Introduction

Telesupervision usage has increased since the onset of the COVID-19 pandemic given the physical distancing and isolation requirements. For healthcare workers in healthcare settings, clinical supervision remains a critical mechanism for obtaining support for their role (i.e., skills, knowledge, and competencies), and for their own mental health and wellbeing at work (i.e., coping with work stressors, and managing burnout) [1,2]. For several professions, clinical supervision is mandated through professional associations, registration guidelines, and/or organisational policies and directives. When face-to-face clinical supervision is not possible, technology such as Microsoft Teams, Zoom, phone, and e-mail tend to be used. This is referred to as telesupervision or internet supervision where supervisors and supervisees meet asynchronously via e-mail or webchat, or synchronously via videoconferencing or phone [3]. Despite the lack of face-to-face or in-person contact, telesupervision still needs to cater to all supervision functions or aspects, namely formative, normative, and restorative, in line with Proctor’s tripartite model of supervision [4]. Formative functions include the supervisee gaining skills and knowledge (e.g., conducting an assessment, making a splint). Normative functions include clinical governance and quality assurance (e.g., compliance with policies, guidelines, protocols). The restorative function is dedicated to supporting the supervisee’s emotional wellbeing at work [4].

Evidence on what makes telesupervision high quality and effective for practicing healthcare workers remains limited. A pre-pandemic systematic review on this topic found a scarcity of studies and called for further studies to add evidence to this area [5]. Another systematic review of physicians’ perceptions of providing videoconference supervision and support to junior doctors in rural areas, also identified a scarcity of studies [6]. Available evidence suggests that telesupervision can be of high quality and effective if set up well [5]. Confirming this, a pre-pandemic multiple-baseline single-case design study in psychotherapy has showed that telesupervision can obtain comparable outcomes as that of in-person supervision, provided the supervisor is effective (i.e., open, supportive, and a good communicator), and technology used is familiar [7].

While pre-pandemic telesupervision research remained predominant in the mental health professions (e.g., psychology, counselling), and in the pre-registration or pre-qualification (i.e., student) and training space, studies of telesupervision practices of registered or qualified healthcare workers, especially in non-mental health areas, remain scarce. A qualitative study of the effectiveness of videoconferencing to support orthopaedic trainees in Queensland (Australia) highlighted the crucial role of selecting the right technology to maximise benefits [8]. Another pilot qualitative study conducted in Victoria (Australia) in 2012 explored views of registrars, supervisors, and patients on the use of a video camera for remote supervision, identifying some highlights and pitfalls. This dataset was re-analysed and published in light of the COVID-19 pandemic [9]. Xavier and colleagues [10] evaluated videoconference delivery of clinical supervision and education of 20 psycho-oncology staff. In this study the supervision component delivered by telephone was rated by 80% of participants as extremely satisfying. These participants also received complementary monthly educational sessions via videoconference [10]. It is noteworthy that all these studies have been conducted in rural areas. However, as Simmons and colleagues [9] point out, telesupervision no longer remains an issue only pertinent to rural areas given its widespread use triggered by the pandemic.

Some information has been made available on telesupervision practices since the COVID-19 pandemic onset. A rapid review of eight COVID-19 studies on the disruptions to clinical supervision practices of healthcare workers and students in healthcare settings documented a surge in the use of telesupervision. Findings indicated that those with prior positive supervisory relationships remained largely unaffected by the switch from face-to-face to telesupervision. Findings also showed that some healthcare workers reported no impact on the quality of supervision following the switch, and that younger participants perceived telesupervision to be less effective compared to their older counterparts [11]. A multi-methods study of 144 health service psychology students that had used both hybrid or blended (i.e., telesupervision and in-person supervision), and telesupervision for clinical training in the United States reported high rates of satisfaction and indicated that telesupervision is highly acceptable and beneficial in this population for training purposes [12]. Examples are also available of COVID-19-related telesupervision practices to support students on placement [13,14]. A survey of healthcare workers in Queensland (n = 250) showed that 16% switched from face-to-face supervision to telesupervision owing to COVID-19, of which 76% reported satisfaction with the switch (unpublished). Given this increasing use of telesupervision and a dearth of evidence in this area, including in-depth exploration, this current study utilised a case study approach to explore factors that influence effective telesupervision practices from a supervisor and supervisee perspective.

Materials and methods

Results

Participants included three supervisor-supervisee pairs (n = 6) from three participating health services. De-identified supervision documents were available from two of the three included pairs (n = 4). Participants were from occupational therapy and physiotherapy. All three supervisors and one supervisee were in senior roles, whereas two supervisees were employed in junior roles of which one was a recent graduate with five months post-graduation experience at the time of study. Frequency of supervision sessions ranged from fortnightly to every four to six weeks. Duration of sessions ranged from 45 to 60 minutes. At the time of the study, telesupervision arrangements had been in place between five months and two years. Only one of the three pairs used an agenda to guide the sessions, whereas two pairs had a supervision contract in place. All supervisors and supervisees had met each other face-to-face prior to commencing telesupervision. All three supervisors had visited the respective supervisee’s work area that was in a different geographical location. While none of the six participants had undertaken any specific training related to telesupervision, only one participant reported some awareness of best practice guidelines in this area. All participants were trained in general clinical supervision. Two of the three supervisees were working in a clinical role, with the third supervisee working in a combined clinical and management role. Two supervisors were working in education and training roles, and the third in a clinical role. All three pairs reported using both Teams and phone for their telesupervision sessions, dependent on the availability of a confidential space and computer for the session.

