C o m m u n i t y R e s e a r c h S u p e r v i s i o n o f Q u a l i f i e d C o m m u n i t y R e h a b i l i t a t i o n W o r k e r s A B S T R A C T : Supervisors o f Community Rehabilitation Workers (CRW s) have a critical role to p la y in supporting an d developing the skills and effectiveness o f CRWs. This p a p er reports on research co n d u c te d by the W its/Tintsw alo C om m unity R e h a b ilita tio n , Research and Education (CORRE) Programm e am ongst p a st and present supervisors o f qualified CRWs. The aim was to understand different approaches used in supervision, the problem s encountered and possible solutions, and the perceived im pact o f CRWs within rehabilitation services. Thirteen supervisors o f qualified CRWs com pleted a p o sta l or hand delivered questionnaire, w hich contained a range o f open-ended and sem i-structured questions. The fin d in g s included the supervision activities, the problem s around supervision and the benefit o f a C R W service. The need fo r com m unity based rehabilitation (CBR) practice protocols and standards was highlighted. These fin d in g s were one o f a series o f steps towards the developm ent o f a CBR managem ent manual f o r the Northern Province. K E Y W O R D S: SUPERVISION, C O M M U N ITY REH ABILITATIO N W O RKERS (C R W ’S), C O M M U N ITY BASED REH ABILITATIO N (CBR), WITS/TINTSW ALO C O M M U N ITY REHABILITATION, RE SE A R C H A N D ED U C ATIO N PRO G R A M M E (CORRE) Mr. Sichangwa passed away in 1999. We wanted him to be the second author, as he played an important role in preparing for and collecting data for this research. MONIKA PETRICK, MSc'; KASENGA SICHANGWA, BSc (Hons)1; MARK COLLINSON, BSc (Stats and Maths)2; KATHERINE PICKFORD (Graduate Diploma Physiotherapy)3 1 Wits-Tintswalo Community Rehabilitation, Research and Education programme 2 University of South Africa (UNISA) Physiotherapy Department, Tintswalo Hospital INTRODUCTION T he W its-Tintsw alo Com m unity R eha­ b ilita tio n , R e se a rc h an d E d u c a tio n (C O R R E) Program m e (previously the W its-T in tsw alo C om m unity R eh ab il­ ita tio n W orker T rainin g P ro gram m e (CRW TP)) started training com m unity rehabilitation w orkers (CRW s) in part­ nership with the G azankulu and later the N orthern Province governm ents in 1991 (C oncha, 1993). T his w as done in response to a dire need for rehabilitation services in rural areas (Concha, 1993). T he CRW s w ork in the com m unity (offering a service at people w ith disabi­ lities’ hom es and in their rural villages) as part o f the rehabilitation team o f the local hospital or non-governm ental organisation, thus helping to im prove rehabilitation service provision (H om er and Hoffman, 1999). They receive regular su p erv isio n by th erap ists from the local hospital. At the tim e o f the study, there w ere 52 qualified CRW s, each covering betw een one and four rural vil­ lages, m ostly in the Northern Province, w ith a few in M pum alanga, Lesotho and Swaziland. Supervision o f CRW s is necessary, as these w orkers need support, links w ith the ho sp ital and u pgradin g o f skills (Schneider, 1996). H offm an (1992) em phasises the threefold role o f the supervisor as being adm inistrative, edu­ cational and supportive. N ewly qualified therapists are often, however, not skilled as supervisors o f support staff (H om er and H offm an, 1999). In order to equip supervising thera­ pists for their role, C O R R E has pro ­ vided a series o f seven w orkshops to tra in th e se s u p e rv iso rs o f s tu d e n t CRWs since 1993 (Evans, 1997). Seven w o rk s h o p s fo r th e su p e rv is o rs o f qu alified CRW s have since also been conducted. T h e study aim ed to establish the supervisors’ perceptions on supervising CRWs. It served as input into the devel­ opm ent o f g u id elin es and p ro tocols for CRW supervision in the N orthern P ro v in ce , and to g u id e the new ly appointed com m unity based rehabili­ tation (CBR) manager. METHOD In February 1998 a questionnaire was distributed to 41 past and present super­ visors o f qualified CRW s (all the super­ visors the authors could trace) w ho had supervised from 1993 to 1998. The questionnaire was developed as follows: The authors (three w ith expe­ rience in the supervision o f qualified CRW s and one a statistician) drew up a preliminary questionnaire, that attem pted to e stab lish the p ercep tio n s o f the supervising therapists on supervision o f CRW s. This questionnaire was then given to two therapists w ho supervise qualified CRW