Clinical supervision of healthcare trainees (e.g., students, interns, fellows, residents) has long been cited as an important component of provider preparation across specialties (Terry et al., 2020). Integration allows a supervisor to identify trainee strengths, while providing constructive feedback in order to foster the enhancement of professional competencies and evidence-informed practices. It further allows a supervisor to monitor the trainee’s quality of services and areas for improvement to not only protect patients, but gatekeep the field (Board of Educational Affairs Task Force on Supervision Guidelines, 2014). Although a standard for healthcare training, supervisors were met with unforeseen challenges prompted by the exponential spread of the coronavirus 2019 (COVID-19) pandemic, prompting a rapid shift from traditional face-to-face (F2F) services to the use of technology to provide continued supervisory experiences. Despite an increasing amount of literature across healthcare specialties highlighting how the integration of technology with supervisory practices can lead to outcomes comparable to traditional F2F methods in terms of rapport, clinical focus, and educational attainment (Jordan & Shearer, 2019); the idea of telesupervision has demonstrated variability in terms of definition and application within the literature. As a result, the following brief discussion aims to outline considerations for supervisory practices in the age of technology.

Telehealth’s Role in Accessible Healthcare

Telehealth, or the integration of telecommunication technology with healthcare services, has demonstrated rapid expansion in response to the COVID-19 pandemic. While identified as having several unique benefits over traditional F2F practices (Gurney et al., 2021), such as convenience and reduced costs for patients (e.g., gas expenses, parking fees), telehealth has also been repeatedly identified as a means to overcome geographic, socioeconomic, cultural, and language challenges that act as barriers to access among those underserved and of minority status (Bailey et al., 2021). As a result, telehealth holds promise as a means to reduce disparities and foster equity, although significantly more work and infrastructure is required to make this a reality for the countless who continue to remain in need (Haynes et al., 2021).

The Dichotomous Focus of Telesupervision

In line with the expansion of telehealth, supervision has evolved. Telesupervision is the supervision of a trainee from a distance through the use of technology (e.g., video, telephone, email). Using this broad definition, the supervision can target a trainee’s use of either F2F or telehealth services. For example, a supervisor in an academic medical center can connect to a rural outreach trainee via videoconferencing and discuss either (1) the trainee’s use of technology to provide distance care (i.e., telehealth) or (2) the trainee’s F2F practices with a patient in the rural setting.

Despite advances, regulatory bodies have not fully caught up to the changing training methods. For instance, while many licensing boards and accrediting bodies have historically limited the amount of supervision that could be provided via electronic means (versus F2F), such requirements were heavily, and potentially temporarily, modified or waived in response to COVID-19, with many allowing for greater flexibility to meet trainee needs (e.g., American Psychological Association, 2020). Nevertheless, regulatory bodies must continue to utilize available literature to clarify the role of telesupervision, as well as any restrictions in healthcare training.

Targets and Methods of Providing Telesupervision

Technology can be applied to either live or scheduled (i.e., non-live, delayed) supervisory practices, whether occurring through individual or group formats. Live telesupervision allows for in-the-moment monitoring of the trainee’s performance, allowing for concrete and specific feedback. It also allows an opportunity to address challenges before finishing the appointment, giving the trainee an opportunity to remedy any ongoing patient-related issues (e.g., crises, incorrect information provided by trainee). As live supervision is likely time-limited due to it taking place during a trainee’s patient visit, it is often supplemented with scheduled supervision. Scheduled supervision allows for a more thorough discussion, evaluation, and reflection of the trainee’s performance.

