CHPTER ONE: SUPERVISION

1. Introduction
The Palestinian health system is certainly one of particular complexities given the
peculiar political and economic circumstances the country is experiencing. Within the
health system, supervision is viewed as an inherent component of service quality for
promoting professional practice in the health field. This is despite the fact that the
question of clinical supervision is a relatively new concept that have gained attention
only recently in the Palestinian context.

Regardless of; type of facilities, types of providers, types of services being offered, or
ways to pay these services a supervisor of health services works with all elements of
the system to create an environment in which high quality services can be provided to
the care seekers.

This training program offers basic information, tools, and strategies for strengthening
the skills of the healthcare supervisors. Material is organized to be delivered in a four-
days training program in a step-by-step process. While the manual is particularly
useful for new supervisors, a more experienced supervisor may want to use different
parts of the manual at different times as need rises.

2. Program overview
This training program is one of Hanan project plans for enhancing the quality of
service delivery in the West Bank and Gaza. It will be implemented in a selected
number of Maternal Child Health Nutrition clinics where Hanan operates in
partnership with the Ministry of Health (MOH) and other prime health care providers.
The decision to instigate this program was guided by primary findings from the health
facility assessment Hanan team had completed. It was also supported by MOH as well
as other key health organizations and professionals who all agreed that establishing
such a program will contribute to improving the quality of care offered at the
respective health facilities. Direct beneficiaries from this training program will be
Hanan satellite team, MOH supervisors & clinic directors. At a later stage, other
potential beneficiaries could be supervisors working in facilities lying beyond the
scope of Hanan project partnerships.

3. Purpose of the training program

This program is designed to improve; knowledge, skills and values of supervisors

who will have a great input on other practitioners & help them to establish, maintain,
and improve standards and quality & promote innovation in clinical practice.

4. Aims of this training:

• Broadening & understanding the concept of clinical supervision in different
community health sectors NGO'S & government.

١
• Improve & unify the services for the purpose of improving the quality of care
offered for women & children.
• Establish a system of clinical supervision to be applied in all MCHN clinics.
• Improve the performance of clinical supervisors by equipping them with
appropriate theoretical and practical knowledge towards strengthening their
supervisory skills.
• Advance participants analytical skills as it applies to situations from local
Palestinian context.
• Facilitate and foster teamwork spirit and skills through investing in participants
won field experiences.

5. Training period: three-four days.

6. Training time: 8:30-1:30.

7. Place: the first period will be in Hebron.

8. Target Group: Doctors, nurses midwives who have the responsibility

of supervision in the primary health sectors both governmental & NGO'S, have the
desire to participate, have the time to prepare training assignments & and are
committed to create the system in their respective work setting.

9. Program outcomes
• Enhance client care
• Encourage clinical effectiveness
• Promote evidence-based practice
• Enhance professional knowledge
• Increase analytical thinking
• Establish a consistent system to support continuing professional development
• Increase self confidence
• Enhance staff morale
• Support staff retention
• Comply with established protocols and guidelines

٢
 Part One
Introduction to supervision

1.1 Aim and objectives of this part

After completing this session participants will be able to demonstrate a good
understanding of the concept of clinical supervision and the role of supervision in the
care delivery process.
This will be achieved by enabling participants to;
• Define clinical supervision (CS) in its broadest sense differentiating between
internal and external supervisor.
• Identify the responsibilities, role, required skills and personal characteristics of
a CS.
• Describe the benefits of CS.
• Discuss the core of CS & its application.
• Develop an understanding of major CS models.

1.2 Learning methods: facilitator presentation, discussion, group work

1.3 What is clinical supervision (CS)?

A thorough scrutiny in the relevant literature revealed many definitions of clinical
supervision. The Vision for Future (1993) 1, for example, identified twelve key
targets, the tenth of which is related to clinical supervision whereby it is defined as
follows:

"A formal process of professional support & learning which enables individual
practitioners to develop knowledge & competence, assume responsibility for own
practice & enhance consumer protection & safety of care on complex clinical
situations. It is central to the process of learning & to expansion of scope of practice
& should be seen as a means of encouraging self assessment & analytical & reflective
skills" (Vision for Future, 1993).

The UKCC frequently addressed clinical supervision as a key aspect of quality

healthcare. In its position statement (1996) it stated that clinical supervision is:
"A process that brings practitioners & skilled supervisors together to reflect on
practice" … "A process that aims to identify solutions, improve practice & increase
understanding of professional issues. Or
A process of guiding, helping, training & encouraging staff to improve performance
in order to provide high quality of health services.

Supervision is carried out by a responsible person for the performance of clinical

staff (medical officers, nurses, and midwives) in addition to non-clinical staff
(receptionist, cleaners etc).

1
This definition was also adopted by Hanan Project.

٣
The UKCC (1996) further believes that the following key conditions will assist in the
development & establishment of effective clinical supervision:
• Support practice, enabling practitioners to maintain & promote standards of
care.
• Practitioners & managers should develop process of clinical supervision.
• Ground rules should be agreed so that both practitioners & supervisors can be
confident & open in their approach to clinical supervision.
• Clinical supervision is based upon a clinically-focused professional relationship
involving a practitioner reflecting on practice guided by a skilled supervisor.
• An effective preparation for clinical supervision should include principles &
process of clinical supervision.
• Evaluation should be carried out to determine the influences on client care.

1.4 Who is the clinical supervisor?

A CS is the person who is responsible for maintaining the quality of health services
on a day to day bases(internal supervisor) or who travels to the site for periodic
supervisory visit (external supervisor).

1.5 Responsibilities of the clinical supervisor

• Protection of the public.

• Identify standards for good performance.
• Work with staff to assess performance vis-à-vis set standards.
• Combine professional & practice responsibilities for changing inferior or poor
practice
• Carry out clinical audit for monitoring performance.
• Act as a guide for the team & ensure the provision of quality service.
• Discuss with the team the code of their practice, clinical guidance &
evaluation & assessment tools.
• Has an administrative & educational responsibility,
• Monitor staff levels & skills in relation to safe practice.
• Investigate any allegation of professional misconduct.

1.6 Clinical supervisor Criteria

• Expertise: recognition may be informal through skill & experience and may
come from peers, while formal recognition is gained through status & training
and may be communicated by your senior/s.
• Experience: have breadth & depth of experience in his/her field of specialty.
• Acceptability: should be acceptable to those he/she supervises.
• Training: further training & experience of supervision is considered essential
to help develop skills of both supervisors & supervisees. Update his/her skills &
knowledge through attending training courses in clinical supervision.

٤
1.7 Behaviors favored in supervisors after Hagler (1991)
• Benevolence
• Confident in practitioner
• Empathy encouragement
• Positive reinforcement
• Promotion of client care
• Role modeling.

1.8 Role of supervisor

• Teacher: he/she responsible to determine what is necessary for the supervisee
& clients to learn. Evaluative comments are also part of this role.
• Counselor: he/she addresses the interpersonal & intrapersonal reality of the
supervisee. Doing so, the supervisee reflects on the meaning of an event for
him/herself.
• Consultant: allows supervisee to share the responsibility of learning.
Supervisor becomes a resource for the supervisee but encourage the
supervisee to trust his/her own thoughts, insight, & feelings about his/her
work with the client.
• Supervisor responsible of ensuring that work get done through state an agency
rules, regulations, & policies are fairly & equitably applied to all employees.
• Supervisor is a management representatives: balance organizational needs
with employee right on a daily basis.
• Responsible to inform their employees about their performance.

1.9 Skills required in supervisor

• General skills: supervisor required to provide the right balanced of skills to
enable them to be able to challenge, question & help people confront their
attitudes, believes & habits.
• Communication skills: he/she should be attentively & actively, listening &
being able to comment openly, objectively & constructively.
• Supportive skills: to be able to identify when support is needed & offer
supportive reposes. The relationship should not be a hierarchical.
• Specialist skills: be oriented to specific skills.

1.10 Personal characteristics of successful supervisor after

Rogers (1983)
• Approachability- experienced at being nonjudgmental & willing to listen.
• Openness- to new ideas, experiences, change & constructive criticism from the
supervisee.
• Trustworthiness- able to keep confidences has the supervisee's best interests at
heart, & not pursuing one's own agenda.

٥
 • Consistency- between wards & action.
• Self confidence- both as a practitioner and supervisor
• Self disclosure- prepared to reveal something of who they are as a person and a
professional and of their own life.
• Warmth- towards supervisee.
• Flexibility- in style, strategies and interventions and in responding to the
supervisees needs.
• Attentiveness- familiar with, listening and engaging with the supervisee.
• Commitment- to the supervisee and process.
• Supportiveness: offering emotional, practical & intellectual support.
• Reliability: turning up to sessions, avoiding cancellation.
• Congruency: being a unified person not a faced.
• Non defensiveness: accepts constructive criticism as useful not as threatening.
• Concern: cares about supervisee as a person & professional.
• Investment- of time & self.
• Self aware: consciously observing, evaluating & monitoring self.

1.11 Benefits of clinical supervision

• Provides an opportunity & a forum to reflect aspects of client care that may be
difficult, & opportunity for solving problems.
• Encourages evidence based-practice.
• Develops new knowledge, skills & values.
• Creates confident decision makers, which leads to empowerment & self
assurance, leading to innovative & creative practice.
• Improves relationship between supervisor & practitioners, & between
practitioners & clients.
• Monitors the quality of care that is being delivered to supervisee's clients.
• Enhances the professional functioning of supervisee & ensure quality of care.
• Provides a forum for practitioners to demonstrate accountability.
• Has a potential to reduce discomfort through active management of stressors.
(Fowler, 1996; Butterworth, 1996; Palmer, 2000)

1.12 Core of clinical supervision

• Time & duration of CS it is emphasize on having continuity & be arranged at

regular intervals.
• Professional learning & development process: continuous learning from
experience, practice or problem solving & integration process of professional
experience, skills & knowledge.
• Goals: the formal nature of CS is attained from its goals, focus & objectivity.
These goals described as individually emphasis based on supervisee needs or
organizational needs.
• Content: practice oriented, comprised of everyday experiences &
characterized by assessing one's performance & relevant knowledge (Fowler
1996). It also focuses on practice (problem related to client care), organization

٦
 & management (division of work, team's functionality, co-operation &
collaboration), education, training & personal development.
• Supervisory relationship "possible scenarios" :
1. One-one with a supervisor from the same or different clinical
setting or profession
2. One-group with a supervisor from the same or different clinical
setting or profession
3. Peer one-one/group – where there is no hierarchy but different
experiences facilitate the discussion. This is very similar to the
peer review process but tends to involve a wider focus than
review of patient notes, may involve peers that do not have a
similar background and occurs on a more frequent basis
4. Triadic – one to one supervision with a third party as observer
giving feedback to both
5. Network – similar to peer group supervision, but where those
involved do not work together on a regular basis

1.13 Conceptual models of clinical supervision

Many CS models were developed or refined by different authors. Regardless of the
emphasis of the model, all tend to encompass aspects of personal & professional
support, educational & quality assurance functions. The main argument has been that
there does not appear to be a single model of CS appropriate for all levels of staff and
all clinical specialties but that a model implemented in practice should always be
tailored for specified needs and purposes (Fowler 1996b); that is to say
contextualized.

Brocklehurst (1994) identify a number of common features in a majority of

definitions which encompasses; supportive, educational & managerial functions as
the prime elements of clinical supervision. Prior to that as developed by Kadushin
(1976), these features are:

• The supervision relation is of fundamental importance.

• Supervision has a number of related aims including; ensuring safe practices,
developing skills, encouraging personal & professional growth & supporting
staff.
• The process of supervision requires structures & procedures.
• Supervision is an active process necessitating equal input from supervisor &
supervisee.

Eventually, supervision models tend to fall into three major categories;

a. Growth and support models emphasizing relationships main constituents
(Faugier)
b. Role models describing elements of the main functions of supervision
( Proctor)
c. Developmental models emphasizing the process of the supervisory
relationships (Page and Wesket)

٧
1.13.1 Faugier Growth and Support Model
Faugier’s (1992) model is one of the most cited “growth and support” models in the
nursing literature. Faugier sees the role of the supervisor as facilitating growth both
educationally and personally in the supervisee, whilst providing essential support to
their developing clinical autonomy. To achieve this, the supervisor must be aware of
the elements in the relationship over which they are influential:

• Generosity of time and commitment, as well as praise

• Rewarding of development and effort
• Openness to feelings and experiences and parallel processes
• Willingness to learn and develop
• Thoughtful and thought provoking
• Personal not subjected to unnecessary structure
• Practical focusing o practice and improvement
• Orientation respecting the opinions and ideas of others
• Relationship learning to make new and increasing use of self
• Trust without this there is no effective relationship

1.13.2 Proctor interactive Model

Proctor proposed three functions for the clinical supervisor. These are :

Formative

Develop skills and understanding of supervisee through educative process.