s to com plete and com ­ m ent on, as a p ilo t study. T he final questionnaire then included the changes they suggested. C O RRESPO ND EN C E TO: M Petrick PO Box 558 A cornhoek 1360 Tel: (013) 797-0058 (W) SA J o u r n a l o f P h y s io th e ra p y 2001 V o l 57 No 1 13 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) T he follow ing areas w ere covered in the questionnaire: 1. Professional training and w ork expe­ rience o f the supervisors 2. Supervision experience and training 3. C urrent supervision practice 4. B enefits o f CRW s to the service and for the respondents 5. Problem s o f supervision 6. C urrent support for and requirem ents o f supervisors The questionnaire contained close- ended, open-ended, sem i-open and filter questions. T he inform ation sought by each o f these types o f questions can be found in Table 1. A five-point ordinal scale was used to capture frequency o f activities (Table 1). The questionnaire contained an expla­ nation o f how the five point ordinal scale should be used to answ er the questions and gave an exam ple. Each question had the scale (five blocks) next to it and the respondents had to tick one o f the blocks. The five categories used in the scale were “alw ays” , “m ost o f the tim e/often” , “som etim es (about h a lf the time)”, “rarely” and “never” . As both ends o f the scale contained im portant infor­ m ation, the authors grouped the results o f the categories “rarely” and “never” to g e th e r and also the categ o ries o f “m ost o f the tim e/often“ and “alw ays” together for data analysis. T he authors thus reflected the results on either end o f the scale. RESULTS Professional training and work experience of the supervisors Thirteen (32% ) o f the supervisors o f qualified CW Rs responded, three (23%) w ere p h y sio th e ra p ists, th ree (23% ) w ere com m unity speech and hearing w orkers, one (8% ) was a prim ary health care adm inistrator and one (8% ) was a com m unity nutritionist. All the respon­ dents had qualified as professionals at least 5 years previously and m ost were fem ale (n = 11 (85%)). Supervision experience and training The m ost frequently given reason for becom ing a supervisor (n = 5 (38% )) was that the supervision o f CRW s is part o f a therapist’s jo b description in the N orthern Province. Just over half (n = 7 (54% )) o f the respondents had been supervising CRWs for less than one year. Seven respondents (54%) had training on supervising qualified CRWs, all this at C O RRE. One supervisor (8%) had also received undergraduate training in CRW supervision. Current supervision practice Ten (77% ) o f the respondents w ere supervising CRW s at that stage. O f the three (23% ) that w ere not, one (8% ) did not give a reason, one (8% ) had only supervised w hile the local hospital had a therapist shortage and the other (n = 1 (8% )) had CRW s who refused super­ vision. T he n u m b er o f CRW s each supervisor saw varied from two to six (m ean = 3,7). M o st respondents (n = 8 (62% )) visited their CRW s at least once a month. In m ost cases ( n = 9 (69% )) the supervision was regular and did not only happen in response to the CRW asking for help. R espondents spent betw een 2 and 18 days (m ean = 6,5 days) w orking in the com m unity (ie. out o f the hospital, in rural villages) each m onth. TABLE 1. Information obtained from the questionnaire using open-ended, semi-open and filter questions and a five point ordinal scale Open-ended How the respondent became a supervisor o f qualified CRWs W h a t the respondent had gained from supervision How supervision problems could be solved Supervision skills still felt to be lacking The explanations o f the answers given on the amount o f support the respondent received from the superintendent, the provincial head office and CORRE Aspects the respondent wanted the CBR manager to help with Semi-open The five most important benefits o f having CRWs in the respondent's rehabilitation service The five biggest problems he/she had with the supervision of qualified CRWs Filter questions If the respondent supervised qualified CRWs at that time W hether the respondent would encourage others in h is / her profession to also become CRW supervisors W hether any training on supervising qualified CRWs had been received W hether special supervision forms were being used W hether the respondent wanted CORRE to run workshops on supervising qualified CRWs (all o f the above had sub-questions which had to be completed depending on whether the answer was YES or N O ) Five point ordinal scale Various