Journal of Telemedicine and Telecare >
Volume 14, Number 8 >
Pp. 415-420
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RESEARCHOriginal articles |
Communication Aid Centre, Frenchay Hospital, Bristol, UK
Correspondence: Victoria Styles, Communication Aid Centre, Frenchay Hospital, Bristol BS16 1LE, UK (Fax: +44 1179 186 558; Email: Victoria.styles{at}nbt.nhs.uk)
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| Introduction |
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People who are not able to access specialist AAC services are at risk of depression, loss of identity, reduced control over their own environment, reduced ability to gain education or gain employment and may be at increased risk of neglect/harm and abuse.2 It is therefore essential that people with severe communication disorders, who need access to the specialist centres, are able to access the services they require. An estimated 600,000 people in the UK have difficulties in communicating and could potentially benefit from AAC devices or communication aids.3 However, there are currently only 19 centres in the UK that offer AAC services.4
Telemedicine is a potential solution. However, there have been very few studies investigating its application to the field of speech and language therapy (SLT).5 Hill and Theodoros reviewed the literature and found a total of 13 studies focusing on videoconferencing in the field of SLT.6 They pointed out, however, that the evidence is unreliable and that more robust research is needed to establish whether videoconferencing is an effective tool within the discipline.
Mashima et al.7 suggested that remote health provision has potential benefits within the field of SLT, particularly because of the increasing demands on the service, combined with personnel shortages. They also noted the benefits of care being provided in the patient's natural environment, which they believed would result in therapeutic interventions being more effective, due to the meaningful environment in which it is carried out.
There appears to be only one study investigating the application of videoconferencing in AAC.8 This concluded that videoconferencing was a successful medium for sharing information effectively and quickly, for training professionals and supporting clients at a distance. The study, however, only looked at the process of reviewing information and training sessions, and did not investigate the application of videoconferencing for the purpose of initial assessments.
The present study was conducted to answer the question ‘Is videoconferencing an acceptable method of delivering an AAC service remotely?’ The aim was to establish whether assessments, training sessions on communication devices and review appointments could be performed via a videoconference to a standard that was acceptable to all of those involved in the process.
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Questions were adapted from statements used in Yip et al.'s survey of patient satisfaction with videoconferencing.9 The question items were formulated to produce a yes/no response, where ‘yes’ indicated satisfaction with a particular aspect of the videoconference. The questionnaire was divided into four sections. The first section aimed to discover whether successful communication interactions could be achieved via a videoconference. The second section looked at technical aspects and, specifically, whether the visual and auditory information received was of a satisfactory quality. The third section of the questionnaire related to the type of appointment taking place, i.e. whether it was an assessment, review or training session on a device. The study aimed to discover whether the function of each of these different sessions could be met via a videoconference. The final section of the questionnaire explored the participants' general feelings about the videoconference sessions.
There were three versions of the questionnaire, one for use following an initial assessment session, one for use following a review session and one for use following a training session.
Two versions of all the client questionnaires were produced. The first was for those participants who had written language comprehension with no cognitive difficulties. This questionnaire appeared as text only. A second version was provided for participants who had written language or cognitive language difficulties. This version included a reduced number of questions. Symbols were added to support the client's understanding of written text.
The questionnaire was approved by the host NHS Trust's research and development department and it was then piloted on two clients. Following this process a small number of changes were made. Ethics approval was granted by the appropriate committee.
The inclusion criteria for the project were that potential participants required an AAC assessment, and that those accompanying them had to consent to the sessions being carried out remotely, by videoconference. Individuals who were under the age of 11 years were excluded. Those who required voice amplification or switching assessments were also excluded. Participants were recruited via incoming referrals to the CAC during a 5-month period.
In order to gain a sample that reflected the typical range of clients who are referred to the CAC, a patient impairment matrix was devised. The gross areas of difficulties were plotted. These were: general health, motor difficulties, cognitive difficulties, language difficulties (expressive and receptive) and whether the condition was progressive in nature. Each of these areas needed to be represented in the participant sample. Each client, therapist and relative/carer combination formed a participant group. A total of 10 participant groups were required.
The videoconferencing units (iPower 600, Polycom) were connected via the hospital LAN at 768 kbit/s. The participants at the far end had an accessories box available to them. This included life-size photographs of all the devices that were demonstrated during the videoconference, including various screen shots from the devices so that the client could perform the assessment tasks. Also enclosed was a copy of the CAC-Frenchay Screen for AAC, as well as accessories such as pens, paper, clipboards, rating scales and a stylus, to replicate communication aid access.
