in KwaZulu-Natal in 2000. Evaluation at the end of the programme showed that there was improvement in the supervisory process, supervisors had more understanding of their roles, and selfconfidence and problem-solving skills were improved (Reid, 2002, p.7). A study conducted by Gwele and Makhanya, (cited Lehman et, 2001, p.6), in one district in KwaZulu-Natal, found that supervisory process, frequency and duration had been improved by training of supervisors. Training of clinic supervisors in KwaZulu-Natal In South Africa, a supervisor s manual which contains policy guidelines and checklists, for use by clinic supervisors to assess the quality of PHC programmes, and clinic administration, was developed. Clinic supervisors are to use checklists to facilitate reflective practice, and to provide technical guidance to clinic nurses (Rohde, 2006, p.5). Training supervisors in the use of this manual in KwaZulu-Natal was started in 2001. The 5-day training was conducted by provincial facilitators. Three days of this training were dedicated to clinic visits, where supervisors practised using the tools under the guidance of district facilitators. According to J.Dalton (PHC Technical Advisor,KZN), the provincial human resource development (HRD) and the districts were expected to continue with the process (personal communication, July 30,2008). Who is the clinic supervisor? In KwaZulu-Natal, clinic supervisors, also called Service Area PHC supervisors, are professional nurses who are appointed based on the fact that they have a minimum experience of 3 years of working in a primary health care (PHC) setting. They are 6

usually based in district hospitals or community health centres (CHC), and are responsible for a certain number of clinics in a specific service area. Clinic supervisors report to the nursing manager, who is part of the district hospital management, or to a PHC or CHC manager (see Figure 1). Although supervisors may be, and usually are, experienced primary health care nurses, more often, they have not had any training to supervise health care workers, hence the need for supervisors to be trained. Supervisory frequency and process A supervision policy is necessary for well-structured supervision (DOH, 2007, no page number). The supervision policy outlines the supervisory process and the roles and responsibilities of the supervisor. Over the years, it had been recognised that supervision of primary health care facilities was not given any priority; supervisory visits have been known to be irregular, and not well planned (Rohde, 2006, p.7). The policy, therefore, states that: there needs to be a dedicated supervisor for a number of clinics; clinics visits should be scheduled in advance; each clinic should be visited once a month; the supervisor should spend at least 3 4 hours in a clinic there should be reliable transport (Rohde, 2006, p.7); (DOH, 2007). Activities of the clinic supervisor Supervisory activities need to be focused on assessment of compliance to standards, transfer of knowledge and skills, provision of feedback, identification of problems, and development of action plans (Marquez et al, 2002, p.10).the Primary Health Care Supervision manual has listed the key activities to be carried out during supervisory visits (DOH, 2007, section 1). See Box 1. 7

Supervisors role in quality supervision The revised PHC Clinic Supervision Manual, which has not yet been implemented, has included a section on Quality Supervision (QS). This is aimed at improving supervision, and supervisors are expected to assess and facilitate quality. Assessment involves observation and assessment of patient management and resources at the facility, using a checklist. Facilitation involves giving feedback to health care personnel, problem solving, planning and monitoring (DOH, 2007, section 3). In this new version of the supervision manual, supervision has been expanded to include observation of case management (DOH, 2007, section 3). This is in line with the concept of clinical supervision. In the previous edition (2002), currently in use, observation of case management or patient care was not explicitly mentioned. Although various checklists are being used, there are no checklists for patient care observation. It is clear that clinic supervisors have a responsibility to do clinical supervision to ensure quality of health care services. This should form part of the day-to- day activities, whenever the supervisor interacts with supervisees. In addition to other challenges that lead to the supervisor not being able to effectively fulfil her role, the fact that guidelines and training on supervision do not clearly spell out the clinical supervision role has led to supervisors overlooking this important role. Previous studies conducted in South Africa on supervision did not explore supervisors role in assessment of and provision of clinical skills. This article explores the role of the clinic supervisor in clinical supervision. Issues raised are about the ability of the external clinic supervisor to provide clinical supervision: do supervisors possess the necessary skills? Are they able to physically access the clinics they supervise in order to allow the face-to-face interaction, which is necessary for clinical supervision? 8