activities used during supervision W hether the CRWs w ork in the community and keep statistics on client- related and additional activities The CRWs' various responses to supervision 14 SA J o u r n a l o f P h y s io th e ra p y 2001 V o l 57 No 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) TABLE 2. Activities that happen most of the time or always during CRW supervision (ratings obtained using a five point ordinal scale) ACTIVITIES N* % G iving emotional support and encouragement to the CRW 12 92 Supervising in the CRW's village 10 77 Helping the CRW with therapy for clients 9 69 Observing the CRW working with clients 8 62 G oing through administration 8 62 Problem solving 7 58 Improving the CRWs therapy skills 7 54 Transporting CRWs to distant clients 7 54 Individual work with one CRW in h is / her own village, rather than supervising a group o f CRWs at once 6 46 * N = number o f supervisors TABLE 3. Desirable activities that happen rarely or never during qualified CRW supervision (ratings obtained using a five point ordinal scale) ACTIVITIES N* % Rarely or never liaising with the CRW and community leadership on CBR programme implementation 11 85 Rarely or never giving lectures/ workshops to CRWs on work-related topics during supervision 9 69 Rarely or never seeing the CRWs w ork with a group during supervision 8 62 Rarely or never improving the CRW's group skills 7 54 Rarely o r never w orking with a small group o f CRWs during supervision 7 54 * N = number of supervisors T he activities rep orted to happen m ost o f the time or always during super­ vision can be seen in Table 2. T he m ajority o f respondents said they rarely or never supervised their CRW s in the hospital (n = 12 (92%)). However, w hen asked how m any super­ vision sessions w ould happen in the hospital in a three month period, eight respondents (62% ) indicated that they w ould have one to three sessions. D esirable supervision activities that rarely or never occurred during super­ vision are listed in Table 3. All o f the respondents (n = 13 (100%)) stated that their CRW s w orked in the com m unity always or m ost o f the time. Two respondents (15% ) rem arked that their CRW s were hospital based, while one (8% ) said that despite this fact, supervision w ould always happen in the community. Eleven o f the respondents (85 %) said that the CRW s kept clien t statistics always or m ost o f the time. Only six respondents (46 %) were sure that the statistics w ere accurate. Eight o f the respondents (62% ) said that the CRWs kept statistics o f other activities apart from client care, seven (54% ) o f whom thought these statistics were accurate. T he overall response to supervision was good: Twelve (92%) o f the respon­ dents stated that the CRW s were often or always ready for the supervisors at the correct tim e and place. Ten (77%) said that the CRW s often or always pre­ pared clients for supervision, that they thanked supervisors for the supervision given and that they never refused super­ vision. Nine (69%) agreed that the CRWs were never resistant to supervision and that they often or always prepared ques­ tions in advance. Benefits of CRWs to the service and for the respondents T he su p erv iso rs w ere very p o sitiv e about supervision, as all but one ( n = 12 (92% )) w ould encourage others in their profession to also becom e CRW super­ visors. T hey gave m any benefits o f having CRW s for the service and for them selves, the m ost frequently m en­ tioned o f w hich can be seen in Table 4. The personal benefits m ost often m en­ tioned by the supervisors were the asso­ ciated learning and im provem ent o f the supervisors’ skills. Problems of supervision The m ain p ro blem s asso ciated w ith supervising qualified CRWs and some solutions are given in Table 5. Current support for and requirements of supervisors Only five (39% ) o f the respondents felt that their su p erin ten d e n t gave them adequate em otional and organisational support, and four (31% ) said that they received enough financial support. O nly five (39% ) o f the respondents felt that the provincial head office gave them adequate em otional support, while three (23% ) felt that they got sufficient financial and organisational support. The majority o f the therapists felt that CO RR E gave them adequate orga­ nisational support (n = 9 (69% )) and em otional support (n = 8 (62% )). All the re sp o n d en ts in d icated that they would like C O R R E to run w orkshops on supervising qualified CRW s, preferably annually or biannually. The respondents