Achieved by reflective practice leading to greater understanding of client’s needs and
development of self-awareness in the service of a quality outcome. The supervisee
can also examine their clinical interventions and ensuing consequences.

Restorative

A supportive process that enabling the supervisee to understand and deal with any
reactions which may result from their work stressors.

Normative

These managerial elements the quality control aspect required from those who work
with the public. The supervisor's duty bound to ensure the highest standards and
principles are upheld.

This model combines the different functions of supervisor and demonstrates how it
can focus predominately on one or other function at different times. However, the
ultimate quality of nursing work demands that the supervisor should always consider
them as interrelated and overlapping.

٨
 Functions of Supervision as Proposed in Proctor Model

Education

Support Oversight

1.13.3 Page and Wosket Cyclical Model

Page and Wosket proposed a model for CS that is composed of five stages. These are;

Stage 1 Contract
Underpins the entire process and relationship, provides, and supports gives structure,
direction and purpose. Re-contracting can occur at any stage and is the sign of a
healthy and growing relationship.

Stage 2 Focus
This is the subject or material under consideration. maybe some aspect of work and
develops the supervisor’s responsibility for making the best use of the supervision
process .It encourages intentionality (direction and purpose) and reflection and
ensures the supervisee has prepared for supervision in advance of the meeting.

Stage 3 Space
Creating space is at the heart of the supervision process and is where the supervisee is
held, supported, challenged and affirmed in their work. Movement and insight also
occurs here.

Stage 4 Bridge
This process ensures that learning and awareness from the supervision is carried into
the work situation. It may be as simple as an awareness that nothing tangible needs to
change.

٩
Stage 5 Review
This may take the form of evaluation or assessment; it ensures that practitioners
actively reflect upon, monitor the standard and practice of their own professional
practice.

(1)
Contract

(5)
Review (2)
Focus

CS

(3)
(4) Space
Bridge

Sources: Page, S. and Wosket, V. Supervising the Counselor, Routedge 1994.

١٠
 Part Two

PERFORMANCE, QUALITY, & SUPERVISION:

WHERE IS THE LINK?

2.١ Aim of this part

The participants will be able to demonstrate a good understanding of the link between
performance and quality on the one side and CS on the other.

This will be achieved by enabling participants to;

• Understand the concept of "quality of care" conceptually and operationally.
• Understand the quality cycle.
• Develop deep understanding of 'Total Quality Management' (TQM) as the
guiding philosophy of 'Quality'.
• Grasp the link between performance and quality and appreciate its significance.
• Comprehend steps of the performance and quality improvement process.
• Interpret and employ 'audit' as quality monitoring instrument.

2.2 Method of training: facilitator presentation, discussion, group

work, situation analysis, role play.

2.3 Quality of Care Conceptually & Operationally

o Definitions
Roemer & Aguilar (WHO, 1988) define quality of care as;
"Proper performance (according to standards) of interventions that are known to be
safe, that are affordable to the society in question and that have the ability to produce
an impact on mortality, disability and malnutrition."

Institute of Medicine (1990) define quality of care as "the degree to which health
services for individuals and population increase the likelihood of desired outcomes
and are consistent with current professional knowledge".

Esselstyn (1958) stated that “Standards of quality of care should be based on the
degree to which care is available, acceptable, comprehensive, continuous, and
documented, as well as on the extent to which adequate therapy is based on an
accurate diagnosis and not on symptomatology".

١١
2.4 The Quality Gurus
• Edward Deming

Deming saw quality improvement as being analogous to reduction in process

variation. Deming's approach started with understanding the causes of two types of
variation.

1. External influences on the process which he described as uncontrolled

variation due to "special causes". Examples are changes of operation,
procedures, and raw materials. All these interrupt the normal pattern of
operation.
2. Controlled variations which are due to chance, random, or "common
causes". All of these by definition are due to the process itself, its
design or installation.

For Deming, quality improvement must begin with identification of the two types of
variation. The next stage is to eliminate the "special causes" and only then work on
the "common causes". Management improves the process by re-designing it to
improve it's capability to meet customer needs.

Deming also stressed the crucial importance of the need for a deep understanding of
businesses work processes. Without this, true progress will not be made. Over the
years Deming thoughts expanded, to cover issues of managing people, leadership and
training in order to achieve quality goals.

• Joseph Juran

Juran published "The Quality Control Handbook" in 1950 which became the standard
reference book on quality world-wide.

Juran developed his TQM philosophy around his "quality trilogy"

1. Quality planning: the process for preparing to meet the quality goals
2. Quality control: the process for meeting quality goals through operations
3. Quality improvement: the process for break through levels of performance

Both he and Deming correctly stressed the need to involve people throughout the
organisation in quality improvement but in particular that most quality issues are
down to management dealing with systems. The emphasis is on getting the system
correct rather than blaming failure on operator error. Juran particularly emphasized
the use of quality teams and training them in measurement and problem solving.

• Kaoru Ishikawa

Ishikawa is regarded as the father of the quality circle approach which was involved
in building shop floor teams.

١٢
• Philip Crosby

Crosby presented his "4 Absolutes of Quality" as the cornerstones of his approach

1. Quality is defined as conformance to requirements, not just as goodness

2. Quality is achieved through prevention not appraisal
3. The quality performance standard is "zero defects" and does not allow and
build in acceptable levels of errors and inefficiencies
4. Quality is measured by the price of non-conformance

Crosby spread the word that, as in the title of his most popular book, "Quality is
Free". He believes that by setting up processes that are designed to prevent errors, by
having people trained and motivated to operate them as designed, not only will quality
improve, the costs of production will be reduced.

• Robert Maxwell
According to Maxwell (1984), there are six dimensions of quality in health care; these
are:

Quality Circle after Maxwell

Quality

Maxwell, R. “Quality Assessment in Health”, BMJ 13, 1984, pp. 31-34.

١٣
2.5 Quality cycle

Identify an
area for
action

Set
Re-evaluate priorities

Quality
Cycle
Take action Decide
to remedy approach
deficiencies

Identify
Monitor specific
performance achievable &
measurable
standards

(Steve Cottrell & Paul Gilligan 2000)

2.6 Why is Good Quality of care important?

• Providing high quality health care as a basic human right is a critical element
of health care services.
• High quality services ensure that clients receive the care that they deserve.
• Provide better services at reasonable prices which attract the clients.
• Provide care to all who need it equally.
• Can managing health problems effectively, reducing deaths & chronic ill-
health, reduce the need for emergency intervention & help prevent
overburdening of referral facilities.

١٤
 • Increase the use of services, attract more clients, reduce the cost & ensure
sustainability.
• Improve the staff moral.

Situation I:
Write down a case that you face through
your work as a supervisor for your area of
practice where you find a defect in your
staff performance, identify your action &
your method of follow up, i.e.; your
intervention. Interpret your action guided
by what you got to know in this session.

2.7 Total Quality Management (TQM)

In trying to define TQM is it is well worth considering the relevance and meaning of
the three words in its title.

Total- The responsibility for achieving Quality rests with everyone in the institution
no matter what their function is. It recognises the necessity to develop processes
across the institution, that together lead to the reliable delivery of exact, agreed
customer requirements.

Quality- The prime task of any business- certainly including that of health- is to
understand the needs of the customer, then deliver the service at the agreed time,
place and cost, on every occasion.

Management - Top management lead the drive to achieve quality for customers, by
communicating the institution's vision and values to all employees; ensuring the right
processes are in place; introducing and maintaining a continuous improvement
culture.
Marking out key determinants of quality WHO (1998) states them as; technical
competence of the providers, their inter-personal skills, the availability of basic
supplies & equipment, the quality of physical facilities, infrastructure, and linkage to
other health services & existence of a functional referral system.

١٥
2.8 Implementing TQM

(1)
Unit strategy development
(2)
Communicating strategy
(3)
Clarification of Management responsibilities
(4)
Audit of existing Quality improvement activities and attitudes
(5)
Quality Quality costs
indicators Directorate / service area/locality Patient feedback
Standard & Staff
Quality planning
protocols communication
Outcome and empowerment
monitoring
(6)
Directorate seminars to raise staff awareness
(7)
Develop Directorate Quality Management System
- staff empowerment - Process improvement
- patient responsiveness - Continuous quality improvement

2.9 Continuous Quality Improvement (CQI) involves all Staff

Putting the customer

first

Anticipating and Meeting and

knowing customer exceeding customer
expectations expectations

Getting the service Reducing the costs of Reinforcing good

‘right first time’ poor quality staff performance

١٦
2.10 What is Supervision for Performance & Quality Improvement?

Supervision for performance and quality improvement focuses on;

i) Goal: the goal of supervision is to support & promote delivery of high

quality health services. If this goal is clearly stated the supervisor can
transform the negative impression of supervision into positive one.

ii) Process: clear step-by-step process encourages supervisor and staff to set
performance standards for their site, make sure standards are met, find out
what is helping or hindering good performance, identify and implement
ways to improve performance and quality, and regularly monitor and
evaluate outcomes.

iii) Style: inclusive of as many stakeholders as possible, achieve results

through teamwork & provides constructive & useful feedback. The
underlying theory is that people work better when they actively participate
and are listened to, treated well, encouraged to do a good job and
recognized for a job well done.

Situation II
In conducting periodic observation of clinical staff, you
find that they are not properly decontaminating their
instruments after use. Specifically, they are not using the
correct formula for mixing chemical disinfectants, and
they are not leaving instruments in the solution for the
appropriate amount of time. Assuming that they are
being careless or do not know to do this correctly, you
arrange for them to attend a 1-day course on infection
prevention. After they return, you find that they still are
not decontaminating their instruments according to the
procedures outlined in the clinic guidelines. List some
possible reasons why this problem persists. What can
you as a supervisor do to increase the compliance with
the procedure outlined in the clinical guidelines?

١٧
2.11 Factors that affect performance:
• Information & communication.
• Environment.
• Motivation & inventive to perform well.
• Organizational support.
• Appropriate skills, knowledge & attitude to do the job

To help achieve high quality of health services the performance and quality
improvement process involves the following steps:

1) Create a shared vision with stakeholders. A shared vision encourages

everyone to work towards the same goal & is created by involving many different
stakeholders (people who have an interest in the services being provided) those
can be; staff, community, members & leaders, government & nongovernmental
organization.

2) Define desired performance for the work site. Good performance

needs from the people to know what they are supposed to do. Performance
standards need to be set; staff needs to know their duties & how they are expected
to perform them, desired performance goals, strategies & culture which guides the
health service delivery site, as well as the perspectives of the clients & the
community it serves.

3) Assess site performance. Continuous assessment of how people are

performing compared to how they are expected to perform. This can be done
through ongoing informal basis or formally on periodic basis by observing staff or
getting feedback from the clients & staff.

4) Find causes of performance gap. You as a supervisor may find a practice

or area of performance that is exceptionally strong. Recognize this strength,
identify possible reasons for this exceptional performance & work with staff to
apply this strength to other area of practice. A performance gap exists when there
are discrepancies between the actual performance & standards that you & your
stakeholders set. So the reason for this gap should be explored with the staff and
hindrances of desired performance must be examined. Sometimes, the real cause
for poor performance is not obvious and might need time to find.

5) Select & implement intervention to improve performance. Once the

causes of the performance gap are determined the supervisor & the team need to
identify, prioritize, plan & implement interventions to improve performance.
These interventions might be directed at improving the knowledge, skills of staff,
improving the environment or support system (supply system, management
system) that enable staff to perform well.

6) Monitor & evaluate performance. Once the intervention/s has been

implemented, it is significant to determine whether or not that intervention yielded
the desired result. Did it move you closer to meeting the established standards? If

١٨
 not, you will need to go back again and take another look at what is hindering
performance to make sure that the interventions are being targeted appro

The Performance and Quality Improvement Process2

Create A Shred Vision With Stakeholders

Define
CONSIDER Desired
INSTITUTIONAL Performance
CONTEXT
Select Implement
What resources, Find
strengths and Gap Intervention Interventions
Causes to improve to improve
challenges face
your site? of Gap performance performance

What is your Assess

mission? Site
Performance
What does the
community expect
of you?
Monitor & Evaluate Performance

Small groups exercise 1: participants will apply this framework

to establish a unified approach to implement performance
improvement process in their clinical setting.

2
Adopted from the performance Improvement framework that was developed through a collaborative effort
among members of the performance Improvement Consultative Group (PICG) In: Supervising Health Services:
Improving the Performance o People. By Caiol, et al (2001). JHPIEGO Corporation.