Whether live or scheduled, targets of supervision should be multifaceted. Common targets include, but may not necessarily be limited to, the trainee’s clinical skills, interpersonal skills, documentation skills, ethical/legal adherence, and telehealth-specific skills. First, in addition to the trainee’s knowledge of general evidence-informed practices, supervision should focus on the trainee’s ability to adapt known F2F methods to the novel telehealth modalities while maintaining fidelity. Interpersonal skills should also be evaluated, including a trainee’s ability to effectively foster rapport via the selected telehealth technology. Additionally, tele-etiquette (e.g., dress, setting, speech volume) should be evaluated, including the trainee’s ability to effectively convey their desired messages via technology without a disruption to the patient care. For instance, the trainee must learn to pause after speaking via video to avoid talking over the patient and having one of the speakers cut off from the video program. To ensure that the trainee captures what occurred during session, administrative components should also be supervised. More specifically, documentation of the telehealth practice, including what modality was used, where the patient was at the time of service (if applicable), where the trainee was at the time of service (if applicable), if there were any technological issues, and an indication if any time was lost in the service, has each been suggested for documentation (Perle, 2021a). The trainee’s knowledge of ethics and legality should also be formally reviewed during supervision. In addition to focusing on current guidelines and differences from traditional ethical and legal mandates provided by guiding organizations, licensing boards, and governmental agencies, supervision should explore any cross-state or cross-country telehealth use, or intention. Finally, telehealth skills themselves should be reviewed. Such supervision can outline a trainee’s decision-making process for the selection of specific telehealth methods, how the literature advocates for such methods for the specific individual and demographic/cultural factors, how to coach patients to appropriately utilize the telehealth methods, and how to problem-solve technological issues that may arise.

Regardless of supervision targets, which may vary by a trainee’s responsibilities and provision of services, it should be noted that different healthcare programs have varying standards for the use of live and scheduled supervision, as well as requirements for recorded versus self-reported data from trainees. As a result, supervisors must be knowledgeable of current field and training standards to ensure adherence. Common types of telesupervision approaches that may be used include (Perle, 2021b; Wood et al., 2005):

Live – Monitoring Only

In this type of supervision, the supervisor observes the trainee in real-time from a distant location without directly contributing to patient care. For example, a supervisor can connect as a third party to a telephone call or video visit and observe the full trainee appointment with their audio and video muted to avoid interrupting.

Live – Monitoring with Intervening

In this type of supervision, the supervisor both observes from a distant location and contributes to the visit in a co-provider model. For example, a trainee, supervisor, and patient can all connect to the same video appointment. The trainee can take the lead, with the supervisor supplementing information and assessments, as needed. This model allows for a developmental approach in which a trainee is given greater amounts of responsibility and autonomy in the patient care as they develop. Similarly, as a trainee masters skills, they are provided with opportunities to apply more complicated approaches with more complex patients. It also allows the supervisor to model techniques with the patient.

Live – Bug-in-the-Ear

In this type of supervision, the supervisor observes the trainee’s session from a distant location (i.e., monitoring only), while providing real-time communication only audible to the trainee through a one-way receiver placed in the trainee’s ear. For example, a trainee can meet with a patient F2F at a rural site, with a supervisor monitoring from a distant location via video. Throughout the visit, the supervisor provides in-the-moment feedback regarding positives (with associated labeled praise for reinforcement), and instructions on how to modify approaches to optimize outcomes, as needed.

Live – Step-out

In this type of supervision, the supervisor observes the trainee’s session from a distant location with or without intervening (i.e., could involve monitoring only, monitoring with intervening, or bug-in-the-ear). At a set time in the appointment, the trainee “steps out” of the appointment to consult with the distant supervisor to review strengths and challenges of the session before returning to the patient to address any issues raised in the supervision, and finish the appointment. For example, a trainee can meet with a patient either F2F or via video. Two-thirds of the way through the appointment, the trainee tells the patient they will consult and return shortly, at which point they connect with the supervisor via video, telephone, email, messaging program, or another agreed-upon method for feedback. Following the feedback, the trainee returns (sometimes with the supervisor virtually present), applies feedback, and completes the visit.

Scheduled – Case Review

In this type of supervision, trainees present the supervisor with pertinent patient information that is reviewed by the supervisor before feedback is presented. Pertinent information can include files, notes, or other clinical documentation. For example, a trainee can use an encrypted email system or electronic health record to send the supervisor their appointment notes to be reviewed together at a scheduled time.

Scheduled – Audio and/or Video Review

In this type of supervision, trainees present the supervisor with audio and/or video recordings of the appointments that are reviewed before feedback is provided. For example, a trainee can use a secure file sharing program to send the supervisor a video recording of a medical examination to be collaboratively viewed during the scheduled supervision.