All videoconference trials were carried out within the same building. This involved the assessing therapist participating from the CAC known as the ‘near end’ and the participant group participating from a room in a different part of the building, known as the ‘far end’. At no time did the participant group meet the assessing therapist in person. This allowed a true simulation of a remote videoconference session to take place. If the assessment outcomes dictated it, participant groups were invited back for subsequent training or review sessions. These sessions replicated the process outlined above.
All aspects of a standard face-to-face session were replicated. The only difference was that the client could not physically use the communication aids that were being demonstrated. During face-to-face assessments, clients are typically shown eight different aids. This is after provisional assessment, once inappropriate aids have been ruled out. It would not be practical to send all of these aids out to the patient by post for the purposes of assessment. To overcome this difficulty, detailed demonstrations of the aids took place. The clients were provided with life-size photographs of the aids that were demonstrated and they were set tasks using these paper replicas.
Following each videoconference session, all participants were asked to complete the relevant satisfaction questionnaire. The questionnaire was completed after the video link had been terminated. Participants remained together to complete the feedback questionnaire and were permitted to discuss their thoughts. Those who needed support completing questionnaires were aided by those who accompanied them.
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Participants gave an average satisfaction score of 88% (range 86–94) (Table 2). Of the 24 participants who went on to complete review sessions, the average satisfaction score was 95% (range 87–100) (Table 3). The percentage change in satisfaction from the assessment session to the review session (Table 4) was used to assess the hypothesis that participants would become more satisfied with videoconference sessions the more they were exposed to it.
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The assessing speech and language therapists made a number of comments in their feedback forms which related to the ability to run sessions smoothly over the videoconference. Particular comments were made about writing continuation notes for record-keeping purposes. Therapists reported that breaking eye contact over the videoconference, in order to write up notes, felt much more uncomfortable when compared to writing notes during a face-to-face session.
During assessments more than one assessing CAC therapist was often present. These therapists commented that there appeared to be fewer opportunities, or it felt more uncomfortable to share opinions and to discuss assessment findings when assessing via a videoconference. Therapists suggested that they felt more under pressure to produce a smooth flowing session.
One therapist noted the importance of setting out guidelines from the outset, regarding how successful communication would be achieved. The introduction of these guidelines followed a session whereby the local therapist and parents talked between themselves at the far end. The information on the questionnaire stated that at times the participants seemed unaware of the therapist's presence at the near end and consequently interacted with one another only.
A number of CAC and local therapists highlighted the importance of the local therapist's role at the far end, to ensure a successful videoconference session. It was suggested that there was a heavy reliance on the local therapist to feed back additional information which could be lost in the medium, such as interpreting subtle communication responses.
In order for the session to be of benefit, all CAC therapists commented on the importance of having all members at the far end being within the field of view of the camera. Difficulties were experienced when individuals wanted to contribute but did not want to be seen on screen. A CAC therapist commented that all participants who wished to contribute to discussions must agree to be in camera view prior to the start of the conference.
Comments were received about the pacing of the session. It was suggested that the pace of the session would need to be consciously slowed, to allow participants at the far end plenty of opportunities for discussion. The CAC therapists were advised to ask the participants at the far end more frequently, if they had anything to contribute or if they would like to ask any questions.
One therapist reported that their client had become fatigued much sooner in the session over a videoconference than she would have done had the assessment been carried out face to face.
One carer stated that it was quite difficult for clients to follow instructions, and felt this was due to the CAC therapist's inability to model tasks over the system. Overall, clients, their carers and relatives reported experiencing successful communication interactions over the videoconference.
Local therapists were also generally positive about communication over the videoconference. Concerns were raised regarding subtle non-verbal communication being lost. Local therapists who participated early on in the trials commented on how they found it disconcerting that the assessing therapist was not making accurate eye contact with them over the system. The set-up of the equipment was adjusted, and this feedback did not then re-occur.
Many of the comments received from the participants related to the quality of the sound and visual images of the videoconferencing system. Some groups of participants felt that it was sometimes difficult to see and hear both the therapist and/or the devices being demonstrated. Some participants commented that this potentially affected the communication interaction at times.
