“Building the boat while sailing” – adapting towards telementoring literacy

Abstract

Background

As telemedicine becomes a core component of modern healthcare, its effective application involves more than just the use of digital tools. An evolving skill set is required for current and future clinicians to adapt to this environment. Telementoring is a subset of telemedicine that involves clinician-to-clinician interaction, providing remote expert guidance in clinical care and medical education, with the potential to reduce global disparities. Yet, how trainees and mentors adapt to this virtual setting for effective learning remains unclear. To generate transferable insights across contexts, research on technology-enhanced environments must use designs that are both practice-oriented and theoretically grounded. Therefore, to investigate how telementoring shapes clinicians’ competency development, this study adopts a theory-informed case study of a telementoring Point-of-Care Ultrasound (POCUS) program in a resource-limited setting.

Methods

We applied a design-based research approach to bridge educational theory and practice and to enhance understanding of complex learning in authentic environments. This project took place in two healthcare centers in Uganda. Three design principles (authentic learning, deliberate practice, and scaffolding complexity) guided a two-cycle iterative design, evaluation, and re-design of telementoring sessions following initial in-person POCUS training, attended by 24 clinicians. Data sources included field notes, observations, and semi-structured interviews with seven POCUS trainees, two department heads, and two POCUS mentors collected over the twenty-one-month project duration. Data were analyzed using reflexive thematic analysis.

Results

Our findings capture the adaptive, iterative learning trajectories of clinician trainees and mentors engaged in telementored POCUS training in real-world contexts, characterized by participants as “building a boat while sailing.” Their adaptive capacity developed through (1) cultivating an enhanced situational and socio-cultural awareness, (2) refining feedback and mentorship practices, and (3) scaffolding technological and task complexities. Our project also showed a limit to adaptability and competency development via telementoring in relation to task complexity.

Conclusions

We introduce the concept of ‘telementoring literacy’ as the adaptive capacity of clinicians -- at both ends of the digital connection -- to effectively engage with clinical skill training and patient care through telementored interactions. Refining the components of telementoring literacy will further enable trainees and mentors to enhance telementoring implementation across different settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-026-09641-6.

Introduction

Telemedicine, broadly defined as medical care through digital connectivity, is becoming a core component of modern healthcare [1]. Effective telemedicine practices extend beyond the use of digital tools and require an evolving skill set from today’s clinicians [2]. The American Telemedicine Association conceptualizes telemedicine as encompassing three primary applications: (1) clinician-to-clinician interaction or telementoring, (2) clinician-to-patient interaction or teleconsultation, and (3) patient-to-technology interaction or telemonitoring [1]. In this study, we focus on telementoring because it holds particular promise within medical education. Particularly, during the introduction of innovations, it can help to compensate for the shortage of bedside teachers [3, 4], support continuous professional development [5], and reduce disparities in healthcare and education among frontline clinicians in remote areas [6]. As technology-enabled medical education is rapidly expanding, we must understand how to prepare today’s healthcare professionals for effective participation in telementoring [4, 7].

Despite growing evidence of its feasibility and effectiveness, current telementoring research faces three critical limitations that restrict our understanding of how to adapt and support its adoption. First, emerging studies predominantly assess feasibility or patient-related outcomes, rather than underlying educational processes or core competencies [2, 6, 8]. Several scholars critique this lack of educational grounding and argue that it restricts the transfer of insights across contexts, underscoring the need for theory-informed designs to explain how technology supports learning [9–11]. Second, even when education is explicitly foregrounded, research tends to focus on simulation-based learning environments, leaving a substantial gap in our understanding of telementoring’s effectiveness in authentic clinical settings [5, 12]. Lastly, high-quality studies are rarely conducted in resource-constrained settings where telementoring could play a transformative role in reducing disparities in medical training and healthcare delivery [4, 5, 13]. Together, these gaps highlight the need for research on how to adapt telementoring to support remote learning and patient care, especially in resource-constrained settings, building on educational theory and close-to-practice study designs [14].