١٩
2.12 Putting quality into practice: Audit as an Instrument

AUDIT: compare standard with practice, its objective is to assess strength &
weakness of the MCHC (Maternal & Child Health Centers) quality management
system by evaluating the effectiveness of management/technical requirements of
quality management system, planned arrangement & evaluating the implementation
efficiency.
Nothing shall be called good practice until there is evidence that it achieved &
continues to achieve the desired outcome (DoH, 1993).

• The word audit in general means to examine accounts

• Audit is related to accountability which is to be called to account for ones
actions.
• Good standards do not guarantee good practice.
• Audit measures practice rather that provide evidence as in research.
• Audit ensuring that right thing is done rather than find out the right thing to
do.
• It is designed to influence me not you (Nixon, 1992).
• Audit provide a baseline data for future audit, identify trends & to gather
information for national, health authorities, professional bodies & other
agencies.
• People who audit are in fact performing an evaluation purpose to examine &
develop care to improve practice.

There is a range of audits currently in place. Medical, clinical, managerial,

professional and consumer audits are discussed below.

1. Medical audit.

Medical audit is defined as being a systematic, critical analysis of the quality

of medical care, including the procedures for diagnosis and treatment, the use
of resources, and the resulting outcomes and quality of care for the patient.

2. Clinical audit.

Clinical audit is basically audit by professional services, such as nurses,

midwives, physiotherapists etc., other than medical practitioners.

3. Managerial audit.

Managerial audit can be seen as largely concerned with the use of resources in
the provision of health care.

4. Professional audit.

Professional audit is concerned with areas which appertain to standards that

are acceptable for professional practice, for example relating to acceptable
standards required for the prescription of medications (Doyal, 1992).

٢٠
5. Consumer audit.

Consumer audit can be said to review the quality of care provided by health
services from the patient’s point of view. It establishes the patient’s quality
agenda through a range of observation and interview techniques identifies and
defines standards of service which patients should reasonably expect, and
measures performance against those standards (Dennis, 1991).

2.13 Requirement for audit:

• Explicit criteria for good practice.

• Objectives measurement of performance.
• Cases selected or using agreed criteria.
• Comparison result.
• Identification of corrective action.
• Documentation of review procedures result. (Shaw 1989, 1992).

٢١
2.14 Stages of audit

Sustain Identify
changes & Topic and
re-audit Audit team

Identify Agree
necessary Stages of Audit standards
changes and
and agree criteria
an action

Analyze Select
data and sample
compare and collect
results with data
standards

٢٢
 Part Three
Supervision and Performance

3.1 Introduction:

It is important for the supervisor to identify the desired performance through setting
reasonable, observable and measurable performance standards which help in guiding
the rest of the work. Once the standards stated it become the responsibility of the
supervisor and the team to assess the effectiveness of those standards.

3.2 Aim and objectives of this part

This part will concentrate on how to state performance standards & gain skills in
using the assessment tools that are considered important for the supervisor.

This will be achieved by enabling participants to:

• Define performance standards and its benefits.
• Identify sources and means for setting standards.
• Practice their role in improving the performance of their supervisees.

3.3 Method of training: facilitator presentation, discussion, group

work, situation analysis.

3.4 Performance standards means the level of performance required to obtain

a desired outcome.

3.5 Benefits:
1. The staff will know exactly what is expected from them to do which helps
them to do better work.
2. Protect the public by establishing criteria to maintain and improve services.
3. Assess the extent to which expectations have been met.
4. Provide staff with clear and achievable targets against which to measure
progress.

٢٣
 Situation IV
You are giving feedback to a new staff
member who continues to leave important
sections on the client record card blank. The
staff member responds by saying “The
person who showed me how to do this told
me I only need get the client’s name and
number of children they had. Are you
saying I need to fill in all the blanks?” What
would you do to clarify your expectations to
the staff member.

3.6 Sources of Performance Standards

International (example is listed in Appendix ?)
National (example is listed in Appendix ?)
Job description (an example of job description is in Appendix ? that facilitate the
participants knowing the main components of job description.

3.7 How to set standards for the worksite

• Determine priority areas
• Identify and obtain the various resources that are available to help you set the
standards.
• Work with your staff to create and adopt appropriate standards for your
situation.

3.8 Criteria of standards that you need to look for: Kemp and Richardson
(1990) state the following about standards:-
• Realistic – means they can be achieved
• Measurable – means capable of expressing a result
• Appropriate – for the patient population for which it will be applied
• Desirable and Acceptable - for the above reasons and to ensure it does not
offend against culture, professional ethics, policies or procedures

٢٤
 • Unambiguous – must have clear meaning, leaving no room for doubt, using the
correct words.

3.9 Supervision & Performance Assessment

Situation V
You have worked with staff to strengthen site
standards and feel that they( now represent
Appendix
the level of service that your clinic should be
providing. In conversations with staff
someone suggests looking at whether the
new standards are being met. The question
is then asked “What and how should be
assessed to see if we are meeting our
standards? How would you respond? Write
your responses.

Question one: What to assess?

In order to find out how your site is doing you need to periodically assess various
aspects of the care within your facility, including:

1. Clinical practices – do clinical practices meet the standards set and contribute to
the provision of high quality services?
2. Client satisfaction – how do clients feel about the services offered; are their
needs being met?
3. Provider satisfaction – are the providers satisfied with how services are being
provided?
4. Client flow and load – is the clinic functioning as effectively and efficiently as
possible?
5. Client-provider interaction – is communication between the providers and the
clients respectful and mutually satisfying?

٢٥
6. Stock management – are the essential supplies available and accessible when
needed?
7. Record-keeping – are the records being completed in a thorough and consistent
manner?

Question two: How to assess?

Situation VI
You are meeting with the team to decide how
best to determine if your site meets the
standards for clinical services. Some of the
providers do not appear to be comfortable
with you assessing their clinical skills. What
other options could you and the team use to
assess the clinical skills of the providers?
Write your responses.

٢٦
Methods for Assessing Site Performance
ASSESSMENT FOCUS OF PERSON ASSESSMENT HOW TO USE THE
METHOD ASSESSMENT CONDUCTIN METHODS / TOOLS ASSESSMENT
G RESULTS
ASSESSMENT
Conduct Self Any worker at Worker Checklist derived Person/team using
Assessment the clinical site from job description self assessment tool
Teams of Team and appropriate can meet periodically
workers guidelines with the supervisor to
discuss areas of
achievement and
areas needing
improvement.
Conduct Peer Any worker at Colleagues Checklist derived Peers can give
Assessment the clinical site from job description feedback to each
Teams of and appropriate other in an informal
workers guidelines and comfortable
environment on
specific performance
areas.
Conduct Any worker at Supervisor Meeting with staff Supervisor can share
Supervisor the clinical site Observation of the results with
Assessment Teams of clinical practice individuals or teams
workers Case reviews to acknowledge good
Audits performance and
identify specific areas
needing
improvement.
Obtain Client People seeking Staff Meetings Staff and supervisor
Feedback services at the Supervisor Questionnaires/ can evaluate site
site Interviews operations and staff
Suggestion Box performance based
on feedback from
clients.
Poll People living in Staff Meetings Staff and supervisor
Community the community Supervisor Questionnaires/ can make changes to
Perceptions where the site is Interviews site operations,
located maybe even add new
services, based on
feedback from
community members.
Review Any system or Staff Review of records, Staff and supervisor
Records and aspect of clinic Supervisor reports, log books, can monitor
Reports operations statistics efficiency and
outcomes of clinic
operations.
Benchmark Any system or Staff Visit other sites Staff and supervisor
aspect of clinic Supervisor Interview workers at can get new ideas
operations other sites about how to provide
Interview clients and better services
community members
at other sites

Source: Supervising Health Services: Improving the performance of people (2001). Draft for
External Review. JHPIEGO- USAID. Maryland: USA.

٢٧
 Part Four

Ethics & Supervision

4.1 Objectives of this part:

• Define ethics.
• Know the ethical principles
• Discuss related issues important for the supervisor (human rights, informed
consent, privacy & confidentiality etc).
• Identify the ethical guidelines that help supervisor to provide the best care.

4.2 Ethics Defined: "is the process of making moral decisions about the
individuals & their interaction in society while still attempting to protect the right &
welfare of those same individual". (kurpius 1991). From this definition it is important
to know that supervisors who practice ethically should have correct combination of
education, practice & experience to help supervisees develop their skills.

4.3 Ethical principles

A) Principle of respect for persons:

• Treating persons with rights.
• Respecting the autonomy of individuals.
• Protecting those who suffer loss of autonomy through illness, injury or
mental disorders. And working to restore it for those who lost it.
• Recognizing that pt’s has such basic human rights as the right to know,
privacy and to receive care & treatment.

B) Principle of justice:
• Demand for universal fairness.
• Distributive justice not retributive.
• Justified public health measures:
o Not to lose sight of the individuals rights.
o Non discrimination
o Equality of outcomes for groups & relates to the broader political
responsibilities of health, professionals in controlling, allocating
resources. In planning research and development

C) Principle of beneficence:
Beneficence: is the duty to care
Advocacy: defending the right of the vulnerable client is a requirement of
beneficence.
It is indispensable whenever there are people in need of support or urgent care &
attention.
The reciprocity in our duty to care for one another should make us realized that
we all need others to speak with, do things for us or defend our right when we are
too weak to do so for ourselves.

٢٨
The power of true care is aimed at sharing knowledge & skills with the vulnerable
individual so as to empower that person to reassert control over her or his own life.

D) Accountability
This is one of the legal issues to be answerable for what one has done or not done,
according to the norms or standard of the particular role.
In other word it is the responsibility of one's action.
Why we are in need for accountability.
1. Increase technology.
2. Increase recognition.
3. Nursing role impact.
4. Moral and legal dimensions.

E) Competence
Supervisor needs to know everything, and more, than is expected of the supervisee.
The supervisor must be expert in the process of supervision. To achieve competence
supervisor receive training in performance of supervision as well as supervision of
supervision.

F) Dual relationship
Supervisor should understand that dual relationship is to be managing properly.

G) Safety
All reasonable steps must be taken to ensure the safety of supervisees & their clients
during their work together.

H) Confidentiality

Confidentiality is an often-discussed concept in supervision because of some

important limits of confidentiality both within the therapeutic situation and within
supervision.

I) Liability

There are three safeguards for the supervisor regarding liability:

(1) Continuing education, especially in terms of current professional
opinion regarding ethical and legal dilemmas;
(2) Consultation with trusted and credentialed colleagues when questions
arise; and
(3) Documentation of both counseling and supervision, remembering that
courts often follow the principle "What has not been written has not
been done" (Harrar, Vandecreek, & Knapp, 1990).

٢٩
 CHAPTER TWO
COOMUNICATION: INTERACTING WITH OTHERS

• Introduction

Interactive processes in organizations are crosscutting and multidimensional. They are

instruments for strategic and operational levels of management including those lying
at the first line–a cornerstone of which is supervision and its interpersonal,
informational, and decisional roles. Many of the problems that occur in
organizations are the direct result of people failing to interact with one another. Faulty
interaction leads to confusion and can cause the best plan to fail. This chapter intends
to explore and look into such interactive processes and means for making them work
and promote supervision outcomes.

• Aim of the chapter

After completing the chapter participants will be able to demonstrate a good
understanding of the key interactive processes and skills including those of;
communication, conflict resolution, negotiation, problem solving and teambuilding.

• Chapter objectives

• Grasp concepts related to communication, conflict, negotiation, delegation,

teambuilding, coaching and mentoring and problem solving.
• Comprehend the interrelatedness between the concepts above as processes
entailing different degrees of interaction between individuals and groups within
the organization.
• Develop deep understanding of role the addressed concepts have in successful
implementation of supervision in health care.
• Employ gained knowledge in adopting tools needed for assessing and
measuring various dimensions of supervision.

٣٠
2.1 What is communication?

Communication is the transference and understanding of meaning; a process from

send to receiver; skill includes speaking, listening and reasoning

• Poor communications is one of most frequently noted sources of interpersonal

conflict; yet we spend 70% of our time communicating
• A Canadian study showed 61% of senior executives believed they
communicated well with employees; whereas, 33% of those below in mid
management believed senior executives were effective and 22%-27% of non
management believed senior executives to be effective communicators

2.2 The process of communication;

Encoding: converting a communication message to symbolic form (by sender);
factors affecting how message encoded: skill, attitudes, knowledge, and socio-cultural
system

Decoding: retranslating a sender's communication message; affected by how

decoded: skill, attitudes, knowledge and socio-cultural system

Message: what is being communicated; speech, writing or visual; expression

Channel: the medium through which a communication message travels; formal

memos, emails, voicemail, meetings; channel choice depends on whether info is
routine (straightforward message less chance for misunderstanding) or non-routine
(more complicated and open to misinterpretation; high performing manager pays
attention to media used to communicate

Communication Apprehension: undue tension and anxiety about oral and/or written
communication; 5-20% suffer from this

Channel Richness: the amount of information that can be transmitted during a

communication episode; face to face scores highest on richness (ability to handle

٣١
multiple cues, facilitate rapid feedback, and be personal; impersonal media such as
bulletins and general reports scores lowest on richness.