Research methodology Study setting A study was undertaken in 3 rural districts of KwaZulu-Natal province in South Africa. KwaZulu-Natal provincial Department of Health is made up of 11 districts which have been divided into three clusters. Two health clusters (clusters 1 and 3) are made up of 3 districts each, while the third cluster (cluster 2) consists of 4 districts. Cluster 3, the study area, comprises 3 districts, Umkhanyakude, uthungulu and Zululand, and there is a total of 19 district hospitals; this includes 2 hospitals that serve both as regional and district hospitals; as well as 148 primary health care clinics. Research design This was an observational, cross-sectional, descriptive study conducted in the primary health care service. Both quantitative and qualitative methods were used to collect data. Investigation of the role of clinic supervisors formed part of the study undertaken to evaluate referral and support systems between primary health care clinics and district hospitals in the 3 districts. 58 primary health care clinics were randomly selected, and 22 district hospital-based clinic supervisors responsible for these clinics were identified. Research population Fixed provincial and municipal clinics and district hospitals (including a hospital functioning as both as district and regional hospital) in the three districts of Area 3. Mobile clinics, community health centres, and specialised hospitals were not included in the study. 9

Research instruments A structured facility review questionnaire and an interview guide were used to collect data from the clinics and to conduct interviews of clinic supervisors, respectively. Reliability and validity of the research instrument To ensure data reliability and validity, instruments were standardized and piloted. Data collectors were trained in the use of the data collection tools. Data collection process The 58 clinics were visited by trained data collectors between July and September 2007. During these visits, clinic managers were interviewed on the clinic supervisor s activities; records of supervisory visits were also reviewed. During the same period, the 22 clinic supervisors were interviewed and their supervision records reviewed by researchers. The qualitative part of the supervisors interviews was audio-taped. Ethical considerations Permission to undertake the study was obtained from the KZN provincial head of health, Area 3 Manager, district and hospital management. Ethics approval was obtained from the ethics committee at the University of KwaZulu-Natal. District and hospital management were informed about the selected clinics in their respective districts. A schedule of visits was sent to clinic supervisors responsible for the selected clinics at least two weeks before the visit, to enable the clinic supervisor to inform the relevant clinic managers in advance. Dates for interviewing of clinic supervisors were also planned with the supervisors. The study was conducted in partnership with the Department of Health with the aim of 10

assisting the management to identify strengths and weaknesses in the clinic support systems. Participants were, therefore, obliged to participate. Participating supervisors and facilities were allocated codes, so as not to identify them both in the database or in the report. Data analysis SPSS version 13 (SPSS Inc., Chicago, Illinois, USA) was used for analysis of quantitative data. Quantitative data was analysed descriptively, with frequency tables and bar charts summarizing categorical variables, as well as means, medians, standard deviations and ranges used to summarise numerical variables. Audio-tapes of the supervisors interviews were transcribed verbatim, and all transcriptions were validated by different researchers. Content analysis of each transcript was done independently by two different researchers, who then met to validate and confirm themes that each had extracted. Results Data was collected in 58 clinics; 22 clinic supervisors were interviewed. (See table 1). The mean number of years of experience as professional nurse was 20.8 years, with a range of 3 33 years. Supervisors training 16 out of 22 (73%) supervisors had been trained in clinic supervision by provincial (external) facilitators; 14 (63%) of these were trained in the last 5 years. The majority of supervisors felt that the course had equipped them with the skills and tools to do their job well. 19 of 22 (86%) supervisors had a PHC diploma. However, only 8 (36%) were trained in the last 5 years. Most supervisors had also been exposed to many of the 11