This study addresses these gaps by using a design-based research approach and by examining the case of a telementored pediatric Point-Of-Care Ultrasound (POCUS) program in a low-resource setting [4]. Portable ultrasound technology in the hands of bedside clinicians promises to have a substantial impact on patient care internationally, particularly in low and middle-income countries (LMICs) where diagnostic resources are often scarce [4, 15]. However, POCUS is a complex psychomotor skill requiring sustained bedside teaching beyond an initial course and is constrained by a shortage of qualified mentors [3, 16, 17]. For LMICs specifically, recent reviews confirm the potential of telementored POCUS, highlighting the necessity to tailor programs to local needs [4]. Nevertheless, a significant gap remains regarding the underlying educational processes and required skill set for health professionals to leverage this modality [18]. Here, we present a theory-informed study on a telementored POCUS program to uncover how telementoring can support learning and how healthcare professionals adapt to effectively use telementoring in their clinical work environment.

Methods

Study design

We applied a Design-Based Research (DBR) approach, which allows training interventions to be developed and refined within authentic learning environments. In DBR, theory drives iterative cycles of design, evaluation, and redesign, leading to the refinement of contextually sensitive theoretical principles [19]. Rather than attempting to control confounding contextual factors, DBR seeks to understand their influence, advancing theoretical knowledge about the nature of complex learning environments in order to inform and improve training across different settings [20]. Five key characteristics include: (1) DBR is conducted in real-life learning environments; (2) it involves collaboration among experts from different fields; (3) the intervention has to be grounded in theory; (4) it follows iterative cycles of design, implementation, and evaluation; and (5) it uses flexible research methods to assess both outcomes and underlying processes [19].

This study involved two iterative cycles between September 2023 and May 2025, allowing for prolonged engagement with the context, participants, and evolving intervention (Supplemental Materials: overview DBR cycles). Figure 1 depicts the DBR structure, based on the model presented by McKenny and Reeves [21].

Fig. 1.

Model for conducting educational design-based research (Adapted, with permission, from McKenny and Reeves [22])

Setting and participants

This study was embedded within a larger project, NOD-pedFEND (Novel and Optimized Diagnostics for Pediatric tuberculosis - Feasibility of Novel Diagnostics for tuberculosis), which aimed to investigate the accuracy of POCUS for the diagnosis of tuberculosis in children under five years in Uganda, thus creating the need to design a specific POCUS training program for local professionals. The study involved two centers in Uganda: (1) an outpatient clinic, headquartered at the national referral hospital, and (2) a regional referral hospital for children. Children who underwent POCUS scans were enrolled in the NOD-PedFEND study, and POCUS was added as part of the study protocol. Although children and parents were not the primary focus or participants in this educational study, they provided informed consent, received a financial token for participation, and could withdraw or decline POCUS at any stage of the study.

Participating trainees were suggested by the NOD-pedFEND research team and recruited using convenience sampling. Twenty-four clinicians (pediatricians, clinical officers, medical officers, and nurses) followed the initial in-person training (see “Intervention” below). They all had different roles in the NOD-pedFEND study. In the first cycle of telementoring, five clinicians were selected as key users, as per the decision by the head of department, and were able to dedicate clinical time to POCUS practice. However, due to the workload and time constraints, the sample was narrowed down. Two participants (one clinical officer and one medical officer) continued using telementoring in cycle two, driven by their intrinsic motivation. Unfortunately, we were unable to systematically follow up on all participants who discontinued. For more details, we refer to the supplemental materials (Supplemental materials: Overview DBR cycles).Two European teachers (a pediatric POCUS educator and a pediatric radiologist) participated throughout the project. Ethical approval was granted by the Oxford Tropical Research Ethics Committee (565 − 23) and by the Research Ethics Committee of Makerere University in Kampala (SBS-2023-476).

Reflexivity

Our international, multidisciplinary team included educational researchers (EBr, PL, LL, WvM), POCUS teachers (MH, XS), clinicians with clinical and research experience in LMIC (EJ, EB, JvB) from Europe, and Ugandan research team members from the NOD-PedFEND group (EN, MJ, GB, LM). Alongside core DBR principles such as iterative integration of multiple data sources, methods, and theories, we employed investigator triangulation to improve credibility. Two principal investigators led the teaching and telementoring (MH) and field work (EJ), assisted by JvB, GB, and LM, who conducted interviews and observations without involvement in the teaching intervention. Reflexivity involved regular meetings in which interpretations, positionalities, and methodological choices were critically discussed. An audit trail documented research steps and decisions, including the influence of power, underlying motives, and researchers’ roles [23].