Feedback Loop: the final link in the process; puts the message back into the system
as a check against misunderstandings; receiver needs to give feedback and sender
needs to check comprehension

2.3 Barriers to Communication

Anything that prevents understanding of the message is a barrier to communication.

Many physical and psychological barriers exist:

1. Culture, background, and bias - We allow our past experiences to change

the meaning of the message. Our culture, background, and bias can be good as
they allow us use our past experiences to understand something new, it is
when they change the meaning of the message then they interfere with the
communication process.
2. Noise - Equipment or environmental noise impede clear communication. The
sender and the receiver must both be able to concentrate on the messages
being sent to each other.
3. Ourselves - Focusing on ourselves, rather than the other person can lead to
confusion and conflict. The "Me Generation" is out when it comes to effective
communication. Some of the factors that cause this are defensiveness (we feel
someone is attacking us), superiority (we feel we know more that the other),
and ego (we feel we are the center of the activity).
4. Perception - If we feel the person is talking too fast, not fluently, does not
articulate clearly, etc., we may dismiss the person. Also our preconceived
attitudes affect our ability to listen. We listen uncritically to persons of high
status and dismiss those of low status.
5. Message - Distractions happen when we focus on the facts rather than the
idea. Our educational institutions reinforce this with tests and questions.
Semantic distractions occur when a word is used differently than you prefer.
For example, the word chairman instead of chairperson, may cause you to
focus on the word and not the message.
6. Environment - Bright lights, an attractive person, unusual sights, or any other
stimulus provides a potential distraction.
7. Smothering - We take it for granted that the impulse to send useful
information is automatic. Not true! Too often we believe that certain
information has no value to others or they are already aware of the facts.
8. Stress - People do not see things the same way when under stress. What we
see and believe at a given moment is influenced by our psychological frames
of references - our beliefs, values, knowledge, experiences, and goals.
9. Filtering: a sender's manipulation of information so that it will be seen more
favorably by the receiver.

2.4 Triple-A-Listening to enhance communication

Listening is not the same as hearing. It is hearing with a purpose. Listening is a

conscious activity based on three basic skills: attitude, attention, and adjustment.

٣٢
These skills are known collectively as triple-A listening.

• Maintain a constructive Attitude. A positive attitude paves the way for

open-mindedness. Don't assume from the outset that a supervisory session is
going to be dull. And even if the supervisee makes statements you don't
agree with, don't decide he or she is automatically wrong. Don't let reactive
interference prevent you from recalling her/his key concerns.
• Strive to pay Attention. You cannot attain concentration by concentrating
on the act of concentration. Your attention must focus on the
substance/essence of the conversation. When you hear a conversation the
words enter your short-term memory, where they have to be swiftly
processed into ideas. If they aren't processed, then they will be dumped from
short-term memory and will be gone forever. Attentive listening makes sure
the ideas are processed.
• Cultivate a capacity for Adjustment. Although some supervisors clearly
indicate what they intend to discuss, you need to be flexible enough to
follow the discussion regardless of the direction it may take. If, however,
you are thoroughly lost, or if the speaker's message is not coming across and
you need to ask a clarifying question, do so.

2.5 Good Listeners…!

• Look for the ideas being presented, not for things to criticize.
• Listen with the mind, not the emotions. Good listeners write down
something they disagree with to ask the speaker later, and then go on
listening.
• Filter out distractions and concentrate on what the speaker is saying.
• Understand that speakers talk about what they think is most important. Good
listeners know that a good discussion may not contain the same information
as textbooks.
• Want to see how the facts and examples support the speaker's ideas and
arguments. Good listeners know that facts are important, because they
support ideas.
• Want to learn something new and try to understand the speaker's point. A
good listener is not afraid of difficult, technical, or complicated ideas.
• Listen closely for information that can be important and useful, even when a
discussion is dull.
• Try to understand the speaker's point of view.
• Use any extra time or pauses to reflect on the speaker's message and think
about the next points.

2.6 Tips for Effective Listening

1. Make eye contact

2. Use head nods and appropriate facial expressions
3. Avoid distracting actions or gestures
4. Ask questions
5. Paraphrase (restate)
6. Avoid interrupting the speaker

٣٣
 7. Don't overtalk
8. Make smooth transitions between role of speaker and listener

2.7 Communication and Conflict

• Conflict can be a serious problem in organizations impacting on performance

and loss of good employees
• But not all conflicts are bad; conflict has good and bad sides
• Conflict is a process that begins when one party perceives that another party
has negatively affected, or is about to negatively affect, something that the
first party cares about; conflict involves opposition, incompatibility or
interaction

2.8 Sources of Conflict are; communication problems like semantic

difficulty, misunderstanding, noise; structure and personal variables

• Structure as a Conflict: when conflict is a function of the jobs people do

rather than the personality; structure includes size (the larger the group the
more specialized and potential conflict especially where members are younger
and turnover high); jurisdictional ambiguity ( where definition of who does
what not clear a fight for territory/resources); diversity of goals among group (
example sales versus credit); too much reliance on participation (participation
and conflict highly correlated);reward systems (conflict when one member
gains at expense of others)
• Personal Values as Conflict. personal variables include personality
characteristics, individual value system; example authoritarian type with low
self esteem lead to potential conflict; value systems explain prejudice,
disagreements over one's contribution to group and rewards deserved

2.8 Conflict handling Intentions

• Competing - assertive and uncooperative; intending to reach goal at sacrifice

of other's goal; convincing another to take blame; best used when quick, vital
action needed, when unpopular action needed; against people who take
advantage of noncompetitive behaviour
• Collaborating - assertive and cooperative; attempt to find a win-win; best
used when both sides concerns important, when object is to learn, merging
insights, working through feelings that have interfered
• Avoiding - unassertive and uncooperative; ignoring; best used when issue
unimportant, when little chance to satisfy concerns, when potential disruption
outweighs benefits of resolution, to cool down, when others can resolve
• Accommodating - unassertive and cooperative; willing to sacrifice your goal
support for another despite reservations; best used when you may be wrong or
a better position exists, to appear reasonable, team building, to minimize loss
• Compromising – mid range for both assertiveness and cooperativeness;
acknowledging partial agreement or taking partial blame; best used when
goals not worth effort of disruption, for a temporary solution

٣٤
2.9 Conflict Resolution Techniques
1. Problem-solving (face to face to identify problem and discuss to resolve);
2. Superordinate Goals (creating a shared goal that needs cooperation of sides);
3. Expansion of Resources (when conflict is from lack of money, resources,
space expansion can be win-win);
4. Avoidance (withdrawal);
5. Smoothing (play down difference and emphasize similarity);
6. Compromise (each gives up something);
7. Authoritative Command (formal resolution by upper level);
8. Altering human variables (using human relations to alter behaviour);
9. Altering the structural variable (changing format by job redesign,
transfer, coordination position

٣٥
2.10 Communication through 'Delegation'

It is impractical for the supervisor to handle all of the work of the department directly.
In order to meet the organization's goals, focus on objectives, and ensure that all work
is accomplished, supervisors must delegate authority. Authority is the legitimate
power of a supervisor to direct subordinates to take action within the scope of the
supervisor's position. By extension, this power, or a part thereof, is delegated and used
in the name of a supervisor.

Delegation is the downward transfer of formal authority from superior to subordinate.

The employee is empowered to act for the supervisor, while the supervisor remains
accountable for the outcome. Delegation of authority is a person-to-person
relationship requiring trust, commitment, and contracting between the supervisor and
the employee.

The supervisor assists in developing employees in order to strengthen the

organization. He or she gives up the authority to make decisions that are best made by
subordinates. This means that the supervisor allows subordinates the freedom to make
mistakes and learn from them. He or she does not supervise subordinates' decision-
making, but allows them the opportunity to develop their own skills. The supervisor
lets subordinates know that he or she is willing to help, but not willing to do their jobs
for them. The supervisor is not convinced that the best way for employees to learn is
by telling them how to solve a problem. This results in those subordinates becoming
dependent on the supervisor. The supervisor allows employees the opportunity to
achieve and be credited for it.

An organization's most valuable resource is its people. By empowering employees

who perform delegated jobs with the authority to manage those jobs, supervisors free
themselves to manage more effectively. Successfully training future supervisors
means delegating authority. This gives employees the concrete skills, experience, and
the resulting confidence to develop themselves for higher positions. Delegation
provides better managers and a higher degree of efficiency. Thus, collective effort,
resulting in the organization's growth, is dependent on delegation of authority.

2.11 Responsibility and Accountability

Equally important to authority is the idea that when an employee is given

responsibility for a job, he or she must also be given the degree of authority necessary
to carry it out. Thus, for effective delegation, the authority granted to an employee
must equal the assigned responsibility. Upon accepting the delegated task, the
employee has incurred an obligation to perform the assigned work and to properly
utilize the granted authority.

• Responsibility is the obligation to do assigned tasks. The individual

employee is responsible for being proficient at his or her job. The
supervisor is responsible for what employees do or fail to do, as well as for
the resources under their control. Thus, responsibility is an integral part of
a supervisor's authority.

٣٦
 Responsibilities fall into two categories: individual and organizational

1. Individual responsibilities to be proficient in their job. Employees are

responsible for their actions. Nobody gives or delegates individual
responsibilities. Employees assume them when they accept a position in the
organization.
2. Organizational responsibilities refer to collective organizational accountability
and include how well departments perform their work. For example, the
supervisor is responsible for all the tasks assigned to his or her department, as
directed by the manager.

When someone is responsible for something, he or she is liable, or accountable

to a superior, for the outcome. Thus, accountability flows upward in the
organization. All are held accountable for their personal, individual conduct.

• Accountability is answering for the result of one's actions or omissions. It

is the reckoning, wherein one answers for his or her actions and accepts
the consequences, good or bad. Accountability establishes reasons,
motives and importance for actions in the eyes of managers and employees
alike. Accountability is the final act in the establishment of one's
credibility. It is important to remember that accountability results in
rewards for good performance, as well as discipline for poor performance.

2.12 Important tips in delegation

1. The first step in delegating is to identify what should and should not be
delegated.
2. The supervisor should delegate any task that a subordinate performs better.
3. Tasks least critical to the performance of the supervisor's job can be delegated.
4. Any task that provides valuable experience for subordinates should be
delegated.
5. The supervisor can delegate the tasks that he or she dislikes the most.
6. The supervisor should not delegate any task that would violate a confidence.

2.13 The Delegation Process. The delegation process has five phases;

1. Preparing includes establishing the objectives of the delegation, specifying the

task that needs to be accomplished, and deciding who should accomplish it.
2. Planning is meeting with the chosen subordinate to describe the task and to ask
the subordinate to devise a plan of action. As Andrew Carnegie once said, "The
secret of success is not in doing your own work but in recognizing the right man
to do it." Trust between the supervisor and employee - that both will fulfill the
commitment - is most important.
3. Discussing includes reviewing the objectives of the task as well as the
subordinate's plan of action, any potential obstacles, and ways to avoid or deal
with these obstacles. The supervisor should clarify and solicit feedback as to the
employee's understanding. Clarifications needed for delegation include the
desired results (what not how), guidelines, resources available, and

٣٧
 consequences (good and bad). Delegation is similar to contracting between the
supervisor and employee regarding how and when the work will be completed.
The standards and time frames are discussed and agreed upon. The employee
should know exactly what is expected and how the task will be evaluated.
4. Auditing is monitoring the progress of the delegation and making adjustments
in response to unforeseen problems.
5. Appreciating is accepting the completed task and acknowledging the
subordinate's efforts.

٣٨
2.14 Communicating through 'Coaching and Mentoring'

Both coaching and mentoring are enabling processes meant to achieve people's full
potential.

Coaching is "a process that enables learning and development to occur and thus
performance to improve. To be a successful a Coach requires a knowledge and
understanding of process as well as the variety of styles, skills and techniques that are
appropriate to the context in which the coaching takes place" (Parsloe, 1999).

Mentoring is "off-line help by one person to another in making significant transitions

in knowledge, work or thinking". It is the process of gaining wisdom from, and
tapping into the experience of, others. We all have mentors, whether we call them that
or not - heroes, people we seek to imitate, people we've learned from.