requested the CBR manager to help them with a wide variety o f aspects, the most frequently m entioned being help in setting up standards/pro­ tocols for the C R W s’ w ork (n = 8 (30 % o f the 27 requests)), including topics such as form s and duty sheets, w ork ethics, responsibility, accountability and prom otion. DISCUSSION In spite o f the low response rate in this study, w hich is one o f its w eaknesses, interesting trends can be seen: M ost o f the supervisors w ere from the three the­ rapy professions (occupational therapy, p h y sio th erap y and speech therapy), SA J o u r n a l o f P h y s io th e ra p y 2001 V o l 57 No 1 15 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) TABLE 4. The benefits of having CRW's in the rehabilitation service and for the supervisor (summary of responses to a semi-open and an open -ended question) BENEFIT N* % Increased rehabilitation service provision 15** 6,3 The presence of CRWs enhances multi-disciplinary teamwork and skills, knowledge and understanding o f all team members 13 14,1 Reduced community w ork load for hospital-based therapists and better referrals and follow-ups 7 7,6 Better awareness of disability, its causes and prevention and better acceptance o f people with disabilities in the community 5 5,4 Empowerment o f people with disabilities/ social problems associated with disability are addressed 5 5,4 CRWs refer clients to the therapists/ hospital and make them a ware o f specific community needs 4 4 ,3 The CRWs' knowledge o f local culture and their community makes the service more acceptable 4 4,3 People are given h o p e / encouragement that something can be done to help them 3 3,3 Supervisors gained knowledge about the CRW's profession, their impressive scope o f w ork and how they access people with disabilities in the community 3 3,3 Supervisors gained experience about values in South Africa, local culture, customs, geography, beliefs and needs 3 3,3 Supervisors gained supervision skills: e.g. to ensure that the CRW uses different w a y s / simple language for getting information from the client and to know how clean, neat and complete a CRW's w ork should be 3 3,3 Other 27 29,3 TOTAL 92 100 N = number of responses; the 1 3 respondents gave a total of 92 responses 15 responses fitted this category, i.e. some o f the 1 3 respondents gave more than one response in this category w hich reflects the m u lti-d iscip lin a ry training o f the CRW s (Concha, 1993). A lthough they w ere experienced thera­ pists, they w ere less experienced with CRW supervision. This is due to rapid staff turnovers at rural hospitals, the a p p o in tm en t o f sta ff in p re v io u sly unoccupied posts and som e o f the long­ standing supervisors not returning the questionnaires. Just over h alf o f the respondents had received training on supervising qualified C R W ’s. T he respondents stated clearly that CRW s w ere beneficial, as they helped to im prove the rehabilitation service provision. T he therapists’ com m unity w ork load was lightened and the com ­ m unity m ade m ore aw are o f disability, its causes and prevention and how to integrate and em pow er people w ith dis­ abilities. The CRW s served to enhance m ulti-disciplinary team work, w hich is in line with the observation o f H om er and H offm an (1999). They acted as a go-between between hospitals and clients, by m aking hospital staff m ore aw are o f the clients’ needs and by referring clients and m aking the clients m ore aw are o f w hat hospital services are available. Supervising CRW s helped to im prove the supervisors’ skills and know ledge o f disability, as well as their understanding o f local custom s and beliefs. A lthough the questionnaire did not contain an initial open-ended question on w hat supervision was understood to be (a possible shortcom ing), the authors are confident that the list o f supervision activ itie s that had to be ra te d was com prehensive, as it had been devel­ oped in consultation w ith supervisors. S upervision given included elem ents o f adm inistration, education and sup­ port (Hoffm an, 1992). The respondents’ em phasis on their supportive role is in line w ith the finding that CRWs experi­ ence considerable am ounts o f stress due to th eir iso la ted w ork en v iro n m en t, w here they lack resources (K rom berg et al, 1999), and therefore need em otional support and encouragem ent. A lthough sup ervisio n aspects such as ad m in i­ stration and educational activities w ere included, one w ould h av e ex p ec ted a larger than rep o rted em p h asis on adm