Design principles

Collaborative discussions in the research team delineated three theoretical principles for the intervention’s design [11, 24]. First, given this study’s context of telementoring for POCUS practice, we adopted deliberate practice as a first guiding principle in shaping the training intervention. McGaghie defines deliberate practice as effortful, goal-directed skill development and refinement, supported by expert feedback under conditions of high standards and psychological safety [25]. Our telementoring intervention operationalizes this principle by enabling remote, real-time feedback and POCUS skill refinement [26].

Second, because learning is considered most effective when trainees engage in real-world, meaningful tasks that reflect their professional practice, our instructional design embraced Herrington’s principle of authenticity [27]. In his framework, authenticity is operationalized by learning opportunities that reflect real-world settings and learning tasks that reflect the complexity of real-life practice [28]. Throughout the project, adaptations were made to adhere to the needs of participants within their authentic settings. For instance, learning tasks were adapted to reflect the prevalent clinical pathologies, and telementoring sessions were (re)designed to match real-life practice in LMIC [4].

Lastly, POCUS is considered a complex psychomotor skill, and different POCUS applications vary in complexity [29, 30]. Within Merrill’s first principle of instruction, we prioritized scaffolding complexity, as a third design principle, defined as the gradual increase in task difficulty alongside the progressive reduction of mentor support [24]. This principle guided the selection of POCUS applications and structured learning progression, gradually increasing task difficulty to promote effective skill mastery [31–33].

Intervention

Based on the local need for enhanced diagnostic options for pediatric tuberculosis, our telementoring program covered two POCUS modalities, strategically selected for their clinical relevance to pediatric tuberculosis diagnosis while representing distinct complexity levels [4]. Lung POCUS served as the foundational application, requiring limited eye-hand coordination and offering a relatively accessible entry point for novice users [34]. Mediastinal POCUS was included as an advanced application, representing a novel diagnostic approach for detecting mediastinal lymphadenopathy in pediatric tuberculosis [35].

A two-week in-person course was considered a necessary basis for continued remote training via telementoring and was implemented in line with standard POCUS training courses. Didactics, hands-on training, and case-based discussions were adapted to participants’ clinical context and pathologies.

The key intervention included recurrent, synchronous telementoring sessions, using a portable ultrasound device (Philips Lumify™) with telementoring software via tablet (REACTS™). Positioning of the tablet and its camera provided a vantage point for the mentor to assess hand and probe handling. The pointer feature (green dot) allowed the mentor to overlay a pointer on the live feed of ultrasound images (Fig. 2), which supported instruction and feedback. During the in-person training, participants practiced working with the material. A standard operating procedure described the process of setting up the telementoring connection and how to acquire, save, and report POCUS images.

Fig. 2.

Telementoring session in progress. The tablet camera enables the remote mentor to observe the trainee’s probe handling on the patient and the resulting image acquisition. The green dot represents an instructional pointer

Following DBR principles, we iteratively matured the intervention over two cycles. In the first cycle, telementoring occurred at the request of the trainees. Adaptations in cycle 2 included scheduling fortnightly sessions for sustained engagement, expanding POCUS practice beyond tuberculosis to all respiratory conditions, and simplifying standard operating procedures for image storage and reporting. In total, 20 telementoring sessions took place (11 in cycle 1 and 9 in cycle 2), of which 4 were observed by investigators. A detailed account of each cycle and the adaptations is available in the supplementary material.

Data collection

A triangulated team of investigators collected predominantly qualitative data from field notes, observations, and semi-structured one-hour interviews (Supplemental materials: semi-structured interview and observation guides). Field notes were collected by investigators and POCUS mentors to track observations during onsite training and (observed) telementoring sessions. The principal investigators kept team meeting notes as part of the audit trail. Semi-structured interviews were conducted following each DBR cycle (Supplemental Materials: Overview of DBC cycles). After the first cycle, face-to-face interviews with five trainees and two department heads explored their first experiences with the telementoring sessions and addressed successes, barriers, and potential future challenges. After the second cycle, (online) interviews with POCUS mentors included their perception of telementoring sessions with a focus on communication, feedback instructions, and the relationship with the trainees. The trainees were invited to discuss the influence of the local context or practice, feedback instructions, and the role of mentorship in another round of face-to-face interviews, conducted by local researchers who were not involved in the project. We also asked them to describe their own perceived POCUS competency level. All data was collected in English, and interviews were transcribed verbatim.