2.15 Common things coaches and mentors do 'similarities'.

• Facilitate the exploration of needs, motivations, desires, skills and thought

processes to assist the individual in making real, lasting change.
• Use questioning techniques to facilitate client's own thought processes in order
to identify solutions and actions rather than takes a wholly directive approach
• Support the client in setting appropriate goals and methods of assessing
progress in relation to these goals
• Observe, listen and ask questions to understand the supervisee 's situation
• Creatively apply tools and techniques which may include one-to-one training,
facilitating, counselling & networking.
• Encourage a commitment to action and the development of lasting personal
growth & change.
• Maintain unconditional positive regard for the supervisee, which means that the
coach is at all times supportive and non-judgemental of the client, their views,
lifestyle and aspirations.
• Ensure that supervisee develop personal competencies and do not develop
unhealthy dependencies on the coaching or mentoring relationship.
• Evaluate the outcomes of the process, using objective measures wherever
possible to ensure the relationship is successful and the supervisee is achieving
their personal goals.
• Encourage supervisee to continually improve competencies and to develop new
developmental alliances where necessary to achieve goals.
• Work within his/her area of personal competence.
• Possess qualifications and experience in the areas that skills-transfer coaching
is offered.

٣٩
2.16 How do coaching and mentoring compare with Traditional
forms of training?

Traditional forms of training Coaching/mentoring

• Wholesale transfer of new skills,
e.g. change in procedures, new
systems (e.g. software application
training), new job function.
• Programmes are mostly generic
and not tailored to individual
needs. Delegates generally have to
complete standard modules, so
there is little room for tailoring the
programme to account for existing
knowledge, skills or preferences.
• Not always sufficiently similar to
the ‘live’ working environment to
ensure effective skills transfer.
• Best suited to transfer of
knowledge and certain skills rather
than the development of personal
qualities or competencies
• Actively untaps potential.
• Fine tunes and develops skills.
• Development activities are designed to suit
client’s personal needs and learning styles.
• Eliminates specific performance problems.
• Can focus on interpersonal skills, which
cannot be readily or effectively transferred
in a traditional training environment.
• Provides client with contacts and networks
to assist with furthering their career or life
aspirations.
• Performed in the ‘live’ environment
• Highly effective when used as a means of
supporting training initiatives to ensure
that key skills are transferred to the ‘live’
environment.
• Coaches and mentors transfer the skills to
the client rather than doing the job for
them.

2.17 Coaching Skills & Tips

Coaching is about building a person's confidence and capability, about encouraging

them to discover things for themselves, and enabling them to achieve more,
developing their gifts and talents in the process.

2.17.1 Building confidence means that you:

• Actively listen.
• Provide help, support and the necessary resources.
• Involve the person in deciding on and setting goals and targets.
• Show enthusiasm and belief in the person. Acknowledge the person's successes.
• Reflect back to the skills and talents they have already demonstrated.
• Are honest about their worries and concerns, openly discussing their fears and
looking at the worst possible outcomes.

2.17.2 You can encourage people to find things out for themselves by:

• Asking open questions to stimulate them into thinking about what they want to do.
• Asking how the person would like to take things forward.

٤٠
• Encouraging them to come up with their own ideas.
• Listening to their ideas.
• Encouraging them to see the consequences of their proposed actions.
• Asking if they have other alternative suggestions.
• Offering your own ideas as suggestions.
• Asking the person what success looks like.
• Giving the person time to think.

2.17.3 Eight coaching tips to the coach from those on the receiving end

1. Treat me as a person in my own right.

2. Set me a good example.
3. Encourage and support me.
4. Praise me when I do well.
5. Back me up in front of others
6. Keep me informed about what I need to know
7. Take time from your normal duties to coach me.
8. Never under-estimate what I can do.

2.17.4 Unwilling learners

Not everyone takes kindly to being coached. It may take considerable tact and
perseverance to help someone to accept help. Whether someone is willing to be
coached may depend on the approach you adopt with them.

• If you push hard, confront, challenge and criticise, you may simply
generate resistance or withdrawal.
• By staying cool and dispassionate as a coach, you may help learners to
think things through for themselves.
• Yet if you are too distant you may be regarded as impersonal and uncaring.
• Similarly, an over-enthusiastic coach can motivate through excitement
and energy, yet may be seen by some people as intimidating and
overwhelming.
• Be willing to experiment with your coaching style.

٤١
2.18 Communication for 'Team Building'

Team building is an effort in which a team studies its own process of working
together and acts to create a climate that encourages and values the contributions of
team members. Their energies are directed toward problem solving, task
effectiveness, and maximizing the use of all members' resources to achieve the team's
purpose. Sound team building recognizes that it is not possible to fully separate one's
performance from those of others.

2.19 Phases of Development of effective teams

A team begins as nothing more than a collection of individuals who have been
brought together in a work situation. The process of uniting the group to form an
effective team involves successfully completing four phases of development
identified by B.W. Tuckman (1965): forming, storming, norming, and performing.

Phase one is an orientation, the forming of the team. Each person, in the process of
getting acquainted with the other members, seeks his or her place in the group. The
members must reach a common understanding of their objective, as well as agreement
on basic operational ground rules, such as when to meet, attendance requirements,
how decisions will be made, and so on.

· Do members understand the team's objectives?

· Have member's individual objectives been incorporated into the team's
objectives?
· Do members feel the team's objectives are achievable and reflect their own
personal objectives?

Phase two is characterized by interpersonal conflict, the storming of the team.

Individuals begin to compete for attention and influence. Divergent interests surface
as members begin asserting their ideas and viewpoints of the task, and their feelings
about other members. The group must settle issues of how power and authority will
be divided among members.

· What do members see as their responsibilities?

· What do members expect from other members?
· How is leadership being handled?
· Does duplication of effort exist?

Phase three, the group is becoming cohesive, the norming of the team. A sense of
identity or "team spirit" is beginning to develop. Individuals become more sensitive to
each other's needs, and are more willing to share ideas, information, and opinions.
Task considerations start to override personal goals and concerns.

· What is the action plan for achieving the objectives?

· How are decisions made?
· How are problems solved?
· How are conflicts resolved?

٤٢
Phase four is the interdependence of the group, the performing team. The group
emerges as a team. Members now work well together and have a high degree of
productive problem solving, since structural and interpersonal issues have been
resolved. High creativity and intense loyalty of members to each other characterize a
group at this stage.

· How do the members treat each other?

· Do members trust, support, and feel comfortable with each other?
· Do members look for ways to help each other?

2.20 Characteristics of Good Team Building

• High level of interdependence among team members

• Team leader has good people skills and is committed to team approach
• Each team member is willing to contribute
• Team develops a relaxed climate for communication
• Team members develop a mutual trust
• Team and individuals are prepared to take risks
• Team is clear about goals and establishes targets
• Team member roles are defined
• Team members know how to examine team and individual errors without
personal attacks
• Team has capacity to create new ideas
• Each team member knows he/she can influence the team agenda

2.21 Evaluating Team Effectiveness

When evaluating how well team members are working together, the following
statements can be used as a guide:

• Team goals are developed through a group process of team interaction and
agreement in which each team member is willing to work toward achieving
these goals.
• Participation is actively shown by all team members and roles are shared
to facilitate the accomplishment of tasks and feelings of group togetherness.
• Feedback is asked for by members and freely given as a way of
evaluating the team's performance and clarifying both feelings and interests of
the team members. When feedback is given it is done with a desire to help the
other person.
• Team decision making involves a process that encourages active participation
by all members.
• Leadership is distributed and shared among team members and
individuals willingly contribute their resources as needed.
• Problem solving, discussing team issues, and critiquing team
effectiveness are encouraged by all team members.

٤٣
• Conflict is not suppressed. Team members are allowed to express negative
feelings and confrontation within the team which is managed and dealt with by
team members. Dealing with and managing conflict is seen as a way to improve
team performance.
• Team member resources, talents, skills, knowledge, and experiences are
fully identified, recognized, and used whenever appropriate.
• Risk taking and creativity are encouraged. When mistakes are made, they are
treated as a source of learning rather than reasons for punishment.

After evaluating team performance against the above guidelines, determine those
areas in which the team members need to improve and develop a strategy for doing
so.

٤٤
2.13 Communication for 'Problem Solving'
• Day-to-day situations involving supervisory decisions include;
a) Employee morale
b) The allocation of effort,
c) The materials used on the job
d) The coordination of schedules and work areas.

• The supervisor must;

a. Recognize problems,
b. Make a decision,
c. Initiate an action,
d. Evaluate the results.

• In order to make decisions that are consistent with the overall goals of the
organization, supervisors use guidelines set by top management. Thus, it is
difficult for supervisors to make good decisions without good planning.

• An objective becomes a criterion by which decisions are made.

• A decision is a solution chosen from among alternatives. Decisions must be

made when the supervisor is faced with a problem.

• Decision-making is the process of selecting an alternative course of action

that will solve a problem. The first decision is whether or not to take
corrective action. A simple solution might be to change the objective. Yet, the
job of the supervisor is to achieve objectives. Thus, supervisors will attempt to
solve most problems.

• A problem exists whenever there is a difference between what actually

happens and what the supervisor wants to have happen. Some of the problems
faced by the supervisor may occur frequently. The solutions to these problems
may be systematized by establishing policies that will provide a ready solution
to them. In these repetitive situations, the problem solving process is used
once and then the solution (decision) can be used again in similar situations.

• Exceptions to established routines or policies become the more difficult

decisions that supervisors must make. When no previous policy exists, the
supervisor must invent a solution.

• Problem solving is the process of taking corrective action in order to meet

objectives. Some of the more effective decisions involve creativity. To get
better ideas, the supervisor follows the steps in the problem solving process.
The steps are built on a logical analysis.

٤٥
 • The supervisor can think through all aspects of the problem by answering the
following questions.

o What seems to be the trouble?

o Why is it causing the trouble?
o What are the causal factors?
o What can be done in all possibilities?
o Are all these possibilities workable?
o What are the probabilities of success for each of the solutions?
o What are the appropriate alternatives?
o What is the correct choice?
o Have I logically eliminated the other choices?
o When and how can the solution be implemented?
o What is the best way to implement the solution?
o Has the solution solved the original problem?
o Have I planned, organized, and provided for the control of actions
leading to solutions?

2.14 Steps in problem Solving.

(1) define the problem, (2) identify decision criteria,

(3) develop alternatives, (4) decide,
(5) implement the decision, and (6) evaluate the decision.

Step 1: Define the problem. The problem solving/decision-making process begins

when the supervisor recognizes the problem, experiences pressure to act on it, and has
the resources to do something about it. This means that the supervisor must correctly
define the problem. Problem identification is not easy. The problem statement can be
too broad or too narrow. Supervisors are easily swayed by a solution orientation that
allows them to gloss over this first and most important step. Or, what is perceived, as
the cause of a problem may actually be a symptom.

The supervisor must solve the right problem. In order to define the problem, the
supervisor must describe the factors that are causing the problem. These are the
symptoms, visible as circumstances or conditions that indicate the existence of the
problem -- the difference between what is desired and what exists. By not clearly
defining the problem, ineffective action will be taken.

Step 2: Identify decision criteria. The supervisor determines what is relevant in

making a decision by isolating the facts pertinent to the problem. Since there is no
single best criterion for decision making where a perfect knowledge of all the facts is
present, a set of criteria must be used for the problem at hand. These decision criteria
identify what will guide the decision-making process. They are the important facts
relevant to the problem as defined. It is important that decision criteria be established
early in the problem solving process because if the criteria are developed as analysis
of data is taking place, the chances are good that the data will determine the criteria.
Thus, setting the criteria early introduces objectivity. These facts can be tangible as
well as intangible. Tangible facts might include the work assignments, the work

٤٦
schedules, or work orders. Intangible facts could include morale, motivation, and
personal feelings and perceptions.

This process is somewhat subjective, because what serves as important criteria for one
supervisor may be less important for another. For instance, the decision-making
criteria used to hire employees differs across departments; the sales department uses
the number of new store openings in different geographic areas, while the
manufacturing department uses how many units of the product needs to be produced
and how quickly.

Key uncertainties, the variables that result from simple chance, must be identified.
Regardless of the solution chosen, key uncertainties are important because they can be
plusses or minuses. What are the chance variables? Which way would these variables
fall, relative to each of the workable solutions?

Not all criteria have the same importance. (Criteria weights can vary among different
supervisors as well.) Assigning weights indicates the importance a supervisor places
on each criterion for resolving the problem and helps establish priorities. Criteria that
are extremely important can be given more weight, while those that are least
important can be given less weight.

Step 3: Develop alternatives. The supervisor must identify all workable alternative
solutions for resolving the problem. The term workable prevents alternative solutions
that are too expensive, too time-consuming, or too elaborate. The best approach in
determining workable solutions is to state all possible alternatives, without evaluating
any of the options. This helps to ensure that a thorough list of possibilities is created.