short courses offered to PHC nurses (Table 2). Some supervisors said they sometimes only received orientation on new programmes, instead of attending the full training. Supervisory visits Frequency of visits Supervisors reported that they were responsible for 6 clinics on average; however, this ranged between 2 and 20 clinics. Only one supervisor was supervising 20 clinics at the time of the study. 16/22 (72%) supervisors reported that they visit one clinic a day, and the mean time spent at a clinic was reported as 3 hours per visit. While 64% of clinics reported having monthly supervisory visits, only 38% recorded being visited in the past month. Most supervisors said they missed visits due to other commitments, such as attending meetings. 1) It s just there are a number of commitments, the meetings, the workshops; they also impact on your honoring of your visits. Because at times you are called, and some of these meetings are at short notice; you find that you have to cancel; at times you are not even in a position to cancel. 2) I think the pressure that we have as supervisors is that we sometimes find ourselves deeply involved in the institutional issues, which seem to take all the time that we should be spending in clinic supervision. Transport Transport was reported to be one of the reasons why supervisory visits were sometimes missed; with 32% of the supervisors reporting having missed more than one visit in the past month for this reason. Only 7 (32%) of the supervisors said they had dedicated 12

transport to conduct supervisory visits. The majority (68%) said they used pool cars or travelled with other colleagues and there was a general feeling expressed by the majority of supervisors that they need dedicated vehicles, so as to be able to visit their clinics anytime they wish to. 1) I think, if I can be allocated a vehicle to go to the clinic; it s one of the things that can improve the supervisory visits. 2) For instance you travel on the vehicle that goes out to clinics to collect waste. Before you can finish your work, the driver comes back to fetch you, within 2 hours. Scheduling of supervisory visits Most clinics (84%), as well as most supervisors, reported that visits were not scheduled in advance. Supervisors said they were not scheduling the visits because often they had to cancel due to other commitments. Most supervisors felt clearer guidelines regarding supervisory visits were needed, and senior management needed to be more supportive and enable them to perform their supervisory functions. 1) Maybe, something which can be documented? So to say, you are a supervisor, you just know that I m compelled to do 3 visits per month. If I go there, I m going to do this today, and the other day I m doing that. But I don t know, there is no strict guideline or some form of policy Reported activities during supervisory visits The main activities reported to be done during supervisors visits were general supervision and support (43%) and management reviews (16%). Only 22% of the clinics reported having had an in-depth programme review (Figure 2). 13

Clinic - supervisor telephonic contact Most clinics (73%) and supervisors reported at least weekly telephonic contact; but in 74% of these contacts the topics discussed were administrative in nature. 78% of the clinics reported that they never contacted their supervisor for clinical advice (Figure 3). Supervisor s role in clinical skills development 36/58 (61%) of the clinics reported that they had had a skills audit by their supervisors in the past 6 months. 24/58 (41%) of these clinics reported that supervisors had informed them that the skills audit forms had been submitted to human resource development. This skills audit is aimed at identifying staff needing to attend courses, and does not include any observation of skills of health workers. Also, neither records nor reports were found to indicate that supervisors were conducting quality of clinical care reviews or providing clinical tips. Most clinic supervisors reported during interview that clinics did not ask them for clinical advice. Some supervisors said that when clinics phoned for clinical advice, the supervisor referred the clinic sister either to a doctor, trainer or a nurse who had more expertise, such as an advanced midwife. Some supervisors reported that when telephoned for clinical advice, they usually consult treatment guidelines or consult the trainer before giving clinical advice to staff. Only a few supervisors said they were comfortable giving clinical advice; those who reported being able to give clinical advice had recent hands-on experience. Most supervisors felt that they needed to be trained, and also to be involved in cascading training of new programmes/ skills to their staff. 1) I don t have a problem about giving them advice, but in the same time I usually identify a gap that we need to conduct training. 14

2) I always refer to the trainer. I can just go to the trainer. The trainer gives then proper guidance. Thereafter I say: Give me information. 3) I would be comfortable. Because right now the protocols are there, you know, the protocols are there. But I think I would, should it happen, that (it is) the things that I was doing while I was still hands-on, I still have them. Discussion This study demonstrates that most clinic supervisors are experienced nurses and have received training in supervision, have a PHC diploma, and have been trained in most important clinical programs. Although supervisors are appointed to, and have dedicated clinics to supervise, they are not visiting clinics as frequently as recommended. Even when they do visit, they do not schedule clinic visits in advance, and visits are frequently cancelled due to other commitments. The role of senior management in ensuring that supervisors visit clinics regularly, is not clear. It appears, from the fact that supervisors are often made to cancel visits, that clinic supervision is not given priority by senior managers. Some of the supervisors actually expressed this sentiment. Supervisors who participated in the Zimbabwe study on supervisor-provider interactions also reported that they were not being monitored by their provincial supervisors (Tavrow et al, 2002, p.63). Formulation of provincial policy on supervision was meant to address challenges that had constantly dogged clinic supervision, such as the lack of structure and resources. Transport and irregular, unstructured visits are some of the key challenges that were supposed to have been solved by the supervision policy (Rohde, 2006, p.7). This study shows that, despite the implementation of the policy in 2001, these challenges still exist. 15