Data analysis

Our thematic analysis was constructivist in orientation and followed the six-step framework by Braun and Clarke [36, 37]. Early analytical steps were inductive, while later steps -- such as refining and naming themes -- included a deductive lens to explicitly engage the underlying design principles [37]. Initial codes were generated independently by two investigators (MH, EJ) in collaboration with the lead educational researcher (EBr). A shared coding framework was iteratively discussed and refined during regular analytic meetings with the research team (LL, PL, WvM). This ongoing analysis informed subsequent DBR cycles and refinements of the intervention. Information power [38] was considered high in light of the detailed and nuanced data that spoke to all theoretical principles underpinning the DBR approach. To trace participants’ developmental trajectory in our results, we refer to interviews from cycle 1 (C1) and 2 (C2) with local POCUS trainees (T) and mentors (M), as well as observations (O) and field notes from collaborative meetings (FNm) and telementoring sessions (FNt).

Results

Our findings describe how trainees and mentors adapted to telementoring as a means for learning POCUS in real-world practice. This adaptive learning process of this intervention was captured by a participant with the metaphor “we can build the boat while we sail” (C1T4). Participants’ developmental trajectory is illustrated in three themes: (1) the emergent recognition among trainees and mentors of the importance of situational awareness for authentic learning, (2) the evolving role and shared understanding of feedback and mentorship in deliberate practice, and (3) the challenge of scaffolding multiple complexities through telementoring.

Theme 1: cultivating situational awareness for authentic learning in telementoring

Participants valued telementored POCUS practice for enabling “real-time learning” (C1T2) and “continuous practice” (C1T4) during clinical care. Learning alongside patient care made the experience feel like “something real” (C2T1) and was seen as vital for building POCUS competency. However, this authenticity within the telementored learning environment did not come automatically. As the project progressed, participants increasingly recognized that effective telementoring required both trainees and mentors to actively cultivate awareness beyond the POCUS probe and in a broader sociocultural context.

Early sessions revealed that effective telementoring required more than connecting across distance. Learners had to learn how to orchestrate the situation – positioning of the technology, camera angles, themselves, patient, and caregivers – to create a sense of digital proximity.

“You are connecting with someone miles away who wants to see exactly what you’re doing […] I had to really position myself and the patient […] to make them feel as if they are present in real-time” (C1T1).

Successful telementoring often “felt like the mentor was in the room” (C1O1). At other times, however, -- “like looking through a keyhole” (C2FNm) – observations showed how important cues were lost. The clinical environment sometimes impeded trainees from following the mentor’s instructions, and observations illustrated how telementoring occurred in

“a crowded, noisy children’s’ ward, where the trainee had to stand in the little space between two beds […] multiple children were sharing one bed […] (the trainee) had to ask the child’s caregiver to hold the tablet […] to adjust image quality on the tablet with one hand while holding the ultrasound probe on the patient with the other […] (while the trainee) was monitoring responses of child and caregivers” (C2O1-2).

Over time, participants recognized how “situational awareness and being in control of what is happening coincidentally, is something one has to learn while they engage with this technology” (C2T1). Situational awareness here has a dual meaning. Besides focusing on the immediate clinical surroundings during telementoring, participants highlighted the importance of sharing a broader awareness of each other’s context, as this appealed to the participants’ motivation for learning. For instance, practicing POCUS on sick children was an important stressor, yet this pushed trainees to “polish up (their) skills to carry out the exam in the shortest time possible” (C2T2). Challenges in the broader health care system, such as disease burden, limited treatment options, and economic constraints, were both hindrances as well as motivators for participants to “go the extra mile” (C1T2) to “continuously engage in effortful learning” (C2M2). Yet, trainees were primarily motivated by capacity development: “We are living in a technology-based time, and it is crucial for us [in a LMIC] to adjust and keep up” (C1T1). Mastering new technologies and developing local capacity often requires significant effort and does not always produce immediate practical or economic gains. In result, one participant noted, “it needs to be a work of passion” (C2T2). Finding those motivated learners in LMIC was considered key for capacity development as participants emphasized that “it helps to train as many people as possible and those with passion will carry the brand forward.” (C2T2). In sum, cultivating situational awareness of both the telementoring environment and the broader socio-cultural context became central to engage in authentic learning as an important design principle for POCUS skills training and capacity development.