Generating alternative solutions requires divergent thinking (deviating from

traditional.) Groups can be used to generate alternative solutions. Brainstorming is the
process of suggesting as many alternatives as possible without evaluation. The group
is presented with a problem and asked to develop as many solutions as possible.
When brainstorming, employees should be encouraged to make wild, extreme
suggestions. They build on suggestions made by others. None of the alternatives are
evaluated until all possibilities are exhausted.

The supervisor must judge what would happen with each alternative and its effect on
the problem. The strengths and weaknesses of each alternative are critically analyzed
by comparing the weights assigned and then eliminating the alternatives that are not
workable. Probability factors -- such as risk, uncertainty, and ignorance - must be
considered.

Risk is a state of imperfect knowledge in which the decision-maker judges the

different possible outcomes of each alternative and can determine the probabilities of
success for each.
Uncertainty is a state in which the decision-maker judges the different possible
outcomes of each alternative but lacks any feeling for their probabilities of success.
Ignorance is a state in which the decision-maker cannot judge the different possible
outcomes of each alternative, let alone their probabilities. Investigating all the
possible alternatives helps to prevent eliminating the most appropriate one, because a
decision is only as good as the best alternative evaluated.

٤٧
Step 4: Decide. The supervisor must make a choice among the alternatives. The
alternative that rates the highest score should be the preferred solution. The decision
can be assisted by the supervisor's experience, past judgment, advice from others, or
even a hunch.

Timing impacts the decision. The probable outcome and its advantages versus its
disadvantages are affected at any given time. Which alternative is most appropriate at
a given time?

Decisions are made by consensus when solutions are acceptable to everyone in the
group, not just a majority. Everyone is included, and the decision is a win-win
situation. Consensus does not include voting, averaging, compromising, negotiating,
or trading (win-lose situations). Every member accepts the solution, even though
some members may not be convinced that it is the best solution. The "right" decision
is the best collective judgment of the group as a whole.

Consensus gives every person a chance to be heard and have their input weighed
equally. All members accept responsibility for both listening and contributing.
Disagreements are viewed as helpful rather than hindrances in reaching consensus.
Each member monitors the decision-making process and initiates discussions about
the process if it becomes ineffective. The smallest minority has a chance to change the
collective mind if their input is keener.

Group members do not give in just to reach an agreement. They support only those
solutions that they can truthfully accept. If people exercise this power to go against
the majority, they must have listened to the collective wisdom in good conscience. A
block should not be used to place an individual's will above the group's.

Consensus works in an environment of trust, where everyone suffers or gains alike

from the decision. Everyone must listen, participate, get informed, be rational, and be
part of the process from the beginning. Thus, consensus can be time consuming long
and exhausting to the participants. The combined problem solving/decision making
abilities of the group members produce a better decision than that of the individual
member.

Taking action requires self-confidence or courage. Only a person who is willing to

take risks is able to assume responsibility for a decision involving action. The fact
remains that the supervisor is held accountable for the outcome of the decision. Thus,
he or she must be confident that the right problem has been defined and the most
workable solution has been chosen. Self-confidence is the best element for a
supervisor to possess at this stage.

Step 5: Implement the decision. Once the solution is chosen, the decision is shared
with those whose work will be affected. Ultimately, human beings will determine
whether or not a decision is effectively implemented. If this fact is neglected, the
solution will fail. Thus, implementation is a crucial part of the decision-making
process. Including employees who are directly involved in the implementation of a
decision, or who are indirectly affected by that decision, will help foster their
commitment. Without their commitment, gaining support and achieving outcomes

٤٨
becomes increasingly difficult. With this commitment, the supervisor has a reasonable
degree of assurance that the decision will be accepted and have the necessary support.

In order to implement the decision, the supervisor must have a plan for
communicating it to those directly and indirectly affected. Employees must
understand how the decision will affect them. Communication is most effective when
it precedes action and events. In this way, events conform to plans and events happen
when, and in the way, they should happen. Thus, the supervisor should answer the
vital questions before they are asked. Communicating answers to these questions can
overcome much of the resistance that otherwise might be encountered.

Step 6: Evaluate the decision. The supervisor must follow up and appraise the
outcomes from the decision to determine if desired results were achieved. If not, then
the process needs to be reviewed from the beginning to determine where errors may
have been made. Evaluation can take many forms, depending on the type of decision,
the environment, working conditions, needs of managers and employees, and
technical problems. Generally, feedback and reports are necessary to learn of the
decision's outcome. Sometimes, corrections can be introduced for different steps.
Other times, the entire decision-making process needs to start over.

The main function of the follow up is to determine whether or not the problem has
been resolved. Usually follow up requires a supervisory visit to the work area affected
by the decision. The supervisor may have to repeat the entire decision process if a
new problem has been generated by the solution. It is better to discover this failure
during the follow up period rather than remain unaware of a new problem provoked
by the implemented solution.

٤٩
 Application tools on Chapter 2

---------------------------------------------

Tool One

Defensiveness Inventory-- How Defensive Am I?

---------------------------------------------------------------------
INSTRUCTIONS:
For each of the statements below, indicate how true each is for you.

1. Never True
2. Almost Never True
3. Sometimes True
4. Usually True
5. Almost Always True

____ 1. When I get sexually aroused, I start thinking about something else.

____ 2. Whenever I experience anger, I keep it inside, choosing not to express it.

____ 3. I can offer explanations very easily and often for why I commit acts I
recognize deep down as being wrong.

____ 4. I put things off reasoning that I can start tomorrow or make up then what I
should have done today.

____ 5. I misread people by attributing to them thoughts, feelings, and intentions that
are not their own.

____ 6. I feel threatened when I'm in the presence of people I don't like.

____ 7. I am very polite and courteous to adversaries when I would rather attack.

____ 8. When I feel afraid or insecure, I pretend I'm happy-go-lucky, joking around
and laughing.

____ 9. When I have a bad day at school or work, I unload my frustrations on younger
or less powerful people in my circle of family, friends and acquaintances.

____ 10. I've been known to attack, both verbally and emotionally, defenseless people
for no good reason.

____ 11. I am a hero worshipper- imitating sports stars, musical artists or others of
high repute.

٥٠
____ 12. If I didn't belong to a clique or in-group of some kind, I would feel left out.
naked or exposed.

____13. When I get upset, I either go out drinking and partying or just start acting
silly.

____ 14. When mad, I pout and refuse to talk about what upsets me.

____ 15. On days when things are not going well, I dream about better times in the
future.

____ 16. I often replay and win arguments in my mind well after they have finished.

____ 17. I like to find theories and explanations for my unacceptable behaviors,
thoughts and feelings.

____ 18. I don't believe mistreatment directed at me should be taken too seriously. I
maintain that sociological, psychological, and economic factors cause people
to do what they do.

____ 19. I refuse to admit publicly that family and friends do things that are wrong
and personally embarrassing.

____ 20. I pretend not to hear or see things that I don't like.

____ 21. I try to transform my undesirable impulses into actions that are socially
acceptable.

____ 22. I use creative or constructive outlets (e.g., painting, jogging ) to vent my
frustrations.

How to Score
All the above statements reflect defensive acts or tendencies. Add all the numbers that
you placed in the Score column. Divide by 22. Round your score, if necessary. This
will give you your average score.

You are almost never defensive or are possibly

1=
unaware of your defensiveness
2= You are rarely defensive
3= You are occasionally defensive
4= You have strong defensive tendencies
5= You are defensive almost all the time

These results are tentative and may need to be verified. You may want to discuss the
results with someone you trust and know well.

The statements are grouped in pairs, each relating to particular defence mechanisms
that you'll learn about in the chapter.

٥١
 QUESTIONS DEFENCE MECHANISM REFLECTED
1 and 2 REPRESSION
3 and 4 RATIONALIZATION
5 and 6 PROJECTION
7 and 8 REACTION FORMATION
9 and 10 DISPLACEMENT
11 and 12 IDENTIFICATION
13 and 14 REGRESSION
15 and 16 FANTASY FORMATION
17 and 18 INTELLECTUALIZATION/ISOLATION
19 and 20 DENIAL
21 and 22 SUBLIMATION

Source: Mastering Human Relations 3rd Edition, A Falikowski, 2002

٥٢
 Tool two

What's Your Conflict Management Style

Instructions: Listed below are 15 statements. Each strategy provides a possible

strategy for dealing with a conflict.
Give each a numerical value (i.e., 1=Always, 2=Very often, 3=Sometimes, 4= Not
very often, 5= Rarely, if ever.)
Don't answer as you think you should, answer as you actually behave.

____ a. I argue my case with peers, colleagues and coworkers to demonstrate the
merits of the position I take.

____ b. I try to reach compromises through negotiation.

____ c. I attempt to meet the expectation of others.

____ d. I seek to investigate issues with others in order to find solutions that are
mutually acceptable.

____ e. I am firm in resolve when it comes to defending my side of the issue.

____ f. I try to avoid being singled out, keeping conflict with others to myself.

____ g. I uphold my solutions to problems.

____ h. I compromise in order to reach solutions.

____ i. I trade important information with others so that problems can be solved
together.

____ j. I avoid discussing my differences with others.

____ k. I try to accommodate the wishes of my peers and colleagues.

____ l. I seek to bring everyone's concerns out into the open in order to resolve
disputes in the best possible way.

____ m. I put forward middles positions in efforts to break deadlocks.

____ n. I accept the recommendations of colleagues, peers, and coworkers.

____ o. I avoid hard feelings by keeping my disagreements with others to myself.

٥٣
Scoring: The 15 statements you just read are listed below under five categories. Each
category contains the letters of three statements. Record the number you placed next
to each statement. Calculate the total under each category.

Style Total
Competing/Forcing
a. _____ e._____ g. _____ ______
Shark
Collaborating Owl d. _____ i. _____ l. _____ ______
Avoiding Turtle f. _____ j. _____ o. _____ ______
Accommodating Teddy
c._____ k. _____ n. _____ ______
Bear
Compromising Fox b. _____ h. _____ m. _____ ______

Results: My dominant style is ___________________________( Your LOWEST

score)

and my back-up style is________________________ (Your second Lowest score)

٥٤
 Tool three

Leaders Questionnaire
Empowerment Motivation For Employees
This questionnaire on employee motivation focuses on the role of leaders in
empowering employees and improving motivation. Answer the questions honestly to
score your motivational capability.

I arrive at the office on time and do not leave early.

I expect the same levels of accuracy in my own work as my employees’.
I do not blame others. I take responsibility for my part in mistakes.
I encourage a 'no blame' culture where staff are able to admit mistakes and
learn from them.
I do not keep secrets from my employees.
I do not encourage gossip or rumour.
I set high ethical standards for my behaviour towards employees and hold
myself to those standards.
I ensure that staff have the training they require.
I participate in training to improve my own skills and competencies.
Employees have an active role in developing objectives for themselves, their
team and the company as a whole.
I regularly check that objectives between different parts of the team or
company are congruent. Everyone pulls together for the same end rather than
competing for different results.
I have a clear system for handling employee discontent.
Employees are aware of the system for handling discontent and feel
encouraged to use it to address problems.
Members of my team do not ask me simple questions. Significant matters are
brought to my attention. But smaller challenges are considered and resolved
by those responsible. I am not bothered by minor matters.
I do not build rapport with my team by sharing my weaknesses and fears. I am
honest but professional.
Employees are encouraged to make mistakes.
Employees tell me when mistakes have been made, how they have been
rectified and what the key learnings are from such mistakes.
I have a coach or mentor who keeps me focused and motivated about my
work.
I do not teach. Instead I lead, share, encourage and stimulate team members to
grow, develop and learn.
I trust my staff.

Total score ……….

٥٥
Interpretation:

15 to 20: Well done. You are walking the talk. Of those statements you were unable to
tick, which ones would you like to work on?

10-14: The basics are there. Now you need to upgrade. What would need to change
for you to score 15 or more?

5-9: You need to raise your standards. Some essential systems are missing in terms of
empowerment motivation for employees. Commit to raising your score to 15 in the
next 3 months.

0-4: You can probably see the results of your lack of integrity in your team. Take
three simple steps to improve employee motivation immediately. Commit to raising
your score to 15 in the next 6 months.

This questionnaire is provided for businessballs.com by Blaire Palmer of the

Optimum Executive Coaching company: www.optimum-coaching.com

٥٦
 Tool 4

Evaluate Your Team Development

Rating Team Development

How do you feel about your team's progress? (Circle rating).