inistrative tasks, problem solving and im proving the C R W s’ therapy skills during supervision, as these are som e o f the essential elem ents, w hich CO RR E em phasises during the training o f the supervisors o f student CRWs. CRW s have to keep daily client and p erso n al sta tistic s like any oth er governm ent em ployed health worker. T h eir sup ervisin g therapists have to ch eck th ese and h and them in to N orthern Province head office every m onth. T he C R W s’ m onthly statistics are very im portant m onitoring, planning and evaluation tools and have been analysed as part o f an evaluation o f the effectiv en ess o f CRW s b efo re (D olan et al, 1995). T he present findings that not all supervisors w ere convinced that the statistics w ere being done or b eing done accurately, suggests that som e o f the supervisors possibly d o n ’t check the statistics regularly or that the CRW s need further in-service training in the necessity for and the m ethod o f doing statistics. T he CRWs that w ere being super­ vised by the respondents w orked in the com m unity (i.e. in the rural villages 16 SA J o u r n a l o f P h y s io th e ra p y 2001 V o l 57 No 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) TABLE 5. Main problems encountered with supervising qualified CRW's and suggested solutions (summary of responses to an open-ended question) PROBLEM N* % SOLUTION Supervisor doesn't have enough time to supervise fully (e.g. the only therapist in the hospital with a lot o f hospital work) 6 14,3 Do not train more CRWs than the rehabilitation team of that hospital can realistically supervise, as it is unlikely that more professional staff w ill be recruited. Advance planning and regular date setting to ensure supervision time is given high priority. Lack of transport (shortage of hospital cars for therapists to get to the CRW s/ CRWs don't have transport and therefore don't see enough clients) 6 14,3 1 don't know. A transport allowance must be worked out which the CBR manager can help with. Motivate for better transport and gain increased support for supervision from hospital superintendent, region and province. CRWs resent supervision/ suspicion/ see them­ selves a professionals who don't need supervision 3 7,1 This may just require time and getting to know the CRWs better. Make sure receiving continual supervision is part of the job description. Prepare the CRW students for the fact that they w ill always be receiving supervision when qualified. Regular supervision. Tutors o f the CRW training programme to communicate directly w ith the CRWs (not through the supervisors) so they can make independent decisions and feel qualified. N o budget for CRWs and lack of stationary/ photocopying facilities as provincial government is bankrupt 3 7,1 A p p ly pressure at hospital level to motivate for a budget. CRWs need their own budget for stationary and equip­ ment. The hospital doesn't even have money for therapy departments. Increase pressure at provincial level to ensure that CRWs are considered when budgets are being drawn up and allocated. Actually taking the step to get started formally, the supervisor not making time to get through the forms/ handouts to familiarise herself with them and not understanding the mechanism of supervision 3 7,1 A formal induction in supervising qualified CRWs to new therapists, especially if they come from another country (a pile o f forms to go through is not helpful, half a day with someone from the training programme would be more helpful). Head office to encourage new therapists to spend a day observing another therapist doing supervision. N o agreed standards against which performance can be m onitored/ difficulty monitoring CRWs (what are they d o in g / work q u a lity / how much work) 2 4,8 Literature search, research, local negotiation. M onitoring may just require time and getting to know the CRWs better. CRWs are not completing paper work properly so they are difficult to promote 2 4,8 Supervisors to improve their own supervision and paperwork and motivate the CRWs to do the same CRWs don't understand professional etiquette, responsibility and accountability/ have a poor w ork ethic 2 4,8 W ork for registration with the Health Professions Council o f South Africa Other 15 36 Other TOTAL 42 100 TOTAL * N = number o f responses; the 13 respondents gave a total o f 42 responses w here they live and in villages close by) most o f the time and were being super­ vised in their villages and not in the hospital, in line with what they and their su p erv iso rs had been tau