Theme 2: evolving deliberate feedback practices: from psychomotor instruction to mentorship

Discussing the key elements to support POCUS competency via telementoring, trainees emphasized: “First of all, mentorship. Then, practice. Reassurance that this [POCUS competency development] is possible. And then again, more practice.’’ (C1T13). Participants came to appreciate the dual role of feedback: providing real-time psychomotor instruction and building a supportive mentoring relationship. Effective feedback via telementoring involved “realizing mistakes and correcting them immediately” (C1T2), while making sure that they were “not just dealing with a machine, but with a human being — though virtually” (C2T2).

Early in the project, feedback focused primarily on guiding probe handling. Participants described that continued guidance is crucial after physical training, because otherwise “you can’t figure out what you are looking at” (C1T2), so “you need someone to check if it matches with what you think you have seen” (C1T4). A mentor describes how “we needed (to achieve) a common language” (C2M1) for effective psychomotor instruction.

“A prime insight has been that it [competency development] is all dependent on how to get my message across and how it is received. We needed to be very conscious about it, especially with the telementoring” (C2M1).

Observations showed how mentors gesticulated to model the required probe maneuvers, but when “this was not picked up” (C1O1), both trainees and mentors appeared frustrated and helpless.

“There was confusion about how to adjust the probe position. Terms seem to be interpreted differently. The camera was not focused on the probe, hence this misalignment was not observed by the mentor or the trainee. [Mentor] asks for a kind of time-out and indicates not knowing how to help. [Eventually] the examination is aborted.” (C1O1)

“We took almost 30 minutes to get that one view” (C2T2) describes the effort and subtleties of probe handling, leading trainees to wish the mentor “just hold(s) your hand and show(s) how to adjust the probe slightly, because (they) have seen where the pathology is. That’s the difference (between physical and telementoring)” (C1T5). Over time, participants learned that deliberately “using the same words – tilting, rocking, sliding, rotating” (C2M1) with “precise indications and manipulations” (C2M2) were important investments in learning.

Recurrently investing in this common psychomotor vocabulary, “motivating with words of applause” (C2O1) and reacting to non-verbal cues “because I can read their expression and they can read mine” (C2T1) all contributed to mentorship that helped “build a relationship of trust” (C2O2). Considering the relationship development, a mentor reflected:

“While [they] are more fluent in image acquisition, we have the time and space to talk about interpreting and making clinical decisions. […] In the last sessions, I feel the relationship evolving. I feel much more of that sense that they are reaching out for an act of mentorship, not real instructions […] sending clips of what they’ve been doing on their own and asking for advice. So, that kind of mentorship, I think, it’s only getting started.” (C2M1)

Thus, in relation to the deliberate practice design principles, our findings showed that engaging with psychomotor feedback via telementoring was hampered by communicative challenges and required a dynamic relationship between teacher and trainee with dual feedback roles: developing a shared understanding of psychomotor instruction and supportive mentorship.

Theme 3: learning how to scaffold complexities, up to the limits of telementoring

Gradually, both trainees and mentors learned to recognize different layers of complexity:

“At the beginning, the struggle lies in the combination of everything. And after a while, both trainees and I were able to separate what’s a technology issue, what’s an eye-hand coordination issue, and what’s an image interpretation issue. However, that takes time to figure out.” (C2M1)

Trainees reflected how “dealing with the many things (during telementoring) was a learning process” (C2T1) and highlighted how this process provoked emotional responses:

“There is this shock you get at first, and there is that anxiety that you have to deal with. For me, it is something I’ve come to adjust to quickly, because I am used to all the things happening at once and needing to get control.” (C2T1)

While the initial training was designed to scaffold the complexities of the POCUS modalities, participants’ accounts prompted us to shift strategies and address a more foundational process first: dealing with the complexities of the technology itself. One mentor noted how early telementoring sessions had limited focus on POCUS, but almost entirely on establishing and troubleshooting the technological setup, followed by positioning the tablet in a clinical context to allow for feedback on probe handling and image acquisition: “The first sessions were mostly about where to position the tablet for me to visualize their hands.” (C2M1 and C1FNt). Initially, trainees did not realize the importance of probe handling, but “first thought it was all about interpreting the scan image. […] Until realizing that I had to adapt and find someone to hold the tablet for the camera to be positioned adequately” (C2T1).