Known Benefits of Telesupervision

Despite additional outcome research being required to more critically evaluate telesupervision compared to traditional F2F methodologies, the literature has highlighted multiple benefits of using technology in supervision to foster an ethical, legal, safe, and evidence-informed practice (Inman et al., 2019; Jordan & Shearer, 2019; Martin et al., 2017). First and foremost, the use of telesupervision allows for increased accessibility to evidence-informed training and expert advice. Such expertise can be for both general feedback of performance, as well as access to more specialized supervisors who can provide greater insight into more complex populations or assessment/intervention procedures. In this way, the use of technology in the supervisory practices can promote equity and inclusion to a greater degree than traditional F2F methods by exposing trainees to a larger pool of supervisors not limited to those only within the trainee’s immediate geographical area. Such supervisors can provide vital specialized knowledge that can be used by trainees in the immediate and future to reach underserved or marginalized populations. In addition to general knowledge, this approach allows for a greater breadth of knowledge bases the trainee can integrate into their service repertoire (e.g., culturally adapted methods). Complimenting expert supervisors is the availability for increased consultation from the trainee’s peers. Similar to supervisors, peers can be from different locations, have different training experiences, and have exposure to diverse populations or care methods less known to the trainee. Related to the logistics of supervision, the use of technology can foster reduced costs associated with travel for the trainee or supervisor. These reduced costs can address the geographical barriers precluding consistent F2F supervision, especially for those supervisor-trainee dyads that are distant from one another (e.g., urban to rural settings; large distances within a densely populated city). Relatedly, technology encourages increased scheduling flexibility that comes with not having to factor in the time to relocate for the supervision. One of the more unique suggested benefits associated with telesupervision is the potential to reduce the perceived impacts of hierarchical issues between the trainee and supervisor that may present in a traditional F2F process. For example, some have documented that electronic forms of communication have the potential to lower social inhibitions. As applied to telesupervision, this increase in comfort and reduction of a clear power differential that comes from being in a supervisor office can increase the trainee’s comfort, leading to a more open flow of communication and identification of both strengths and areas of improvement for their practice. Should a trainee use telehealth, telesupervision can also allow trainees to become familiar with the novel technology in a controlled, guided, and safe setting before using with real patients. Finally, exposure to technology can have an indirect benefit of fostering skills that can be applied via telehealth in the future, encouraging outreach efforts to underserved areas without requiring a provider to relocate.

Process Differences and Challenges of Telesupervision Compared to F2F Supervision

Despite similarities, several differences exist between telesupervision and traditional F2F methods making adaptation essential to successful outcomes. Perhaps the biggest change relates to possible confidentiality issues arising with the use of technology to communicate from a distance. Issues can include the potential for people listening to conversations from outside of the room, as well as data breaches. Additionally, telesupervision requires a greater level of planning, including the formulation of a “plan b” should the primary telesupervision method become unviable (e.g., internet goes off prompting use of telephone versus video). Similarly, the supervisor must work with the trainee to plan for emergencies, as the distant supervisor may not be readily available. As part of this process, supervisors should outline what are desired means of communication during crises to avoid challenges (e.g., avoiding email to inform of a crisis due to the possibility of delays in transmission and viewing). Further, due to the technological nature, supervisors and trainees may be more prone to distraction during supervision (e.g., receiving emails), requiring self-monitoring and/or intervention (e.g., close email programs) to remedy.

Should a trainee be utilizing telehealth in their patient care, telesupervision must expand in scope to encompass both clinical work and the technological components. In such a situation, it is suggested that a four-pronged approach be utilized. Initially, the supervisor should review, assess, and provide feedback regarding the trainee’s general clinical activities, including how they were able to develop and maintain rapport, what went well in the visit, and what did not go well. Building from a discussion of general care, focus should be paid to technological factors. This portion of supervision can outline any technological issues that presented and how they were (or could be) addressed, as well as what components went well and did not. The integration of the two should then be reviewed, with a focus on how the technology interacted with the clinical services to enhance or hinder the healthcare services. This discussion can outline required adaptations of traditional F2F techniques, and how interactional issues were (or should be) problem-solved. Finally, the supervisor and trainee should create a plan for the next appointment including what needs to be done clinically, how technology will be used, and how any issues that presented in past visits will be addressed.