1. Team's purpose
--- I'm uncertain----- 1 2 3 4 5 --- I'm clear
-- --
2. Team membership
--- I'm out----- 1 2 3 4 5 --- I'm in
-- --
3. Communications
--- Very guarded----- 1 2 3 4 5 --- Very open
-- --
4. Team goals
--- Set from above----- 1 2 3 4 5 --- Emerged through team interaction
-- --
5. Use of team member's skills
--- Poor use----- 1 2 3 4 5 --- Good use
-- --
6. Support
--- Little help for individuals- 1 2 3 4 5 --- High level of support for
-- ---- -- individuals
7. Conflict
--- Difficult issues are 1 2 3 4 5 --- Problems are discussed openly and
-- avoided----- -- directly
8. Influence on decisions
--- By few members----- 1 2 3 4 5 --- By all members
-- --
9. Risk taking
--- Not encouraged----- 1 2 3 4 5 --- Encouraged and supported
-- --
10. Working on relationships with others
--- Little effort----- 1 2 3 4 5 --- High level of effort
-- --
11. Distribution of leadership

٥٧
--- Limited----- 1 2 3 4 5 --- Shared
-- --
12. Useful feedback
--- Very little----- 1 2 3 4 5 --- Considerable
-- --

٥٨
 CHAPTER THREE

SUPERVISORY TOOLS "INSTRUMENTS'

ِ

٥٩
 Supervision Instrument 1
Example on Performance standards
(1)
NATIONAL PERFORMANCE STANDARD:
ENSURE CLIENT PRINACY
SITE-SPECIFIC INDICATORS
PERFORMANCE STANDARD
The provider maintains privacy 1. The door to the exam room is closed
during the consultation 2. The client is shown a curtain, privacy screen or
bathroom where s/he can change, if necessary.
3. The clients are covered with a sheet during the
physical and/or gynecological exam, if
necessary.
4. No other people enter or exit the room during
the exam.

(2)

INTERNATIONAL PERFORMANCE STANDARD:

ENSURE CLIENT PRINACY
SITE-SPECIFIC INDICATORS
PERFORMANCE STANDARD
Nurse-midwifery care is documented Uses record that facilitates communication of
in legible, complete health records. information to consultants & institutions.
Facilitate client's access to their records.
Provide written documentation of risk assessment,
course of management& out come of care.
Provide a mechanism for sending a copy of the
health record on referral.

Source: Supervising Health Services: Improving the performance of people (2001). Draft for
External Review. JHPIEGO- USAID. Maryland: USA.

٦٠
 Supervision Instrument 2

EXAMPLE of "JOB DESCRIPTION"

Job title: Public Health Nurse

Place of Work: Primary Healthcare Center (PHCC)

Qualifications: Certificate in Nursing

Experience: Prefer at least one year experience working in a hospital

Responsible to: PHCC In-Charge

Responsible for: Auxiliary healthcare worker (AHW), Auxiliary nurse-midwife

(ANM), Maternal and child health workers (MCHWs),
Sweeper, Traditional birth attendants (TBAs)

Relation with Ministry of Health (MOH), District health office, District

hospital, Non-government organizations (NGOs), MCHW,
TBAs, Community leaders, Community members.

Roles: The Public Health Nurse is responsible for the promotion of

good health in the mother and child as an administrator, care
provider, counselor, educator, evaluator, facilitator and
supervisor within her area. S/he must be willing to work in both
the PHCC and in the community.

Functions: ADMINISTRATIVE ACTIVITIES

1. Participates in the planning, organizing and implementing

of health services.
2. Makes the daily duty roster according to staff job
responsibilities.
3. Hold and participates in staff meetings
4. Participates in PHCC budgetary and logistics planning.
5. Helps to monitor supply stock levels and equipment.
6. Conducts new staff orientation about:
♦ Her/his job responsibilities
♦ PHCC organization, policies and rules
♦ Activities and services provided by the clinic
♦ The role of the clinic in the community
7. Helps in research activities carried out by staff or other
healthcare agencies.

CLINICAL ACTIVITIES
1. Keeps medical records

٦١
2. Conducts Maternal and Child Health/Family Planning
(MCH/FP)clinics
3. Assesses the nutritional status of adults and children
4. Assesses the needs of pregnant and postnatal women and
gives appropriate nursing care:
♦ Conducts antenatal visits
♦ Assists mothers during normal childbirth
♦ Refers pregnancy and childbirth complications quickly
to the appropriate person or health facility
♦ Counsels mothers about breastfeeding.
♦ Provides basic care to newborn and postnatal mother.
5. Provides immunizations as needed.
6. Provides emergency services to clients.
7. Provides family planning methods, as needed
8. Makes appropriate referrals to other health facilities, as
needed.
9.
COMMUNICATION ACTIVITIES

1. Uses standard, clear, written forms for major activities (e.g.,

client registration, referrals).
2. Assists with planning and running of staff meetings, as
needed.
3. Maintains good interpersonal relations with staff, clients
and community.

COUNSELING ACTIVITIES (GUIDANCE)

1. Counsels and guides ANM, AHW and sweepers as needed.

2. Counsels clients, their families and the community of health
issues.
3. Identifies eligible couples for family planning.
4. Counsels clients for STDs/AIDS and family planning
5. Identifies and counsels high-risk mother and child.

EDUCATIONAL ACTIVITIES – STAFF

1. Identifies training needs for ANM, AHW, MCHW and

others.
2. Recommends in-service education for health personnel.
3. Guides and helps students and encourages pre-service
education.
4. Helps organize and facilitate staff development activities.

EDUCATIONAL ACTIVITIES – COMMUNITY

Conduct health education activities regarding:

♦ Environmental sanitation
♦ Nutrition
♦ STDs/AIDS prevention

٦٢
 ♦ Immunizations
♦ Maternal health
♦ Family planning
♦ Other (to address local health problems)

REPORTING AND RECORDING ACTIVITIES

1. Records daily, monthly and annual clinic activity

information. Shares with appropriate authorities as needed.
2. Maintain up-to-date information on high-risk mothers and
children at the clinic, noting specific problems (e.g.,
malnutrition, blindness, mental retardation, etc.)
3. Maintains inventory list of supplies and equipment,
including breakages and losses.
4. Helps to collect and maintain data on area demographics
(e.g., population, increasing and decreasing health
problems).
5. Keeps staff employment records organized and
confidential.

SUPERVISORY ACTIVITIES

1. supervises MCHWs, Sweeper and TBAs

♦ Gives ongoing feedback (both positive and
constructive)
♦ Evaluates performance based on job responsibilities.
♦ Provides feedback to the health personnel about their
own performance.
2. Evaluates PHCC program achievements according to set
objectives.
♦ Encourages staff and community feedback on quality of
clinic services
♦ Stays interested in receiving feedback and suggestions.
♦ Works with staff and the community to identify gaps in
performance, determine root.

٦٣
 Supervision Instrument 3
CHECKLIST FOR PREPARING A MEETING

Date: _____________ Meeting Topic: __________________________

CHECKLIST FOR PREPARING A MEETING

Step / Task Check (3) box is
step/task
completed
satisfactorily
1. Determine the need for the meeting.
2. State the objective of the meeting.
3. Gather information about the main subject matter.
4. Decide on participants.
5. Select the date, time and venue for the meeting.
6. Prepare the meeting agenda.
7. Sends out letters of invitation and the agenda in advance
to provide adequate notice to participants.
8. Ensure that there is material for the meeting.
♦ Guidelines
♦ Writing pads
♦ Pens
9. Prepare the meeting room.
♦ Ensure that there is adequate space and lighting
♦ Organize seats in a comfortable sitting
arrangement
♦ Make plans for refreshments to be available

ADDITIONAL NOTES (if needed):

-----------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------

٦٤
 Supervision Instrument 4
SAMPLE MEETING AGENDA

Meeting of Maternity Section of Charity Hospital

1 August 2006

9:00 am Opening remarks by the facilitator

9:15 am Introductrion of members present (and apologies for

members absent) ___ All

9:20 a.m. Purpose of today’s meeting – Facilitator

9:30 a.m. Introduction of National service Delivery Guidelines –

Mary Omadi

10:15 a.m. Identification of ways in which current practice differs

from the guidelines – R.A. Shrestha

11:15 a.m. Formation of action teams for follow-up (i.e., define next
steps and timeframe) – Facilitator

11:30 a.m. Any other business - Facilitator

11:45 a.m. Data of next meeting – Facilitator

12:00 a.m. Closure of meeting – Facilitator

Related documents: the participants will practice doing an annual audit plan &
an audit report for their practice setting. In addition to create standards for their work
an example of these will be presented.

٦٥
 Instrument 5

PERFORMANCE STANDARD: ENSURE CLIENT PRIVACY

SITE-SPECIFIC INDICATORS
PERFORMANCE STANDARD
The provider maintains privacy 5. The door to the exam room is closed
during the consultation 6. The client is shown a curtain, privacy screen
or bathroom where s/he can change, if
necessary.
7. The clients is covered with a sheet during the
physical and/or gynecological exam, if
necessary.
8. No other people enter or exit the room
during the exam.

٦٦
 Instrument 6

Clinical Audit
CLINICAL AUDIT: PROFILE

Institution / Hospital PHC MCH

Name: _____________________________________________________
______________________________________________________
Location: ___________________________________________________
______________________________________________________
Telephone: ____________________ Fax: ________________________
Nursing Director: ____________________________________________
Telephone: _____________________ Extension: ___________________
Or Other Responsible Person: __________________________________
______________________________________________________
Date of Profile: _________________ Auditor: _____________________

The purpose of the clinical audit survey is to collect quantitative and

qualitative data about an institution that may be or is used for nurse
education clinical practice experience.

Ward / Clinic / Department

Name: _______________________ Specialty: ___________________
Staffing Levels: Charge Nurse: ______________________________
Staff Nurse: ________________________________
Practical Nurse: _____________________________
Others: ___________________________________
Level of Qualifications: Graduate Nurses: _______________________
Diploma Nurses: ______________________
RN or Equivalent: _______________________

Specialized Nurses:

٦٧
Coronary Care / ICU ________ Number With Course __________
Gynecology ________
Operating Dept ________ Number With Course __________
Ophthalmic
Anesthetic/PAR ________ Number With Course __________
Medical/Surgical ________
Children ________ Number With Course __________
Neonatal ________ Number with Course __________
Urological ________ Number With Course __________
Renal ________ Number With Course __________
Orthopedic ________ Number With Course __________
Mental Health ________ Number With Course __________
Community Health ________ Number With Course __________
Accident/Emergency ________ Number With Course __________
ICU/ITU ________ Number With Course __________

Midwives: Nursing Supervisors ________________

Diploma ___________ Infection Control __________________
Certificate ___________ Nursing Aids _____________________
Practical ___________ Teacher Supervisor _________________
Others ___________ Staff Education Yes No
Have Staff Education Needs Been Identified Yes No
Is there a Staff Orientation Program Yes No
Is there a Student Orientation Program Yes No
Number of Prepared Preceptors __________
Is there a Policy for Infection Control Yes No
Is Staff Education required for Infection Control Yes No

List Staff Education needs if required:

٦٨
_________________________________________________________
________________________________________________________
________________________________________________________
_________________________________________________________
Is there a Policy for Patient Education Yes No
Is Staff Education required for Patient Education Yes No
List Patient Education Needs if required:
_________________________________________________________
________________________________________________________
________________________________________________________
_________________________________________________________
Is there a policy for Maintaining Accurate Patient Records
Yes No
Is staff education required to maintain Nursing Records?
Yes No
Is there a policy for the Administration of Drugs/Medicines?
Yes No
Are there continuing education/staff education programs
Operating Yes No

If yes please list:

________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Organization of Nursing Practice

Area Name: ______________________________________________

Charge Nurse Name: ________________________________________
Number of Beds: __________ Treatment Room Yes No

٦٩
Is there a nursing policy / procedure group Yes No
Are there nursing standards identified and in use Yes No
IS there a Philosophy for nursing care Yes No
Are there education resources in practice areas
e.g. a resource file Yes No
IS there any evidence of research influencing
nursing practice Yes No
Is there a system to evaluate nursing care Yes No
Is nursing care based upon a model for care Yes No
If yes, specify the model in use
________________________________________________________
If staff education is required for the above, please make
recommendations:

Nursing records comment:

Is patient care task driven Yes No

Is patient care individualized Yes No
Can nursing therapies be identified Yes No

Is there an understanding amongst staff of any of the following?

٧٠
Nursing diagnosis Yes No
Nursing interventions Yes No
Nursing care plans Yes No
Are nursing inputs recorded: Always Sometimes Never
Is there a staff reporting system between shifts Yes No
Is there a system to evaluate nursing care Yes No
If yes please describe the system:

Are there regular staff meetings to discuss?