Mentors considered it “very difficult to telementor all of these factors.”(C2M2). Trainees tried strategies like “switching off and only concentrating on the trainer” (C2T1), but worried that “the child’s caretaker may feel I’m not interested in the well-being of their patient” (C2T1). Mentors, sensing this problem coinciding challenges, adapted their approach – “by taking it step by step and recognizing how (as a teacher) you also need to extend your focus—not only to the hands of the trainee, but to the whole environment.” (C2M1). They described how they could “help the trainee by […] distracting the child or interacting with mom” (C2T2). Hence, for a trainee “learning how to learn via telementoring” (C2FN) and for a mentor “learning how to efficiently teach via telementoring” (C2FN) was described as a complex process on its own.

Over time, the participants encountered a ceiling to what their collaborative scaffolding could achieve through telementoring alone. Remote support for lung POCUS was described as “a productive struggle” (C2FNt), where challenges were overcome and deepened learning. In contrast, competency development for mediastinal POCUS proved less responsive to telementored feedback, primarily due to higher psychomotor demands: “You think you’re positioning the probe correctly, but the image doesn’t come out as easily. […] mediastinal requires more [blended] training to master” (C2T1). Moreover, the contextual and technical setup was more complex, requiring “the child lying down with the head tilted back, whereas lung POCUS could be done with the child seated on a caregiver’s lap” (C2T2). Together, these coinciding challenges exceeded the trainee’s capacity or mentors’ support and highlighted the limits of telementoring in this project.

Thus, learning how to teach and learn via telementoring required scaffolding across coinciding technological, contextual, and psychomotor complexities. Although effective scaffolding can enable telementored learning, complexity may exceed what can be scaffolded through telementoring alone, as in the example of mediastinal POCUS.

Discussion

In this rapidly evolving technological era, telementoring offers opportunities to address disparities in healthcare and education worldwide [4, 8]. Informed by three educational theories, this study explored how clinician-to-clinician telementoring supports clinical skill development of POCUS in a low-resource context. Our findings show how effective telementoring relies on iterative, reciprocal adaptations between trainees and mentors to navigate the affordances and constraints of the technology-enhanced learning environment. Across the three themes, a shared learning trajectory illustrates how participants iteratively developed an adaptive, context-sensitive capability to interpret and act on information via telementored interactions, extending beyond discrete skills and competencies [39]. We define this adaptive capability as ‘telementoring literacy’. In what follows, we discuss how a literacy lens may advance medical education and how our proposed telementoring literacy contributes in light of this study’s employed educational theories. In addition, derived from our empirical data, we describe practical considerations that may guide future telementoring program designs (Table 1).

Table 1.

Practical considerations for mentors and trainees to foster telementoring literacy

1. Early expectation management: Acknowledge that mentors and trainees may need to adapt to the technology before meaningful and effective learning can take place. Explore together whether sufficient familiarization with the technology has taken place before focusing on competency development.

2. Enhanced situational awareness: Be aware that effective learning through telementoring requires explicit attention to the situation during real-time telementoring and to the broader healthcare system. Discuss collaboratively how factors on both ends may influence perception and interpretation of information and skills development.

3. Intertwined feedback and mentorship: Keep in mind that a common language (especially for psychomotor instruction) and a trusting, motivating relationship is essential for feedback and mentorship. Check iteratively whether instructions are understood in the same way and discuss jointly what is needed to make telementored practice relevant and efficient.

4. Scaffolding complexity: Note that telementoring involves coinciding technological, situational and task complexities which shapes learning. Consider as a team on how to adapt jointly. When task complexity exceeds what can be scaffolded through telementoring alone, consider a blended learning design.

The concept of literacy is gaining traction in academic discourse and is reflected in the emergence of domain-specific literacies, such as digital literacy [40], feedback literacy [41], or health literacy [42]. Traced back to its origins, literacy refers to the capability to interpret and engage with language for social communication. This capability relies on underlying competencies (such as listening, reading, and writing), which in turn are built from constituent skills (like recognizing letters, decoding words, and constructing sentences). Literacy captures a layered relationship between capabilities, competencies, and skills, making it particularly suited for representing complex learning processes [40, 41, 43, 44]. However, the adaptive and situated nature of complex learning — highlighted by our participant’s metaphor “building the boat while sailing”— remains underacknowledged in existing literacy models. This may complicate expectation management when literacy is positioned as a high-order educational outcome [40]. We refined the conceptual model of literacy to emphasize its iterative and adaptive development in response to contextual demands (Fig. 3). By linking the interpretation of information to adaptive performance in context, literacy helps us understand how clinicians adapt their actions in complex learning environments. This framing aligns with growing calls in medical education to move beyond a focus on competencies and instead educate for capability and adaptability to support performance in variable contexts [39, 45]. In this light, we next unpack the capabilities of telementoring literacy through the educational theories underpinning this study.

