Clinical supervision and quality of nursing care among nurses in Bangladesh


Bishwajit Mazumder1, Beauty Rani Suter1, Nazma Begum1, Mizue Hiura2

1Nursing Instructor, Dhaka Nursing College, Dhaka.

2Nursing Education Expert, The Project for Capacity Building of Nursing Services, Dhaka.

*Corresponding Author E-mail:



Aim: This descriptive correlational study aimed to identify the perception of and to examine the relationship between quality of nursing care and supervision among nurses in Bangladesh. Background: The quality of nursing care is ensured by clinical supervision. However, studies assessing nursing care quality from nurses’ viewpoints in Bangladesh are limited. Method: Data were collected by using self-administered questionnaires answered by 180 random registered nurses. These questionnaires included the Scale of Perception of Nursing Activities that Contribute to Nursing Care Quality (EPAECQC) questionnaire and the Perception of Supervisory Support (PSS) scale. Result: In this study, most of the participants were female, the mean age was 38 years, and over 60% of the participants had over 10 years of work experience.  The EPAECQC score (mean [M] = 3.21, standard deviation [SD] = 0.298) and PSS score (M = 4.07, SD = 0.409) revealed a moderate positive correlation between quality of nursing care and supervision (r = 0.41, p < 0.01). The dimensions of “Patient satisfaction,” “Nursing Care Organization,” and “Well-being and self-care” in EPAECQC had a high impact on the quality of nursing care. Conclusion: Enhancing supervision helps improve the quality of nursing care. Implications for Nursing management: Authorities and organizations should maintain job resources on supervisory and organizational support for nurses to provide a high quality of care.


KEYWORDS: Health Services, Managed Care Programs, Patient Satisfaction, Bangladesh.




Delivery of high quality health care ensures healthcare service sustainability through health promotion by multidisciplinary healthcare providers. Nursing is crucial for providing quality assurance in healthcare services, and nurses hold vital positions in improving the quality and performance of nursing care1,2 to meet clients’ needs effectively.


The quality of care is the degree to which the healthcare services provided to the people increase the likelihood of achieving the desired outcomes3. It is an integral part of nursing care for the continuous improvement of effective care and better patient outcomes.


The quality of nursing care has been a significant contribution to patient health4, and its outcome may be measured through patients’ satisfaction with nursing care5,6,7,8 and the determination of care standard and assessment of practice9. Nurses’ awareness of quality nursing care can also be an outcome measure; however, studies assessing the quality of nursing care from nurses’ perspective are limited10.



Everyone desires a quality nursing care, which is promised by nurses with the help of a supportive work environment and clinical supervision11. Clinical supervision is a process of educational and professional support12 that encompasses the nurse’s emotional support13 and the support for client goal achievement to enhance the quality of nursing care14. It enables a continuum of reflective critical analysis of care to ensure the provision of quality nursing care to patients, and it promotes a safe and effective practice and maintains standards and accountability, with combined professional development and personal growth15,16. Supervision is one of the organization’s responsibilities, and its quality might influence the quality of nursing care in the hospital setting.


In Bangladesh, the quality and delivery of health care are severely deficient. Bangladesh has a nurse population of 2.99/10,000, a doctor–nurse ratio of 1.79:1, and a shortage of more than 280,000 nurses17. Improvement of the quality of health care, including the quality of nursing care, has been extremely limited and unsatisfactory. The Bangladesh health sector is facing challenges affecting the work on quality improvement.


However, reports on the quality of nursing care and supervision from nurses’ viewpoints are still unavailable in Bangladesh. Hence, this study aimed to identify the nurses’ perception of the quality of nursing care and clinical supervision support at a tertiary-level hospital in Bangladesh.



Sample selection:

In this descriptive correlational study, we explored the level and relationship between the perceptions of the quality of nursing care and supervisory support among nurses in Bangladesh. We collected data at a public, referral, and tertiary-level hospital in Dhaka, Bangladesh from June to September 2019.


We selected 180 nurses by a simple random sampling technique. The estimated sample size was calculated for an acceptable minimum level of significance (α) of <0.05, an expected power (1-β) of 0.80, and an estimated population effect size of 0.25 (ᵞ)18.



In this study, the questionnaires consisted of three sections that focused on nurses’ demographic information (age, gender, education level, length of work experience, marital status, and employment situation), quality of nursing care, and the Perceptions of Supervisory Support (PSS) scale.