Regardless of subject matter, the addition of possible technological issues that require time to address suggests that supervisors should consider re-budgeting their time allotment when meeting with trainees. For example, supervisors can increase the length of the meetings, or reduce what is discussed at each supervision. This becomes increasingly important if telehealth services are provided in which more topics (i.e., four-pronged approach) will be reviewed than historically necessary (Martin et al., 2017; Wood et al., 2005).

One of the more unique supervisory considerations that arise from the use of technology is the possibility of cross-state supervision (Tarlow et al., 2020). More specifically, supervisor’s licenses are generally tied to a specific jurisdiction of practice, limiting their ability to practice outside of that state without additional licenses or being part of an interjurisdictional compact. Should supervision be provided across state lines, the supervisor should not only be aware of licensure and practice-related guidelines of their home state (i.e., location of license), but where the trainee is providing services, as well as where the patient is located. This becomes especially important with regard to the management of emergencies, abuse reporting, data security, and legal differences across jurisdictions (e.g., red flag laws, involuntary hospitalization).

Qualities of Effective Telesupervisors Suggested to Prevent and Mitigate Challenges

To mitigate identified challenges, the literature has highlighted qualities of “effective” telesupervisors (Yellowlees, 2019). First, the supervisor should have excellent clinical skills, including an ability to adapt clinical recommendations to technological modalities. Second, the supervisor should have good organizational abilities in order to plan the supervision sessions (i.e., balance topics needed to be discussed), maintain schedules without interruptions, and have back-up plans should the primary methods provide unviable. Third, supervisor should also have refined note-taking skills to chronicle the supervisory sessions, including detailing any arising challenges that could influence patient care or the trainee’s ability to move on in their education. Fourth, as telesupervision can occur through a variety of mediums that require tailored communication, supervisors must recognize the need to enhance specific teaching methods via different mediums (e.g., the need to increase detail and specificity of a clinical technique via an email communication due to the inability to directly demonstrate and answer questions in real-time). Fifth, the supervisor must have an appropriate understanding of technology to not only use it themselves, but assist the trainee in troubleshooting. Such understanding also includes the ability to integrate assistive technologies, such as digital white boards, or programs to securely share documents in a secure manner. Finally, the supervisor must have a high level of patience, as the use of technology can add extra “headaches” for both the supervisor and trainee (e.g., lag, connection issues, delayed emails), leading to escalating tensions.

Training Needs for Telesupervisors

Beyond general clinical knowledge, to ensure the qualities as an effective telesupervisor, individuals must be knowledgeable on multiple topics, which in some cases requires their own training prior to working with trainees (Kilminster & Jolly, 2000). First, telesupervisors must be knowledgeable on traditional supervisory practices and models, as well as methods of providing constructive and productive feedback (Busari et al., 2005). Second, supervisors must be knowledgeable of differences between traditional supervision and telesupervision, including means of accounting for differences and modifying clinical practices to best suit trainee education. Additionally, telesupervisors must learn to adapt styles to account for less nonverbal cues than would be available in a traditional F2F supervision (Soheilian et al., 2022). Finally, if telehealth is utilized, supervisors must be aware of telehealth-relevant competencies (see Table 1).

Table 1 Supervision-relevant telehealth competenciesa
Full size table

Field Next Steps

As healthcare evolves, telesupervision offers an efficient, largely accepted, cost-effective, and evidence-informed method of training healthcare providers both as a primary supervision modality, and as a supplement to F2F (i.e., hybrid; Bernhard & Camins, 2021; Phillips et al., 2021; Thompson et al., 2022; Wood et al., 2005). The current discussion defined telesupervision and possible methodologies, while providing a framework for future discussion and research activities. Ultimately, with increased prevalence, supervisors must adapt to the new technological format. In doing so, telesupervision can assist in meeting the growing demand for evidence-informed healthcare practices, while assisting in fostering equity and reaching underserved populations by providing a clinical foundation to best help these individuals.