Fig. 3.

Conceptual figure of literacy, defining its components. Adapted from existing digital literacy literature to highlight the adaptive and iterative nature of complex, authentic learning processes [40, 46]

As a first component of telementoring literacy, our findings highlight the capability to recognize how context shapes skill learning. POCUS skill development proved highly context-dependent, requiring trainees and mentors to adapt collaboratively to the learning environment. ‘Like looking through a keyhole’, telementoring fostered a critical attention to situational awareness -- both during real-time sessions and in relation to each other’s socio-cultural background – allowing participants to adapt learning goals and apply POCUS to context-relevant pathologies in LMICs.

Theoretically, authentic and situational learning overlap in emphasizing that learning is inherently ‘situated’ in socio-cultural contexts, supporting individual and collective workplace learning [47]. Situational awareness -- a viable, yet tacit construct despite longstanding research [48] – can intuitively be understood as ‘knowing what is going on’ and theoretically as the perception of elements in the environment, their comprehension, and projection to future events, linking to the notion of literacy [48, 49]. Moreover, our project responds to previous calls for a better understanding of how situational awareness manifests in real-world practice and how to foster it as a trainable skill [48]. Our findings can advance educational design by making situational awareness explicit and showing how both mentors and trainees adapted to technology, the immediate situation, and each other’s backgrounds. This expands on the practical training framework to support telementoring, described and characterized as situational telementoring by Bui et al. [13]. Taken together, we have learned that telementoring requires an enhanced situational awareness and the capability to recognize and adapt to context. Framing this as a literacy may prove a valuable training focus and key driver for exploring competencies and skills required for learning in technology-enhanced learning environments [50].

A second key aspect concerns the capability to engage with psychomotor feedback. Our findings highlight the importance of developing a shared language for psychomotor instruction and the intertwined role of feedback and mentorship in deliberate practice. While deliberate practice has shown to enhance POCUS expertise, conditions for such practice in providing feedback within technology-enhanced learning environments remain underexplored [26, 51]. Previous work showed the feasibility of POCUS telementoring in a simulation setting and how psychomotor feedback needed to be supported, e.g., by color coding of the probe and an on-screen pointer via live video-feed, in order to be effective [12]. Our study develops this understanding and extends it to real-world practice by describing the communicative challenges and situational influences that shaped the feedback process.

In deliberate practice, feedback must be specific, immediate, and actionable [51]. However, this framing potentially overlooks the two-way communication needed to build a shared capability to give, interpret, and engage with psychomotor feedback -- a crucial first step highlighted in our findings. We therefore argue that feedback literacy should be considered a component of deliberate practice [41]. Rather than a one-way transmission, feedback-literate trainees and mentors co-construct meaning from feedback and adapt to each other and the context [41, 52]. One participant described this development as effortful and emphasized the need for a trusting, motivating mentorship ‘to go the extra mile’, intertwined with the feedback process [53]. Therefore, this study illustrates how psychomotor skills, two-way feedback literacy, and mentorship are pivotal for enabling effective learning through telementoring within socio-cultural and digital learning environments.

A final component involves the capability to scaffold multiple complexities. Our participants navigated coinciding challenges: technological demands, contextual constraints of the LMIC setting, and variable psychomotor complexities of the two different POCUS applications. Fostering the capability to recognize, interpret, and adapt to complex environments has been described as essential for guiding sustainable digital transitions [54, 55].

Despite the initial intention to focus telementoring sessions immediately on POCUS competency development, telementoring sessions were redirected to first learn how to jointly deal with coinciding technical, situational, and communication challenges. Although variable described strategies were aimed at reducing cognitive load – i.e., by switching off certain inputs or taking stepwise approaches -- participants emphasized the importance of learning to adapt to coinciding challenges collectively, not in isolation. As such, our findings resonate with strategies that foster adaptability, such as supporting conceptual knowledge, productive struggle, and meaningful variation [56]. Preparing trainees to become adaptive experts is considered critical in an area of rapid advances in technology [57].