Quality of nursing care was measured using the Scale of Perception of Nursing Activities that Contribute to Nursing Care Quality (EPAECQC)19. This scale was developed to determine nurses’ perception of the activities that contribute to nursing care quality. It contains 25 questions divided into seven dimensions as follows: Patient satisfaction, Health promotion, Prevention of complication, Well-being and self-care, Functional readaptation, Nursing care organization, and Responsibility and rigor. These questions are rated by a 4-point Likert scale (1= never, 2 = rarely, 3 = often, 4 = always). The higher the score, the higher the level of perception of nursing care quality in an organization.


Clinical supervision was measured by the PSS scale 8, which contains 19 items in three dimensions, namely, “Emotional support,” “Support for client goal achievement,” and “Professional development support.” The items were rated by a 5-point Likert scale (5 = strongly agree to 1= strongly disagree). A higher score indicates a positive outcome that accrues from supervision.


The pilot study was conducted to 20 nurses working in the same hospital. For the internal consistency, the Cronbach’s alpha coefficient was 0.80 for quality of nursing care and 0.82 for supervision, indicating that these instruments are reliable.


Statistical Analysis:

Data were analyzed using the SPSS (version 20). Descriptive statistics were used for frequency, percentage, mean (M), standard deviation (SD), and range. The internal consistency of the scale was analyzed by Cronbach’s alpha coefficient. As indicated by the Kolmogorov–Smirnov one-sample test, the EPAECQC and PSS scale scores were not normally distributed. The difference in each scale between groups was examined by nonparametric tests such as the Mann–Whitney U test and Kruskal–Wallis test. Furthermore, the relationships between quality of nursing care and supervisory support were examined by Spearman’s correlation coefficient (r). The independent variables associated with the perception of the quality of care were determined by multiple linear regression analysis. All tests were two-tailed, and the alpha level for significance was 0.05.


Ethical Consideration:

The International Review Board and the National Institute of Advanced Nursing Education and Research approved this study. All participants provided an informed consent. They were assured of the anonymity and confidentiality of their responses and that only the overall results were presented to the nursing administrators to design the needed managerial interventions.



Table 1 summarizes the demographic information of the 180 participants. The mean age was 38.1 years (SD = 9.4, range: 24–59), and most of them were female (n = 139, 77.2%), married (n = 149, 82.8%), and Muslim (n = 135, 75%). More than half of them had a Diploma in Nursing (n = 101, 56.1%), and others had a Bachelor of Science (BSc) in Nursing or a higher degree (n = 79, 43.9%). Among them, 62.2% had a work experience of over 10 years, and 65.6% had a monthly salary of 30,000 – 40,000 Takas. In 2018, the average income of nurses who worked in a public hospital was approximately 35,000 Takas13. Participants were selected from the medicine ward (n = 84, 46.7%), surgery ward (n = 70, 38.9%), and postoperative ward (n= 26, 14.4%), and most of them chose dayshift duty (n = 151, 83.9%).


Both the EPAECQC and PSS scale obtained a Cronbach’s alpha coefficient of 0.72, which suggests that they are reliable21.



Table 1. Nurses’ demographic characteristics (n = 180)

Demographic characteristics

Frequency (n)




M = 38.1, SD = 9.4, Range: 24–59




















Marital status



























Education in nursing




Diploma in Nursing




Bachelor or/and over



Working experience in nursing


1–10 years




≥11 years



Monthly salary (Taka)








40,001–50,000 or more



Patient wards




Medicine ward




Surgery ward




Postoperative ward



Chosen shift of duty
















Table 2 shows the mean scores of the EPAECQC. The mean overall score of EPAECQC was 3.21 (SD = 0.298), and among the seven dimensions, “Patient satisfaction” (M = 3.62, SD = 0.348) obtained the highest mean score, followed by “Nursing care organization” (M = 3.56, SD = 0.482) and “Nursing care organization” (M = 3.56, SD = 0.482). “Prevention of complications” (M = 2.89, SD = 0.619) and “Responsibility and rigor” (M = 2.97, SD = 0.564) showed the lowest mean score. Among all items, Nurses refer problematic situations to other professionals, according to the social mandates (M = 2.67, SD = 1.029) and Nurses identify the health situation of the population and the resources of patient/family and community (M = 2.74, SD = 0.965) showed the lowest value.


