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The Impact of a Supportive Supervision Intervention on Health Workers In Madede et al. Human Resources for Health (2017) 15:58 DOI 10.1186/s12960-017-0213-4 RESEARCH Open Access The impact of a supportive supervision intervention on health workers in Niassa, Mozambique: a cluster-controlled trial Tavares Madede1, Mohsin Sidat1, Eilish McAuliffe2* , Sergio Rogues Patricio1, Ogenna Uduma3, Marie Galligan4, Susan Bradley5 and Isabel Cambe6 Abstract Background: Regular supportive supervision is critical to retaining and motivating staff in resource-constrained settings. Previous studies have shown the particular contribution that supportive supervision can make to improving job satisfaction amongst over-stretched health workers in such settings. Methods: The Support, Train and Empower Managers (STEM) study designed and implemented a supportive supervision intervention and measured its’ impact on health workers using a controlled trial design with a three-arm pre- and post- study in Niassa Province in Mozambique. Post-intervention interviews with a small sample of health workers were also conducted. Results: The quantitative measurements of job satisfaction, emotional exhaustion and work engagement showed no statistically significant differences between end-line and baseline. The qualitative data collected from health workers post the intervention showed many positive impacts on health workers not captured by this quantitative survey. Conclusions: Health workers perceived an improvement in their performance and attributed this to the supportive supervision they had received from their supervisors following the intervention. Reports of increased motivation were also common. An unexpected, yet important consequence of the intervention, which participants directly attributed to the supervision intervention, was the increase in participation and voice amongst health workers in intervention facilities. Keywords: Supportive supervision, Job satisfaction, Retention, Work engagement, Burnout, Participation, Motivation Background in Malawi, Tanzania and Mozambique showed that Ongoing support is needed for health workers in the negative/critical (rather than constructive/supportive) or frontline of service delivery to perform to their full po- an absence of workplace supervision are strong predic- tential and deliver quality patient care. In a discrete tors of healthcare workers intentions to leave their posi- choice study of more than 2000 health workers across tions [2]. Supervision that consisted mainly of negative Tanzania, Malawi and Mozambique [1], good function- feedback was viewed to be almost as de-motivating as ing human resource management systems emerged as a no supervision. Those who indicated they only receive critical factor in job choice across all grades of health negative supervision were more likely to state intention workers. Supervision and feedback on performance is an to leave their jobs and negative supervision was also important component of Human Resource Management linked with lower levels of job satisfaction. However, as it plays a key role in motivating staff. In a previous health managers commonly neglect supervision, and study, multi-level analysis of data from obstetric services many supervisors lack the knowledge, skills and tools for effective supervision [3]. Despite its’ critical role, supervision and in particular * Correspondence: [email protected] 2School of Nursing, Midwifery and Health Systems, University College Dublin, supportive supervision is not well understood in the con- Dublin, Ireland text of healthcare [4, 5]. In many resource-constrained Full list of author information is available at the end of the article © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Madede et al. Human Resources for Health (2017) 15:58 Page 2 of 11 countries, the traditional visiting inspector model of facility in-charges have not received training in HRM or supervision is common, yet there is broad consensus that supervision. In Mozambique, the personnel charged with this is not effective [6, 7]. District Health Management managing health care workers currently do not have the Teams (DHMT) schedule regular visits to each facility, training for effective management of the workforce [3]. but the evidence shows that these frequently do not hap- Without these skills, it is difficult for them to support pen as planned. Challenges to effective supervision include staff or to find the root causes of poor performance. conflicting responsibilities and demands on supervisors’ In this context, the aim of the Support, Train and Em- time, inadequate finances and transport and accessibility power Managers (STEM) study was to develop and test, problems [5]. This can result in remote facilities receiving through a cluster controlled trial, an intervention to im- only one visit a year. Given that external supervisory visits prove retention and motivation and facilitate staff to be are sometimes their only link to more experienced health more engaged in and ultimately more satisfied in their jobs. professionals, this can leave staff in rural facilities feeling By improving the supervision skills of staff having a super- abandoned and isolated. visory role within facilities, STEM expected to achieve It is clear that the existing supervision paradigm in greater satisfaction and improved performance of workers. resource-constrained countries is inadequate. Models of more supportive supervision processes stress activities Methods that are cognisant of the underlying drivers of health The overall objective of the STEM project (Support, worker motivation, job satisfaction and performance. A Train and Empower Managers) was to strengthen the systematic approach to developing strong Human Re- human resource management (HRM) function at district source Management (HRM) functioning within the and health facility level, by increasing the capacity of health system, with improved mechanisms for manage- managers to support and supervise their staff. The pro- ment support where healthcare workers receive con- ject was implemented in Mozambique by Community structive supervision and feedback aimed at improving Health Department of the Faculty of Medicine of Uni- performance, is needed to increase retention and im- versity Eduardo Mondlane (UEM) and the National prove quality of care. Health Institute (NHI), in collaboration with the Centre A focus on supportive supervision engenders a mind- for Global Health, Trinity College Dublin. The research set where teams of health workers identify their own framework (Fig. 1) sets out the two orienting proposi- challenges and achieve results with support from their tions on which this study is based: supervisors. Direct, on site supervision is the most ef- fective for improving staff performance, but supervisors Regular supportive supervision delivered by local need to have the skills to undertake this role. Previous facility staff will improve job satisfaction and research [5] provides evidence that many managers and engagement and reduce turnover. Fig. 1 The research framework Madede et al. Human Resources for Health (2017) 15:58 Page 3 of 11 Action learning sets will enhance the anticipated a) Nearly 50% of the Niassa Province population reside benefits of supportive supervision as outlined above. in the three selected Districts b) Work with facilities where few or no other non- Figure 1 also lists the key research questions and data governmental or governmental organisations were collection methods. currently providing supervision training c) Include facilities that have greater numbers of Study design healthcare staff to ensure a sufficient sample size d) Include geographically dispersed health facilities STEM used a cluster controlled design to evaluate the which was deemed important to reduce the risk of impact of the following steps: cross-contamination between groups located in neighbouring districts (A) Workshops with district health management teams and facility managers on human resource In the two intervention districts, seven health facilities management were selected to receive the intervention. In Cuamba, (B) Intensive training in supervisory and support skills which served as the control district, four facilities were for managers directly engaged in supervision selected for collection of baseline and end-line data. (C) Action learning sets for staff engaged in Table 1 provides details on the particular districts supervision at district and facility level assigned to each of the study groups. All health facilities in each of the selected districts were assigned to the The design included three groups, with two interven- same group or Intervention—component A. tion groups and one control group as follows: During the workshops in the districts of Mecanhelas and Mandimba, the following topics were covered: Group 1: Intervention with steps A and B = A + B Group 2: Intervention with steps (A), (B), Introduction to STEM project and (C) = A + B + C Action Learning Sets Group 3: No intervention = control
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