The CAC therapists at the near end experienced similar difficulties. In addition they commented that it took too long to control the camera when different shots were required. The importance of setting up pre-set camera positions was emphasized. Lighting problems were also commented upon. There were occasions when the lighting conditions of the rooms changed during the assessment and consequently the far end participants were seen as silhouettes.
CAC therapists typically gave less positive responses in the questionnaire, compared to the other participant groups. The CAC therapists were critical about all aspects of the videoconferences, whereas the clients consistently gave the most positive feedback.
Increased positivity with increased exposure
Participants gave more positive feedback in review sessions, compared to the assessment sessions (Table 4). Carers and relatives reported more dissatisfaction with technical aspects in the review sessions than in the initial assessment sessions. The remaining changes all showed increased satisfaction which supports the qualitative data received from participants.
Satisfaction with videoconference session
The final item of the questionnaire asked all participants to state whether they felt the videoconference assessment was a satisfactory method of carrying out a CAC session. Including assessment, review and training sessions, this question was answered by a total of 51 participants. Only two people answered in the negative. These responses were provided by a relative and by a local speech and language therapist, following an initial assessment.
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It was anticipated that those with learning difficulties would be the most satisfied group, as their cognitive difficulties mean their thoughts can often be influenced by the positive reactions of people around them. The CVA participants however were the most positive group. This may have been because they could understand more fully the reasoning behind the research and could see the benefits for people who were unable to travel to a regional assessment centre.
It was also assumed that the 16–30 years population would be the most satisfied group of participants as, being the youngest group of participants, they would feel more comfortable about using technology. The results supported this hypothesis.
Although many participants indicated areas which needed improvement, 94% of the questionnaires returned stated that videoconference sessions were successful.
Difficulties in managing a videoconference session were expected and therapists conducting these sessions were anticipating that the sessions would feel different from conventional face-to-face ones. As the assessing therapists' experience of videoconferencing grew, the perceived need to produce a polished presentation diminished. This may have been the result of more open communication with the local therapist, explaining much more of her actions, e.g. when writing notes. In order to achieve a successful session, it was deemed important to keep this open channel of two way communication. As pointed out by many therapists, it was also important for the local SLTs to feedback as much information as possible, in order to achieve a successful outcome. It has been acknowledged that this may be difficult for therapists new to videoconferencing, as the therapists at the CAC took time to feel confident about participating in a videoconference. Yet, to achieve a successful outcome, the assessing therapist was dependent on the local therapist achieving this as soon as possible. This is supported by the fact that the perceived increased exposure led to increased positivity about the videoconferencing process.
From the outset, the quality of the videoconference was a concern. It seemed logical that the lower the quality of the conference, the less satisfied participants would be with the sessions. Although over 50% of the participants indicated that there were technical difficulties, e.g. visual or auditory disturbances at some point during the session, only 16% of participants reported experiencing communication difficulties during the session. One explanation for this could be that the technical difficulties experienced were fleeting and therefore did not significantly affect the quality of the conference.
The primary limitation of the present study was the method of data collection. Participant questionnaires were chosen as the method of gaining participant feedback following each videoconference session. Participants were required to provide a yes or no response for each question. This proved to be a restriction. Participating CAC therapists commented that, due to the way that some of the questions were phrased, e.g. the questions relating to technical aspects of the conference, they had to provide responses stating that there were some difficulties. However, they did comment that although the disturbances were present, they did not affect the outcome or success of the session.
Participants were all recruited as new referrals to the service and, as such, received all interventions via videoconference. Participants therefore did not have a direct comparison of a face-to-face intervention at the CAC to inform their responses when completing their feedback forms. It was possible that some of their comments would have highlighted similar issues if they had completed a feedback form regarding a face-to-face session.
A patient matrix was designed which aimed to ensure that a representative sample was collected in respect to the medical conditions of the participants. Service delivery via videoconference was not trialled with every condition. The results, therefore, cannot be generalized for all medical conditions.
In summary, the present pilot study indicated that the CAC service could be performed effectively by videoconference. Clients provided the most positive feedback in their questionnaires, while the SLTs were the most critical of the process. The results indicated that the process had its faults, but as 94% of all participants felt that videoconferencing was an acceptable form of service delivery, it can be concluded that this medium can be used as a form of service delivery. This may mean that patients who have traditionally been denied access to the service because of travel limitations, could potentially access the service via videoconference.
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