Table 2. Mean, standard deviation, range, and the level of dimensions of the quality of nursing care (n = 180)


M (SD)


M (SD)

Patient Satisfaction

3.62 (.348)

1.  Nurses show respect for the abilities, beliefs, values, and desires of a patient while providing nursing care.

3.57 (.661)

2.  Nurses are constantly seeking to show empathy in interactions with the patient (patient’s family).

3.67 (.537)

3.  Nurses involve significant cohabitants of the individual patient in the nursing care process.

3.62 (.571)

Health Promotion

3.15 (.518)

4.  Nurses identify the health situation of the population and the resources of patient/family and community.

2.74 (.965)

5.  Nurses use hospitalization time to promote healthy lifestyles.

3.31 (.807)

6.  Nurses provide information that generates cognitive learning and new abilities in the patient.

3.40 (.774)

Prevention of Complications

2.89 (.619)

7.  Nurses identify potential problems of the patient.

2.90 (.946)

8.  Nurses prescribe and perform interventions to prevent complications.

2.89 (.921)

9.  Nurses evaluate the interventions that help prevent problems or minimize undesirable effects.

2.87 (.865)

Well-being and Self-care

3.42 (.445)

10.   Nurses identify patient’s problems that will help improve the patient’s well-being.

3.61 (.593)

11.   Nurses prescribe and perform interventions that will help improve the patient’s well-being and daily activities.

3.48 (.689)

12.   Nurses evaluate the interventions that help improve the patient’s well-being and daily activities.

3.24 (.835)

13.   Nurses address problematic situations identified that will help improve the patient’s well-being.

3.34 (.702)

Functional Readaptation

3.14 (.479)

14.   Nurses ensure continuity of nursing service provision.

3.34 (.793)

15.   Nurses plan discharge of hospitalized patients in health institutions according to each patient’s needs and community resources.

3.01 (1.008)

16.   Nurses optimize the abilities of the patient and his/her significant cohabitants to manage the prescribed therapy.

3.30 (.838)

17.   Nurses teach, instruct, and train patients for their individual adaptation and teach, instruct, and train patients on what is required for their functional readaptation

2.92 (.971)

Nursing Care Organization

3.56 (.482)

18.   Nurses know how to handle the nursing record system.

3.59 (.632)

19.   Nurses know the hospital’s policies.

3.52 (.655)

Responsibility and Rigor



20.   Nurses show responsibility for the decisions they make and for the acts they perform and delegate, aiming to prevent complications.

3.31 (.756)

21.   Nurses show responsibility for the decisions they make and for the acts they perform and delegate, aiming to ensure well-being and self-care of patients.

3.03 (.951)

22.   Nurses show technical/scientific rigor in the implementation of nursing interventions, aiming to prevent complications.

2.83 (1.044)

23.   Nurses show technical/scientific rigor in the implementation of nursing interventions that help improve the patient’s well-being and daily activities.

2.88 (.999)

24.   Nurses refer problematic situations to other professionals, according to the social mandates.

2.67 (1.029)

25.   Nurses supervise the activities that support nursing interventions and the activities they delegate.

3.11 (.925)

Quality of Nursing Care (Total)

3.21 (.298)

1 = never, 2 = rarely, 3 = often, 4 = always


Table 3: Perception of Supervisory Support scale (n = 180)


M (SD)


M (SD)

Emotional support



1.    Feel more positive about your job?

4.39 (0.942)

2.    Feel as if you are part of the team?

4.28 (1.047)

3.    Feel that your work was acknowledged?

3.84 (1.142)

4.    Leave supervision feeling energized?

3.82 (1.238)

5.    Feel more effective/competent as a worker?

4.07 (0.952)

6.    Look forward to supervision?

2.88 (1.473)

7.    Feel more positive about your agency?

4.16 (1.004)

8.    Think that supervision improved your relationships with team members?

3.88 (1.122)

9.    Think that supervision improved your relationship with your supervisor?

3.98 (1.051)

10. Feel that your stress was reduced?

3.50 (1.146)

Support for client goal achievement



11. Achieve better alignment between client’s goal and your goal for client?

4.03 (0.927)

12. Gain new perspective on client?

4.29 (0.780)

13. Reprioritize your efforts toward a client’s goal?

4.38 (0.727)

14. Gain greater clarity on a client’s goal?

4.18 (0.970)

15. Leave supervision with ideas/suggestions to assist a specific client to achieve a goal?

4.41 (0.722)

Professional developmental support



16. Get feedback on your performance?

4.06 (0.876)

17. Discuss your career development?

4.26 (0.879)

18. Receive coaching or training on job skills?

4.44 (0.840)

19. Discuss productivity?

4.40 (0.843)

Supervision (Total)


4.07 (0.409)