g h t during student CRW training. This practice is advocated by the W orld H ealth O rga­ nisation (1994), as it helps to ensure that a com m unity based service is delivered. S om e p arts o f su p erv isio n such as checking adm inistrative planning and sta tistics can, how ever, be do n e at SA J o u r n a l o f P h ysio th e ra p y 2001 V o l 57 No 1 17 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) hospital, perhaps at a time when the CRW s have to com e to hospital for a rehabilitation m eeting. It is, however, o f concern that some CRW s were hospital based, although they seem ed to be w ork­ ing in the com m unity m ost o f the time. A nother area for concern was that some important elements o f practice, such as com m unity liaison and group w ork (w orking with support groups or groups for health prom otion/disability aw are­ ness) were not em phasised during super­ vision. The CRW s need to be helped to im prove these skills, as these form an integral part o f CBR (O ’Toole, 1991). G roup work and com m unity liaison are difficult activities and this is w here CRW s need support (O ’Toole, 1991; Peat, 1997). Supervising therapists may not feel com fortable with com m unity developm ent activities if they have not received training in these areas, but, if therapy skills alone are m onitored, the com m unity developm ent aspect o f the C R W s’ task (such as gardening, health prom otion, participatory rural appraisal techniques and the action - reflection m ethod) will fall away. Further training in com m unity developm ent and CB R for therapists (Peat, 1997; Schneider, 1996), as well as learning from CRW s, are possible solutions. S upervision o f CRW s was in process in all the areas covered by the respon­ dent group, ex cep t fo r one, a n o n ­ governm ental organisation, w here the CRW s did not w ant to be supervised. This is a concern, as w ithout sup ervi­ sion any C B R pro gram m e m ay fail (Taukobong, 1999). R eceiving sup er­ vision is part o f the C R W s’ scope o f practice. A lthough the C R W s’ overall response to supervision was positive, resentm ent or suspicion about supervi­ sion was reported by three supervisors. This may com e about if supervision is not regular or if there is a poor relation­ ship between the supervisor and the CRW. W hilst a recently qualified CRW will accept close supervision, a more experienced CRW w ho has had super­ vision for m any years may see close supervision as a lack o f trust. The expe­ rienced CRW still needs supervision, but in a way that gives her some form o f rec o g n itio n fo r h er ex p erien c e (V anneste, u n pub lished), perhaps by putting the em phasis on the sup ervisor’s supportive role. Resistance to supervi­ sion can be overcom e by com bined CRW and supervisors w orkshops on supervi­ sion, such as a provincial w orkshop held in 1998 in Pietersburg. Local m eetings within rehabilitation teams can also help to rebuild trust and re-instate regular supervision. S u p erv isio n o f q u alified CRW s required a considerable tim e-com m it- ment. As m ost supervisors were in hos­ pital posts, they had to carefully balance the tim e spent in the hospital and in the com munity, in order to be able to deliver the best possible service. Lack o f time for supervision is a very com m only described problem w ithin the health sector (Jung and T ryssenaar, 1998). H owever, by m aking CRW supervision a priority, a therapist has a w ider impact on disability prevention and rehabilita­ tion than sim ply dealing with one client at a time at a hospital level (H om er and H offm an, 1999). T he lack o f a CRW budget and resources was a w idely felt problem . Lack o f transport, particularly to reach the C R W s’ villages, is a problem in m any p arts o f the w orld (R e h a b ilita ­ tion World Health O rganisation, 1994). A ccording to the w hite paper for the transform ation o f the health system in South A frica all health professionals should serve all the people in their catchm ent areas, not only clients attend­ ing hospitals (D epartm ent o f Health, 1997). The allocation o f hospital vehi­ cles to therapists for supervision visits should therefore be a high priority. The reh a b ilita tio n sta ff in an area o f K w azulu-Natal have solved this pro­ blem by fundraising for a C B R vehicle, which they now use for supervision. Transport can in m any cases be shared (R ehabilitation World H ealth O rgani­ sation, 1994), e.g. the therapist could go out to the C R W ’s village with a m obile clin ic and co n tin u e the su p erv isio n on