The training site
Remote supervision training site eligibility and selection
To be eligible for remote supervision, the practice needs to have a workforce and community need; that is, these locations have a need for a GP and a clear desire from the community for someone to fill this role. It is expected that most remote supervision training sites will be in rural and remote locations, although the guidelines could be applicable in any location that does not have an accredited onsite supervisor.
Eligibility requirements include:
- No (or very limited access to) onsite accredited supervisor
- Willingness to engage a GP registrar and to provide cultural support
- Adequate consulting space and equipment appropriate for a remotely supervised registrar
- Suitable, stable and safe housing
- Good reliable IT connectivity
- A willingness to establish an onsite supervision team.
Identification and ratification of a new remote supervision training site will be a collaborative effort by the RACGP regional and relevant local team, the accreditation team, the remote supervision team and the state censor. This will involve a detailed discussion between the training site, the RACGP and, potentially, the community about factors that may impact the implementation of a remotely supervised placement.
Determination of the model of remote supervision suitable for a training site should follow from a discussion with the training site and other key stakeholders. It will be influenced by a number of factors, including the availability of supervisors, nearby practices, the clinical needs of the training site, the scope of practice for the registrar and local retiring GPs.
Remote supervision training site accreditation
Accreditation of remote supervision training sites will follow usual RACGP processes as per the National Accreditation Framework, with additional criteria and activities specific to remote supervision. To achieve accreditation as a remote supervision training site, the training site must meet the RACGP Accreditation standards for training sites and supervisors and the additional remote supervision requirements as per the Remote supervision training site accreditation requirements. These include:
- review of the RACGP remote supervision guidelines
- completion of the remote supervision training site requirements table
- provision of a draft outline of the onsite supervision team that will support the registrar during the remote supervision placements (the team can be further developed closer to the placement and during the orientation period)
- review of the Remote supervision risk management template and starting to think about potential risks and mitigation strategies relevant to the site (this will be completed during the orientation period with the remote supervisor and the registrar).
The RACGP should be assured that any serious risks in this site have mitigation strategies in place as per the Remote supervision risk management template. It may be that during discussions about risk management planning it is deemed that the training site is not appropriate for remote supervision at this time. In some areas, the community may require more discussion about a remotely supervised registrar, and the RACGP regional or local team will need to advocate across the community with their concerns.
Although accreditation of a remote supervision training site and accreditation of the remote supervisor are separate processes, it is important that potential supervisors are identified and engaged early on to ensure the supervisors are appropriate and the model of remote supervision can be confirmed well in advance of the placement commencing. It is also preferable that the remote supervisor is involved in the selection of the registrar.
Onsite supervision team
Clinical supervision when the supervisor is not always onsite requires a team approach. When the supervisor is offsite, the role of those working onsite with the registrar becomes more important. It is recognised that supervision to enhance learning is complex,22 and that a strong relationship with an onsite multidisciplinary supervision team will assist learning within the different domains of clinical practice.
Rural and remote locations often have a skilled team of onsite nurse practitioners, remote area nurses and other staff. For some registrars, working in this context may require a changed mindset, moving away from hierarchical thinking. The supervisor has an important role in orientation to establish a strong working relationship with such a multidisciplinary team.
A typical onsite supervision team for remotely supervised placements will be multidisciplinary and involve three to four key people. The make-up of the team will depend on the type and size of the service and could include:
- the practice manager
- a nurse
- an Aboriginal health worker/practitioner
- a hospital doctor or local GP, if present
- a cultural mentor
- allied health professionals
- administrative staff.
The team members should be aware of potential conflicts of interest between their support roles for the registrar and other roles, such as being a colleague or manager.
The purpose of the onsite supervision team is to:
- ensure that registrars working in rural, remote and isolated locations have support and guidance that enables safety for themselves, patients and staff, as well as an environment for learning and growth
- provide a basis for effective communication and relationships between the registrar, local staff and patients, as well as with other health professionals attending the clinic
- collaborate with the remote supervisor in risk mitigation and management
- facilitate ad hoc reflection and debriefing in conjunction with the remote supervisor if required.
Establishing this team may require appropriate education or professional development and discussions to ensure the onsite team understands the role of the registrar and remote supervisor.
This will need to be relevant to the background of each onsite team member. It should be focused on the establishment and growth of working relationships, the purpose of the training term and partnership development. It is expected that the relationships between the registrar and this team will have a significant impact on learning opportunities, and ultimately the success of the term.
One member of the team will be nominated as the team lead and will be the remote supervisor’s main point of contact. The team will meet every one to two months, depending on the registrar’s term, usually connecting remotely with the remote supervisor.
Whenever there is discussion or communication between remote supervisors and the onsite team, it should be clear that there may need to be a response to the communication, involving the registrar. It should also be clear to the registrar that people will be ‘talking about them’ as well as talking with them.
Although some locations have a high staff turnover, a nominated onsite team, even with changing personnel, can work to ensure that the registrar is supported and that ongoing learning is enabled. The team will function more as a network with an ‘inner core’ of stable and regular members and external supports who will be called upon when needed.
Wider local, community and external supports
Although not part of the formal supervision team, other options for support will depend on the location. Relevant supports and escalation pathways should be identified prior to the placement and documented and discussed with the registrar during their orientation period.
Additional supports could include:
- the closest referral hospital or health service able to continue or escalate care, or able to give verbal advice
- rural training hubs
- Royal Flying Doctor Service/CareFlight/retrieval services
- district medical officer/remote medical practitioner
- visiting specialists
- a backup supervisor if the remote supervisor is not available
- IT support linked to the health service for the registrar and supervisor for communication issues, remote access and other software and hardware issues
- regional primary health network or state rural workforce agency
- local HealthPathways web-based portal
- online community of practice for appropriate and mediated support.