5-point Likert scale: 1 = strongly disagree to 5 = strongly agree


Table 3 lists the mean scores of the PSS scale. The mean overall score of PSS was 4.07 (SD = 0.409), and among the three factors, “Professional developmental support” showed the highest score (M = 4.29, SD = 0.553), followed by “Support for client goal achievement” (M = 4.26, SD = 0.551) and “Emotional support” (M = 3.88, SD = 0.481). Regarding “Emotional support,” the item feel more positive in a job (M = 4.39, SD = 0.942) obtained the highest score, followed by feel more positive in the agency (M = 4.16, SD = 1.004) and feel as if you are a part of the team (M = 4.28, SD = 1.047). Conversely, look forward to supervision acquired the lowest score (M = 2.88, SD = 1.473). For the “Support for client goal achievement,” the items reprioritize efforts toward a client’s goal (M = 4.38, SD = 0.727) and leave supervision with ideas/suggestions to assist a specific client to achieve a goal (M = 4.41, SD = 0.722) showed relatively higher scores than the other items. Regarding “Professional development support,” most items have higher mean scores than the mean overall score, except for getting feedback on your performance (M = 4.06, SD = 0.876).


We examined the statistical difference between the demographics (age, gender, education, salary, work experience, patient wards, and religion) and the EPAECQC and PSS scores as independent variables. We compared two independent groups in age (≤40, >40), gender (male, female), education (Diploma in Nursing, BSc in Nursing or over), salary (30,000–40,000 Taka, 40,001–50,000 Taka, and more), and length of work experience in nursing (1–10 years, ≥11 years). Furthermore, we compared three independent groups based on patient ward (Medicine, Surgery, and Postoperative) and religion (Muslim, Hinduism, and Christian). The PSS scale and salary were statistically different (Z = −2.51, p = 0.012). The score of the higher-salary group (≥40,001 Taka) was higher (M = 103.9) than that of the lower-salary group (M = 83.4). The EPAECQC and the characteristic variables were not statistically different.


Table 4 shows the correlation among the dimensions of EPAECQC and the factors of the PSS scale. The PSS scale positively correlated with EPAECQC (r = 0.412, p < 0.01). Among the three PSS factors, “Emotional support” (r = 0.336, p < 0.01) and “Support for client goal achievement” (r = 0.442, p < 0.01) demonstrated a weak correlation, but not the “Professional development support” (r = 0.095, p = 0.203).


The variables in the PSS scale that had an impact on the quality of nursing care were identified by multiple regression analysis. After converting the data into a logarithm, we conducted a stepwise selection method. The three PSS factors were included in the model. Unlike the “Professional development support” (β = −0.12, p = 0.13), the “Support for client goal achievement” (β = 3.43, p = 0.00) and “Emotional support” (β = 0.19, p = 0.013) were significant predictor variables, thereby regarded as good candidate variables (R = 0.47, R2 = 0.21, p = 0.000). However, none of the variance inflation factors showed multicollinearity (VIF = 1.32).


Table 4. Spearman’s Correlations
















2.Patient satisfaction








3.Health promotion








4.Prevention of complications








5.Well-being and self-care








6.Functional readaptation








7.Nursing care organization








8.Responsibility and Rigor







9.Supervisory Support








10.Emotional support








11.Support for client goal achievement








12.Professional developmental support







Continue Table 4
















2.Patient satisfaction








3.Health promotion








4.Prevention of complications








5.Well-being and self-care








6.Functional readaptation








7.Nursing care organization








8.Responsibility and Rigor







9.Supervisory Support








10.Emotional support








11.Support for client goal achievement








12.Professional developmental support







**Correlation is significant at the 0.01 level (two-tailed).

*Correlation is significant at the 0.05 level (two-tailed).

QNC, quality of nursing care




The sociodemographic analysis in this study showed that most of the participants were female, the mean age was 38 years, and over 60% of the participants had over 10 years of work experience. Our participants may reflect the reality of nursing in Bangladesh, where 90% of the nurses were female and the mean age was 35 years in a public hospital20.


Nurses’ perception of the quality of nursing care:

This study demonstrated that nursing activities contributed to the quality of nursing care in Bangladesh. Based on the mean score in the scale, most participants perceived nursing activities according to the quality standards for nursing care.


Our participants perceived that “Patient satisfaction,” “Nursing care organization,” and “Well-being and self-care” are the most important among all dimensions. Nurses identified such activities as having a higher impact on improving the quality of nursing care. “Patient” satisfaction” was also perceived as the one with the highest impact among nurses in Portugal19.


Patient satisfaction in the quality of nursing care received is a key component of the quality of healthcare services22, and it can be measured by the views of patients and relatives23. Our participants were also aware of the importance of respecting patients' values and showing empathy when interacting with patients and family to improve patient satisfaction.