foot. Vanneste (unpublished) used bicycles and m otorcycles for CRWs and supervisors in Rwanda. S upervisors need support because o f the various stress-evoking aspects o f supervision. A key tim e for support is during transition into the role o f a supervisor (H om er and H offm an, 1999). M ore support for the supervisors o f CRW s is needed from superintendents and provincial head office. Superinten­ dents w ould benefit from more exposure to and updates on the w ork o f their C RW s. T he p ro v in cial h ead office needs to define a strategy for offering more support to supervisors. CORRE offers a lot o f support to the supervisors o f CRW students (H om er and Hoffman, 1999), but less to supervisors o f qualified CRW s, thinking that supervisors would continue in their role after the CRW student qualified and provide in-service train ing for new sup erv iso rs. Som e supervisors who were not involved in student CRW training recognised their own lack o f know ledge about CBR and requested orientation. The results o f the study showed a need for standards and protocols to guide the C R W s’ work. During student training, C O R R E defines the roles o f supervisors and students. Student super­ visors attend a transitional supervisors w orkshop that looks at the role o f quali­ fied CRW s and supervisors. W hen this research w as condu cted, supervision w as largely determ ined by the local hospitals, hence the need for provincial protocols. The process o f developing a C B R m anagem ent manual (containing m onitoring docum ents to address stan­ dards and protocols, based on a system used in Rwanda (Vanneste, unpublished)) had been started in 1996 and a CBR m anager was appointed towards the end o f 1997. It was established that com ­ pliance with the existing m anagem ent guidelines was poor, possibly because there had not been a CB R m anager to drive the process and not everyone had felt part o f it. A new task team including all stakeholders was formed. This group planned and ran a w orkshop in 1998, designed to use existing docum ents and the experience o f stakeholders as tools to produce w orkable, acceptable CBR m anagem ent guidelines. A fter further discu ssio n s and am endm ents by the desig n ated task team , the w orkshop a g re e m e n ts w ere c o m p ile d as the Northern Province CBR m anagem ent m anual (1998). This manual was im ple­ m ented in August 1998, and following a two year trial period an evaluation is now required. 18 SA J o u r n a l o f P h y s io th e ra p y 2001 V o l 57 No 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) RECOMMENDATIONS M ore em phasis should be placed on com m unity developm ent, group work and checking the C R W s’ adm inistration (including statistics) during supervision. Supervisors also need further training in com m unity developm ent and CBR. R e a listic hum an reso u rce p lannin g, including lim iting the num ber o f CRW s trained to the am ount o f supervision available in an area can help to keep the su p erv isio n load m anageable. Supervising therapists should continu­ ing lobbying the support o f their super­ intendent in term s o f the provision o f a C B R budget and resources, such as transport. Practical m easures such as supervising small groups o f CRW s at the sam e tim e may also help to reduce the driving load and expenses. CRWs and su p erv iso rs can fu n d raise for resources. T he provincial head office needs to offer m ore support to super­ viso rs o f CRW s. In addition, m ore w orkshops for supervisors o f qualified CRW s and support for new supervisors are strongly recom m ended. CONCLUSION T he supervisors o f CRW s saw many benefits o f having CRW s as part of the rehabilitation team. Supervision of q u alifie d CRW s was in place and despite som e problem s experienced, the su p erv iso rs w ere p o sitive about it. Supervisors o f qualified CRW s would like to have m ore supervisors w ork­ shops and requested help from the CBR manager. T he CB R m anager’s post was filled for one year, after which funding for the post stopped. N egotiations are under way at present to establish a CBR m an ag em en t team or to ap point a CBR m anager in a N orthern Province post. It is clearly apparent that the super­ viso rs o f qu alified CRW s continu e needing support, due to the m ulti-skilled nature o f this task. The CBR m anage­ m ent team / m anager could provide some o f this support. ACKNOWLEDGEMENTS T hank you to all the supervisors who participated in this research. 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