The fact that supervisors are not able to visit their clinics regularly undermines the concept of clinical supervision, which requires face-to-face interaction. The current supervision manual has put emphasis mainly on the use of checklists for in-depth programme reviews and record reviews to assess quality of patient management. Clinical supervision is not carried out by clinic supervisors, and the current guidelines do not provide checklists for this. The fact that external clinic supervisors are no longer practising, and are sometimes overlooked for or do not attend in-service training, leads to clinic supervisors lacking confidence in providing this type of supervision. The study shows limited use of available checklists. Instead, during supervisory visits, supervisors largely perform administrative functions, reported by clinic managers as general supervision. There was no reported quality of clinical care reviews nor were there any records indicating that quality of clinical care review had been conducted; yet this is one, if not the only, way in which supervisors can attempt to assess skills and give feedback on health worker skills. The Zimbabwe study also found that very few clinic supervisors discuss patient issues during supervisory visits. The authors of this article reported that there were no clear guidelines on supervision, and checklists were also not being used. The article also stresses the importance of clinical supervision as one of the supervisors responsibilities. Although the study shows that clinic supervisors are in regular telephonic contact with their clinics, this contact is usually related to administrative problems. Even when clinic nurses contact supervisors for clinical advice, in most instances supervisors refer their subordinates to doctors or any available expert. The minimal role they play is that of conducting skills audit to identify staff that needs to be sent on courses. The supervisor s manual has also not clearly defined this role, except for clinic register reviews to check if correct treatment was prescribed. There has been no mention of observation of case management, and there have been no tools developed for this. 16

Conclusion and recommendations It is unrealistic to expect clinic nurses to provide quality health care services without support and supervision to ensure that clinical skills are developed and maintained. This shows a major gap in the management of PHC services. The latest version of the clinic supervision manual (DOH, 2007) has included clinical assessment and guidance as one of the supervisory activities. It would seem that limitations of the old guidelines/ manual have been recognized. It is, therefore, recommended that the revised manual is introduced as soon as possible, and that relevant checklists are designed to facilitate observation of case management. The introduction of the revised manual and checklists should be accompanied by training of supervisors. The training should include aspects of assertiveness training to equip clinic supervisors with skills to advocate for their clinics. Senior management should be part of supervision policy development and dissemination so that they own and respect the policy. It would be recommended that a follow up evaluation be undertaken, after the new manual has been introduced and implemented, to see if supervisors will implement clinical supervision. 17

References Bryce, J; Gouws, E; Adam, T; Black, R; Armstrong-Schellenberg, J; Manzi, F; Victora, CG & Habicht, JP 2005: Improving quality and efficiency of facility-based child health care through Integrated Management of Childhood Illnesses in Tanzania. Health Policy Plan, 20(1): i69 i76. Chaudhary, N; Mohanty, PN & Sharma, M 2005: Integrated Management of Childhood Illnesses (IMCI) follow-up of basic health workers. Indian Journal of Paediatrics, 72: 735-739. Dalton, J. (janet.dalton@kznhealth.gov.za, 30 July 2008. RE: Clinic supervisors training. E-Mail to P. Nkosi (Nkosip6@ukzn.ac.za). Department of Health 2007: Primary Health Care Supervision Manual. Version 6. Pretoria: Department of Health. Görgen, H; Kirsch-Wolk, T & Schmidt-Ehry, B 2004: The District Health System: Experiences and prospects in Africa. Manual for public health practitioners. 2 nd ed. Wiesbaden: Deutsche Gesellschaft für. Lehman, U 2001: Investigating the roles and functions of clinic supervisors in three districts in the Eastern Cape Province. Durban: Health Systems Trust. Management Sciences for Health 2006: Clinic supervisors manual. South Africa: MSH. Marquez, L & Kean, L 2002: Making supervision supportive and sustainable: New approaches to old problems. MAQ Papers, XXX (4). 18