However, in our study, the activities “Prevention of complications” and “Responsibility and rigor” had a lower impact on improving the quality of nursing care. Nurses perceived that some activities, such as identifying potential problems and performing interventions to prevent complications and referring problematic situations to other professionals according to the social mandates, had a low impact on quality care.


In contrast, a previous study involving hospital nurses in Portugal24 concluded that “Prevention of complications” and “Responsibility and rigor” were highly perceived by nurses as activities that can improve nursing care quality.


In Bangladesh, provision of quality health care has been challenging for nurses for decades. Barriers that prevent quality nursing care are the following: lack of professional recognition, low autonomy in a medical hierarchy, gender inequality with cultural prejudice, staff shortage, low salary, and heavy workload25,26,27.


Despite the widened scope for higher education and the precise evolution of nursing in recent years, nurses still have difficulty in prioritizing clinical practice to prevent complications. Under nurse shortage with fully occupied beds in public hospitals, nurses might be more focused on the disease than health in the clinical setting. Some studies found that nurse activities are only assistance, suggesting that the organization, and the work process are still based on the biomedical model focused on the individual, cure, and illness 28.


In Bangladesh, self-directed learning, critical thinking, and problem-solving have not been emphasized, causing major patient care problems 29. Our results might reflect activities on practice; those less aware activities such as identifying the potential problems for patients and preventing and evaluating complications to minimize undesirable effects, might not be implemented.



The nurses perceived better support by supervisors on “Professional development support,” which includes receiving coaching and training on job skills, discussing productivities, and discussing career development. Regarding “Emotional support,” they seemed to have positive feelings about their work and the agency and felt a part of the team. The study participants worked at a public, advanced medical hospital in the country. Considering social welfare and stability, many nurses seemed to prefer working at public hospitals. They may feel positive about being government employees and part of a team in such an institution. In fact, nurses in Bangladesh who are working in public institutions are more satisfied with their present job than those in private 20.


However, the item of looking forward to supervision obtained the lowest score, and feeling that stress was reduced and leaving supervision feeling energized had relatively lower scores than the average score. For a long time, supervision was regarded as inspection, focusing on error detection and punitive character, in which the supervisor was responsible for ensuring compliance with established activities 28. The nursing supervision process can vary according to the team, organization culture, and the skills and competencies of the supervisor; this variation possibly affects the nurse’s perception negatively in the current practice of nursing supervision.


The high-salary group had a positive perception regarding supervisory support. Monthly income was the best predictor, followed by the work environment, organizational commitment, and job stress27. A higher monthly income might help nurses gain a positive perception of receiving support, personal needs, and their work.


Relationship between quality of nursing care and supervision:

Supervisory support had a significant positive relationship with the perception of quality nursing care. Among the three factors of PSS, “Support for client goal achievement” and “Emotional support” were predictors of nurses’ perception regarding nursing care quality. Hence, these supervisory activities strengthen the awareness of activities related to the quality of nursing care. With the positive effect of clinical supervision on the quality of care for the first-line nurse manager and staff nurses, patient care in the hospital may improve 30. Supervision is necessary in ensuring quality nursing care, leading to improvements in patient care.


Supervision includes assessing nurse’s daily work, work process, and work performance31, building trust32, confidentiality, support33, and empathic experiences, and assisting the health team; all contribute to the improvement of the quality of care34,35.


Nurses can improve and develop their knowledge and skills in their assigned area, provide excellent nursing care, and execute positive performance through supervision.


Currently, the government of Bangladesh has taken many initiatives to improve their nursing profession. Such initiatives include expanding the scope for a higher education in nursing by studying abroad, establishing a recent declaration for improving the nursing profession, and increasing the staff nurses in hospitals. Our results suggest that a high quality of care can be provided if authorities and organizations maintain the job resources such as supervisory support and organizational support for nurses, as well as recruiting and training highly competent nurses.


However, this study has some limitations. The study was conducted in only one public hospital; thus, the results may not be generalizable to all hospital settings. Thus, further study is needed to explore the supervision and quality of nursing care in diverse hospital settings, including private hospitals. Furthermore, the cross-sectional design prevents us from concluding that quality nursing care can be attained by better supervision.



We thank the Project for Capacity Building of Nursing Service (CBNS Project) in Bangladesh, jointly implemented by the Ministry of Health and Family Welfare (MoHFW) and JICA.


Funding sources: This work was funded by JICA for the CBNS Project in Bangladesh.



The authors declare no conflict of interest.



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Received on 12.11.2020          Modified on 30.01.2021

Accepted on 07.03.2021       ©A&V Publications All right reserved

Int.  J. of Advances in Nur. Management. 2021; 9(2):169-175.

DOI: 10.5958/2454-2652.2021.00038.X