Our real-world observations also showed limits to adaptability and POCUS competency development via telementoring, in relation to task complexity. While the struggle in participants’ learning was considered productive for lung POCUS, the complexity of mediastinal POCUS was considered too high to bridge via telementoring. Neither reiterating clear didactics [35] nor remote expert support sufficed, leading to diminished engagement and learning. Participants advocated for a more blended training design combining in-person and telementored practice to manage highly complex tasks. Thus, we consider the capability to manage complexity as a key component of telementoring literacy, but require further study of how levels of complexity can be effectively adapted to support technology-enhanced learning.

Limitations, strengths, and future directions

Conducting this project within existing institutional structures introduced several limitations. First, after training twenty-four clinicians, a pragmatic decision by department heads narrowed participation to five key users, of whom only two continued into the second cycle due to workload and time constraints. While reflective of real-world implementation, this focus on highly motivated participants may have introduced a positive bias. Future research should examine the perspective of those who disengage to better understand and address barriers [58]. Second, one principal investigator had a dual role of both educator and researcher, which may have shaped knowledge generation. Through rigorous reflexivity from the start of this project, we sought to counterbalance these limitations and produce a nuanced account of reality. Third, while digital literacy research has extensively described underlying competencies and skills, our analysis intentionally focused on capability as a higher-order construct [40]. Although these underlying components are embedded in our Fig. 3, we chose not to foreground them in this study. Future research should examine how these underlying components compare across different forms of literacy, including their commonalities and differences.

As a strength, this real-world DBR applied and refined educational theory to telementoring, an area often explored a-theoretically. Because of this, our context-specific study offers insights relevant across diverse educational contexts beyond LMIC, and for other forms of technology-mediated clinical education and patient care [59]. Our findings have shown that becoming literate, or ‘learning to learn’ through telementoring, is a challenging process: it has different layers of complexity, and it has its limits. Future research could explore how trainees and mentors adapt together in technology-enhanced learning across various education and healthcare contexts, and examine how to balance in-person and telementored training. Cultivating literacy in technology-enhanced learning may be essential to prepare trainees for a future shaped by rapidly advancing technologies.

Conclusion

This design-based research study of a telementored POCUS training within a low-resources setting introduces telementoring literacy as a valuable lens to capture how clinicians -- on both ends of the digital connection -- adapt to technology-enhanced clinical learning environments. We define this literacy as the adaptive capability to effectively interpret and act on information through telementored interactions, encompassing complex and situated learning processes that extend beyond individual competencies and skills. Guided by three theoretical guiding principles, we identified key features that supported effective telementoring, including situational and socio-cultural attunement, refinement of feedback practices, and the scaffolding of technological and task-related complexities. Our findings also reveal a ceiling to what can be achieved through telementoring alone when complexity exceeds feasibility. This underscores the need to anticipate blended training designs that combine telementoring with in-person support. As clinical practice and education continue to digitalize, aligning training with real-world demands requires investment in capabilities for effective learning within technology-mediated environments, underscoring the value of adapting towards telementoring literacy.

Authors’ contributions

MH, EJ, EB, and EBr were responsible for the conception and design of the study. Data acquisition was carried out by MH, EJ, XS, GB, ML, JvB, MJ, and EN. Data analysis was performed by MH, EJ, and EBr, while interpretation of the results involved MH, EJ, EB, EBr, LL, and PL. MH drafted the manuscript, and it was substantially revised by EJ, EBr, EB, LL, PL, and WvM. MH and EJ contributed equally to this work. All authors have approved the submitted version of the manuscript and have agreed to be accountable for their own contributions.

Funding

This research was made possible by a grant from the Mr. Willem Bakhuys Roozeboomstichting (2023-2). EB is supported by a fellowship from the European Society for Paediatric Infectious Diseases. The parent NOD-pedFEND study was funded by the National Institute of Allergy and Infectious Diseases of the National Institutes of Health under award U01AI152084 (FEND-TB) and R01AI152159 (NOD TB). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Data availability

The data and materials that support the findings of this study are added and further available from the corresponding author upon reasonable request. Restrictions apply to ensure anonymity of these data, and so not all materials not publicly available.

Declarations

Ethics approval and consent to participate

Ethical approval was granted by the Oxford Tropical Research Ethics Committee (565 − 23) and by the Research Ethics Committee of Makerere University in Kampala (SBS-2023-476) in accordance with the Declaration of Helsinki.

Consent for publication

Written informed consent for publication was obtained from all participants and consent forms for image publication are available for review by the Editor of this journal.

Competing interests

The authors declare no competing interests.