Nursing care inputs and outcomes yes No
Who supervises nursing practice: A Supervisor
A Charge Nurse
Other
If other, please specify: _______________________________________
Is there a staff disciplinary policy Yes No
Is the area used for student training Yes No
Is there a policy for student nurse education Yes No
If yes, please state what the policy is:

How many staff would be eligible to function as preceptors: __________

٧١
Is a preceptor training programme required Yes No
If yes, how many staff could be released from
Each area _________________
Which would be most suitable for staff?
Education/preceptorship Day release
Morning
Afternoon
Will each area require a resource file of
Information related to nursing research and
Practice Yes No

Auditor's comments

٧٢
Instrument 7: Patient Statistical Information
On the day of the audit survey the information required is the number of
specialized categories of patients e.g. diabetics and other medical
disorders or in surgical wards types of surgical cases or ophthalmic, or
orthopedic, neonatal conditions etcetera.

If there is an annual record kept of this type of statistic please enclose it

with the form.

Comment on the area audited in terns of being a learning environment for

students.

٧٣
 Instrument 8
Audit Report

Internal Auditors names:

1.
2.
3.
4.
Procedure Name: Procedure Code:
Auditing# Date: / / .

Auditing Process Summary:

Whole procedure audit.

Make sure that the corrective/preventive actions are implemented.

Others …………….

Auditing Process Description:

The interviewed Audi tees:
1.
2.
3.
4.

General Auditing points:

Procedure Retrieval.
Issue#.
Issue Date:

٧٤
 Instrument 9

EMPLOYEE PERFORMANCE APPRAISAL PROFILE

Name: _______________________Department:--------------------

Position: _________________________________

Length of time in Present Position: ____________

Review Date: _____________Return to Peers. Dept. by: _____________
Probationary period: __________________________ Type of Appraisal:
Annual Evaluation: ___________________________
Incidental Evaluation: _________________________
Section I
Please list at least three (3) main job responsibilities, based on the current
job description, and indicate the assessment (x) that best describes the
employee’s performance of the job responsibility:
Unacceptable: Overall performance must be immediately improved;
Marginal: Considerable improvement required; Acceptable: Performs job
at an acceptable level, some improvement required; Commendable: Little
improvement necessary; Exceptional: Performs at a very high level.

Main Job Responsibilities Remarks for Assessments

Does not meet
Exceeds
Meets

N/A

I. Assessment
1. Utilizes assessment skills
and techniques to determine
patient needs on admission
2. Completes and documents
the nursing admission
assessment in a thorough
and accurate manner.
3. Assesses patient condition
on an ongoing basis.
4. Assesses the need for pt.
/family instruction
II. Planning

٧٥
 Main Job Responsibilities Remarks for Assessments

Does not meet

Exceeds
Meets

N/A
1. Develops and documents a
plan of care based on
patient needs
1. Updates the written plan
of care as necessary
2. Develops patient teaching
and discharge plans as
necessary.
3. Conducts and documents
patient care conference.
4. Collaborates with other
heath team members in
planning care.
5. Organizes works to allow
time for in-services, unit
meetings, etc.
III. Implementation
1. Provides safe,
comprehensive, nursing
care.
2. Carries out the developed
plan of care in a consistent
and flexible manner.
3. Performs procedures
accurately, completely and
safely, according to
established policy and
procedure.
4. Provides care with
minimal supervision in a
timely manner.
5. Maintains a safe
environment for patients.
6. Respects the dignity and
confidentiality of patients,
serving as an advocate as
necessary.
7. Establishes care priorities
based on nursing / medical
patient problems.
8. Able to function quickly
and effectively in an
emergency situation.

٧٦
 Main Job Responsibilities Remarks for Assessments

Does not meet

Exceeds
Meets

N/A
9. Utilizes patient / family
education programs.
10. Collaborates wit other
heath team members in
providing care.
11. Able to adapt to
changing workload.
IV. Evaluation
1. Evaluates and adjusts the
plan of care to meet
changing patient needs.
2. Reviews and evaluates
personal nursing practice
as compared to standards
of care.
3. Contributes to nursing
quality assurance by
assisting in the
identification of recurrent
nursing problems and
cooperating in data
collection
V. Communication Skills
1. Documents according to
policy and procedure.
2. Documents observed
physical and emotional
symptoms and changes.
3. Transcribes orders
accurately.
4. Checks transcribed
orders for completeness
and accuracy.
5. Reports pertinent
information to
appropriate nursing
personnel.
6. Responds appropriately
to pt. / family requests
and questions.

٧٧
 Main Job Responsibilities Remarks for Assessments

Does not meet

Exceeds
Meets

N/A
7. Communicates
appropriately with
colleagues and other
members of the health
care team.
8. Recognizes self-
limitations and requests
assistance.
9. Participates in staff
meetings.
10. Approaches interpersonal
relationships in a manner
that avoids antagonism,
reduces conflict, and
prevents undue anxiety.
VI. Professional Expectations
1. Functions within the
limits of the State Nurse
Practice Act, hospital
policies and procedures,
and Nursing Dept.
standards.
2. Supports the philosophy,
objectives, and goals of
the nursing department
and hospital.
3. Follows appropriate lines
of authority.
4. Demonstrates flexibility
by assisting in other
areas of the hospital as
needed.
5. Continues to establish
and expand personal
knowledge and skills.
6. Attends in-service /
continuing education
programs and shares
knowledge.
7. Provides direct
supervision to other
members of the nursing
team as assigned.

٧٨
Main Job Responsibilities Remarks for Assessments

Does not meet

Exceeds
Meets

N/A
8. Accountable for own
conduct and promotes
good working
relationships.
9. Participates in nursing
committees and other
activities that promote
the growth and
development of nursing
and/or patient care.
10. Participate in learning
experiences for student
nurses.
11. Assists with orientation
of new personnel.
12. Presents a professional
appearance.
13. Performs other duties as
required.

٧٩
 Instrument 10
Employee Performance Appraisal Form

Appraisal period--------------- Date-------------------

Name------------------- Supervisor--------------

The appraisal includes the following (check√ to show what

was used) (use only what is appropriate):(

□ Self appraisal.

□ Observation bye the supervisors.

□ Input from clients and the community.

□ Input from colleagues on contribution to team effort pleas list names of

colleagues.

_____________________ ____________________
_____________________ ____________________

Targets and objectives set for past period Under Review

Note which targets and objectives were achieved, and how, and which
were not. List additional work that was done and discuss why this work
was done.

1. _________________________________________________________

2. ___________________________________________________________________

3. ___________________________________________________________________

4. ___________________________________________________________________

٨٠
List main Achievements and Improvements in the period Under Review (refer to
areas for improvement noted during the last preview)

1. ____________________________________________________

2. _____________________________________________________________

3. _____________________________________________________________

4. _____________________________________________________________

Identify Areas for improvement

Identify areas for improvement. Record what the employee must do to improve and
what the supervisor can do to help.

● Employee

___________________________________________________________
___________________________________________________________

● Supervisor

___________________________________________________________
___________________________________________________________

New competencies

Record what training or staff development was done in the period under review, and
assess the extent to which new competencies were applied on the job. Identify and
record training needs and what will be done to meet them.

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

٨١
Changes to the job Description

How has the job changed in the past year?? Does this change require a change in the
job description?? Are there implications??

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

Set Objectives and targets for the Period Ahead

What objectives related to improving in specific areas and acquiring new skills should
be set?? Rank the objectives, listing the most important one first.

1. ____________________________________________________

2. _____________________________________________________________

3. _____________________________________________________________

4. _____________________________________________________________

٨٢
 Instrument 11
SUPERVISORY VISIT CHECKLIST FOR CONDUCTING A
PERFORMANCE APPRAISAL

Step /Task Check ("√") box if

step/task completed
satisfactorily

1. Establish a schedule for regular performance reviews. □

2. Arrange for time and location, notify employee. □
3. Control interruptions. □
4. Review employee's performance objectives in advance. □

5. Discuss employee's performance with other staff members □

if relevant to obtain more input.
6. At meeting, jointly review the employee's performance □
objectives and progress.
7. Provide positive and constructive feedback, and let □
employee know areas where improvement is needed.
8. Jointly develop performance objectives for next designated □
time period.
9. Jointly develop an action plan for any education, training, □
or in-service activities.
10. Ask employee for suggestions on how the job could be □
performed better or differently.

11. Acknowledge achievements and contributions towards □

shared vision.
12. If, appropriate, discuss with employee opportunities for □
assuming more responsibilities.

٨٣
 Instrument 12
Supervisor's self-Assessment Checklist

Supervisor's self-Assessment Checklist

Skills Area Skill Confident

Working with People . From a team for performance and quality □

improvement
□
. Involve community members
□
. Use good communication techniques
□
- Use active listening
□
- Convey positive body language
□
- Clarify speakers intent
□
- Use appropriate questioning techniques
□
- Facilitate teamwork
□
- Hold productive meetings
□
- Coordinate with multiple stakeholders
□
- Negotiate with staff so solve problems
□
- Manage conflict among staff members
Defining desired . Establish shared wision among team □
Performance for Your
Site . Work with the team to set standards □

. Disseminate standards to the team □

. Create job description for staff □

Assessing Site . Institute assessment procedures □

Performance
- Self assessment □

- Peer assessment □

- Supervisor assessment □

- Client Feedback □

- Polling of community perceptions □

٨٤
 - Review of records and reports □

- Benchmark □

. Assess performance on regular basis □

Finding Root causes . Work with staff to find out the cause of □
performance problems
□
- Used why- why Method
□
- Used performance factors discussion guide
□
. Look at factors contributing to successes
□
Selecting and . Identify interventions to match causes □
implementing
interventions . Look for high performing sites to compare with □

. Prioritize possible interventions □

. Create an action plan □

Learning Interventions . plan for the transfer of training □

. Facilitate ongoing staff development □

. Conduct staff development survey □

. Creat individual staff development plans □

. Coach staff to improve performance □

. Consider alternative learning approaches □

Motivational . Provide constructive feedback on a regular basis □
interventions
. Set performance objectives for staff members □

. Conduct regularly scheduled performance □

appraisals

. Devise systems for staff recognition

□
Environmental . Ensure proper workflow □
Interventions
. Ensure a well functioning logistics system □

. Ensure an acceptable storage system □

. Ensure an adequate physical structure □

. Ensure client transport □

Monitoring and . Regularly assess performance using different □
Evaluating Performance methods

. Regularly measure performance against standards

٨٥
. Use an action plan to monitor interventions □

. Revise interventions, as needed, to achieve results □

. Continuously seek ways to improve performance □

and quality
□

٨٦
 References

• Kemp, N. & Richardson, E., 1990. Quality Assurance in Nursing Practice:

London, Butterworth Heinemann.

• Monica E. 1994. Management In Health Care A Theoretical and Experiential

Approach. Philip Morgan.

• Drmanin.A.1992. Developing Leadership & Skills A Training Manual for

Leader.

• Henderson.C. & Macdonald Sue. 2004. Mayes’ Midwifery Baillier Tindall,

13th edition.

• Core of Ethics. Code of Ethics for Supervisors.www.clinical-

supervision.com/lens%20%&%20ethics%20document.accessed@2/12/2005.

• Supervision Models. Supervision

Model.www.bamaed.ua.edu/kcarmich/bce619/models.html.
accessed@9/12/2005.

• Hyrkas. K. Clinical Supervision & Quality, Examining the Effects of Team

Supervision in Multi-Professional Team.

• Models of supervision. The development of models of clinical Supervision in

UK. www.clinical-
supervision.com/development%20of%20clinical%20supervision.zhtm.
accessed@11/2/2005.

• The Supervisory Relationship.

http://soeweb.syr.edu/chs/onlinefield/supervision/relationship.htm.accessed@
1/7/2006.

• Supervision Process: Complications & Concerns. The Supervision

Process.www.shsu.edu/piic/summer2001/detrude.html.accessed@1/22/2006.

• Evaluation in
supervision.htt://soeweb.edu/CHS/onlinefield/supervision/evaluation.html.acc
essed@2/6/2006.

• The influence of Professional roles on Clinical Supervision, Nursing Standard.

May 2/Vol 15 no 33/2001.

• Health Care Organization in Middle East. Improving Health Care Quality.

Harvard– Dahab, Arab Republic of Egypt (1995). Quality Management
Program for University.

٨٧
• Liz c., Creel, Justin V. Sass and Nancy V. Yinger, 2002, Overview of Quality
of Care in Reproductive Health: Definition and Measurement of Quality.
Population Council and population Reference Bureau. Perspectives on
Quality of Care: No. 1.

• Liz c., Creel, Justin V. Sass and Nancy V. Yinger, 2002, Client-Centered
Quality: Client's Perspectives and Barriers to Receiving Care. Perspectives on
Quality of Care: No. 2.

• Robbins, Stephen P., and Nancy Langton, Organizational Behaviour:

Concepts, Controversies, Applications. Toronto: Pearson Education, 2003.

٨٨