Thematic analysis of data from interviews and supervision documentation resulted in the development of four themes namely: Benefits vs limitations and risks, not often a solo endeavour, importance of face-to-face contact, and characteristics of effective telesupervision.

Discussion

Healthcare workers across the globe switched from face-to-face to telesupervision, due to physical isolation and social distancing requirements triggered by the COVID-19 pandemic. Given the dearth of literature on this topic, this study explored in-depth supervisor and supervisee experiences of effective telesupervision practices, using two data sources, to understand the factors underpinning them. While all participants perceived their telesupervision arrangements as being effective and successful, it is noteworthy that not all factors that influence effective clinical supervision or telesupervision were accounted for [1,2,5]. Gaps were noted in the use of supervision contracts, agendas, lack of formal training in and awareness of best practice telesupervision guidelines, lack of attention to formative aspects, and inadequate record keeping [1,2,5]. This study has highlighted a need for training healthcare workers in effective telesupervision practices. This is an area that healthcare organisations can invest in to ensure staff are trained in best telesupervision practices, given the recent increase in remote working and telesupervision usage.

This study confirms that a key risk in telesupervision is a lack of attention to the formative aspect of supervision, building on previous findings of a study of rural healthcare workers [21]. Telesupervision appears to lend itself well to normative and restorative aspects, creating an issue for ‘hands-on’ areas of practice as identified by physiotherapists in this study. This is also a concern for recent graduates and supervisees that need more input into building their skills and knowledge. In the current study, all supervisees had other professional support strategies in place to overcome the limitations of telesupervision related to the formative aspect. This is in line with previous findings from the study of 16 healthcare workers from allied health that showed existence of other professional support measures [21]. As the pandemic has made telesupervision practices more prevalent, this is no longer an issue that is only pertinent to rural areas [9]. Upskilling healthcare workers in effective supervision practices is needed, so that they are more aware of the risks of telesupervision and can devise strategies to mitigate them. Although, participants in this study did not report using blended supervision models (combination of in-person and telesupervision components), this could be an option well-worth investigating [22,23]. Further studies can investigate the effectiveness of utilising additional professional support strategies that complement telesupervision.

This study confirms the importance of face-to-face contact in enhancing the perceived effectiveness of telesupervision. All participants in the current study had met with each other face-to-face and noted this to have influenced their decision to commence telesupervision. A previous systematic review noted face-to-face contact as a key influence in enhancing the quality and effectiveness of telesupervision, as it helps with building a positive supervisory relationship [5]. A COVID-19 study of 79 post-graduate trainees in social work and other healthcare professions also found that those that had prior face-to-face contact before switching into telesupervision remained largely unaffected by the switch [24]. Healthcare workers in the current study, in line with the previous study [24] indicated a preference for face-to-face or in-person supervision. Where this is not possible, and telesupervision is the only option, it is recommended to preference videoconference methods over the telephone to access non-verbal cues that are crucial in building rapport within the supervisory relationship [5]. Supplementary and opportunistic face-to-face sessions should be factored in where possible.

This study has highlighted the importance of a ‘right’ supervisor and ‘right’ supervisee for effective telesupervision. Participants in this study noted that supervisors relied heavily on supervisees’ accounts of clinical case presentations or issues in the workplace that were discussed in the sessions. Therefore, the ideal supervisee for telesupervision needs to be driven, and be able to co-lead the relationship. Telesupervision may not be suited to supervisees that may be passive learners, those not motivated to learn, and those needing a lot of assistance with their roles. Similarly, the supervisor in the telesupervision arrangement needs to be familiar with the supervisee’s work context, be approachable, accessible, supportive and non-judgemental. This is in line with previous findings from an interview study of 15 participants on blended supervision models to support postgraduate rural medical training in Australia [23], and another interview study of remote supervision with 11 participants [25]. Supervisees in telesupervision can be encouraged to co-lead the supervisory relationship by being better prepared for sessions, self-evaluating, negotiating objectives of supervision, and applying their learning expertise [26–28]. It is noteworthy that characteristics of a ‘right’ supervisor and ‘right’ supervisee for telesupervision is similar to that of face-to-face supervision arrangements. Previous research has noted that while there are similarities, a higher dosage of these characteristics or traits are required in telesupervision to make up for the absence of in-person contact [5,28].

Conclusion

This study explored effective telesupervision practices through supervisor and supervisee perspectives using an in-depth case study approach. Findings of this study have confirmed that telesupervision is suited to supervisees and supervisors with specific characteristics, who are able to navigate the risks and limitations of this mode of clinical supervision. Healthcare organisations have a role to play in ensuring availability of evidence-informed training on effective telesupervision practices, as well as investigating the role of blended supervision models to mitigate some risks of telesupervision. Further studies could investigate the effectiveness of utilising additional professional support strategies that complement telesupervision, including in nursing and medicine, and ineffective telesupervision practices.

Supporting information

Acknowledgments

We would like to acknowledge Dr Tiana Gurney and Ms Martelle Ford for their supportive involvement in the first author’s postdoctoral fellowship which this study is a part of. We thank all the case study participants.