Pariyo, GW; Gouws, E; Bryce, J; Burnham, G & The Uganda IMCI Impact Study Team 2005: Improving facility-based care for sick children in Uganda: training is not enough. Health Policy Plan, 20 (1): i58-i68. Reid, S 2002: A training programme for rural primary care nurse practitioners in South Africa. World Rural Health Conference, 1-3 May 2002 Melbourne. ABC Rural Online. Available from: http://www.abc.net.au/rural/worldhealth/papers/50.htm [Accessed 12 January 2008]. Rohde, J 2006: Supportive supervision to improve integrated primary health care. MSH Occasional paper no. 2. Rowe, AK; de Savigny, D; Lanata, CF & Victora, CG 2005: How can we achieve and maintain high-quality performance of health workers in low-resource settings? Lancet, 366: 1026-35. Smith, MK 1996: The function of supervision. The encyclopaedia of informal education [online]. Available from: http://www.infed.org/biblio/functions_of_supervision.htm [Accessed 11 August 2006]. Strasser, S 1998: Supporting staff through effective supervision: How to assess, plan and implement more effective clinic supervision. Kwik-Skwiz 15. Durban: Health Systems Trust. Tavrow, P; Kim, Young-Mi & Malianga, L 2002: Measuring the quality of supervisorprovider interactions in health care in Zimbabwe. International Journal for Quality of Health Care, 14(1): 57-66. 19

Figure 1: Illustration of the Organisational Position of the PHC Clinic Supervisor (Adapted from KZN - DOH, 2007) Hospital/ CHC Manager Medical Manager Nursing Manager Service Area PHC Coordinator Facility Manager Service Area PHC Supervisor Manager: PHC clinic A Manager: PHC clinic B Manager: PHC clinic C 20

Box 1: Supervisory Activities Regular review of PHC facility performance Review of facility administration, information and referral system, PHC services and community participation activities In-depth Program Review Record review to check if patients are treated correctly and whether standards are adhered to. Clinic manager informed in advance about programme to be reviewed Problem solving Staff share problems with the supervisor; supervisor helps with solutions or refer difficult or problems beyond her scope. Information System Review To ensure quality information system; that registers are used correctly, monthly data compiled correctly and used for service planning and monitoring Referral System Review Referral system monitored; problems encountered are brought to the attention of higher authorities, are investigated and steps taken to address these Training Learning needs identified; in-service training conducted; at least 30 minutes of visit to be spent on in-service training to keep nurses abreast of new knowledge and skills. PHC facility Administration Review Review of personnel-related issues, financial matters, clinic infrastructure, regulatory and legal issues, e.g the requirements of the Occupational Health and Safety Act Community Involvement Review Looks into participation of clinic personnel in community outreach activities; clinic committee meetings 21

Table 1 Number of Clinics and Respondents by district: DISTRICT NO. OF CLINICS NO. OF SUPERVISORS Umkhanyakude 22 6 uthungulu 15 10 Zululand 21 6 TOTAL 58 22 22

Table 2: Training taken by Supervisor in the last 5 years Course Total no. trained (n) % trained % Trained in last 5 years Clinic Supervision 16 73 64 PHC Diploma 19 86 36 AIDS Counseling 19 86 23 Breast Feeding 8 36 14 Dispensing 15 68 68 Essential Drug List (EDL) 9 41 23 EPI 15 68 36 Family Planning 12 55 18 HIV/ ARV 9 41 41 IMCI 16 73 59 PMTCT 8 36 36 STI 14 64 41 TB 17 77 64 23

Figure 2: Reported Supervisory Activities 24

Figure 3: Clinic Supervisor Telephonic contact Reasons for Telephonic contact between Supervisor and Clinic staff, as reported by Clinic Managers n = 58 40 38 35 30 Percentage 25 20 15 22 14 22 10 5 0 Staff administration Clinic administration Clinic supplies Clinical Advice Issues Discussed 25