‘Massive potential’ or ‘safety risk’? Healthworker views on telehealth in the care ofolder people and implications forsuccessful normalizationWendy Shulver1* , Maggie Killington1,2 and Maria Crotty1,2
Abstract
Background: Telehealth technologies, which enable delivery of healthcare services at distance, offer promise forresponding to the challenges created by an ageing population. However, successful implementation of telehealthinto mainstream healthcare systems has been slow and fraught with failure. Understanding of frontline providers’experiences and attitudes regarding telehealth is a crucial aspect of successful implementation. This study aimsto examine healthcare worker views on telehealth, and their implications for implementation to mainstreamhealthcare services for older people. The study includes a focus on two further dimensions of urban versus ruralservices and level of clinician experience with telehealth.
Methods: Seven semi-structured focus groups were conducted with a total of 44 healthcare workers providingservices to older people in the areas of rehabilitation and allied health, residential aged care and palliative care.Focus groups included both telehealth experienced and inexperienced groups. Of the experienced groups, twoprovided services to both urban and rural patients, and two to rural patients. Inexperienced groups included onerural and two urban. Thematic analysis was undertaken to identify predominant themes. Between-group differencesand agreement in viewpoints for each of these themes are discussed and mapped to the theoretical constructsof Normalization Process Theory.
Results: The views of participants varied with the extent of telehealth experience and perception of accessibilityof healthcare services. Four themes describing clinician attitudes and perceptions that could impact on successfulimplementation of telehealth services are outlined: 1) Workability of telehealth: exponential growth in access ordecay in the quality of healthcare? 2) What is an acceptable level of risk to patient safety with telehealth? 3) Shiftingresponsibilities and recalibrating the team; and 4) Change of architecture required to enable integration oftelehealth service delivery.
Conclusions: The use of telehealth technologies to provide healthcare services to older people may be morereadily normalized in areas where existing services are limited. Though exposure to telehealth may be a factor,changes to the perceived feasibility of telehealth in relation to conventional services, as well as supportiveinfrastructure and training and skill recalibration may be more critical to successful normalization of telehealthservices for older people.
Key words: Telehealth, Implementation, Normalization, Normalization process theory, Qualitative, Rehabilitation,Aged care, Palliative care, Allied health
* Correspondence: [email protected], Aged and Extended Care, Flinders University, Daws Road,Daw Park, Adelaide, South Australia, AustraliaFull list of author information is available at the end of the article
BackgroundThe use of telehealth technologies to deliver healthcareservices at distance has been promoted as a promisingand cost-effective way to address the challenges createdby the healthcare needs of an ageing population [1, 2].Rehabilitation and palliative care are key services forolder people as most recipients are aged above 65 [3].Telehealth technologies offer promise for increasingdosage of exercises for older people undergoing rehabili-tation following such events as hip fracture and stroke,which is associated with better outcomes [4–8]. Otherpotential advantages of service delivery to older peoplevia telehealth include reduction of potentially distressingtravel for people such as palliative care patients andpeople with dementia, and better outreach of specialistservices into residential aged care facilities. Defined asthe ‘remote exchange of data between a patient andhealthcare professionals as part of the patient’s diagnosisand healthcare management’ [1], telehealth employs tele-communication technologies to enable transfer of infor-mation in the form of voice, data and images betweenpatients and healthcare providers.While telehealth interventions have been shown to
improve clinical indicators, successful implementationand adoption of telehealth has been slow and fraughtwith failure. Many telehealth services remain at the sta-tus of ‘innovation’, not extending beyond research pilotsor niche markets to become part of routine healthcaredelivery [1, 9, 10].Prior work examining implementation of telehealth
has identified factors such as infrastructure, techno-logical issues, change management, jurisdictional andorganizational boundaries and funding that may impacton successful integration of telehealth services [11–13].The differing interests and perspectives of variousstakeholders including patients, health professionals,managers, policy makers and information technolo-gists are also important [12–15]. While understandingdirect providers’ experiences and attitudes regardingtelehealth services is a crucial aspect of successful imple-mentation, indepth details on how health professionalsview telehealth and their roles in the introduction andprovision of telehealth services remains under explored[14, 16, 17].In Australia, a universal healthcare system is largely
funded by the Federal government, with service pro-vision, including public hospitals and regional healthnetworks, administered and run by state governments.The Australian federal government recently funded aTelehealth Pilots Programme, aiming to develop, deliverand evaluate telehealth services to patients’ homes, witha focus on aged, palliative and cancer care services. TheFlinders University of South Australia received fundingto undertake a trial of aged and palliative care services
delivered via telehealth, in partnership with a public hos-pital, the local rural health network and an aged careprovider in South Australia. The hospital serves a localcatchment area of Adelaide, South Australia, includingprovision of rehabilitation, aged, allied health and pallia-tive care services. The qualitative work presented in thispaper was undertaken as a component of this trial.The aim of the present study is to examine healthcare
worker views on telehealth, and their implications forintegration of telehealth into mainstream healthcareservices in the care of older people. Within this broadaim, the study examines two further dimensions that theliterature suggests can impact and drive implementationof telehealth services, namely the urban/rural divide andlevel of clinician experience with telehealth. There is anexpectation that telehealth technologies will delivergreater access to healthcare for rural and remote popula-tions by enabling delivery of healthcare to people intheir home locations [10]. We also wanted to explore inthis study the acceptability to clinicians of using tele-health in urban areas. Clinician acceptance has beenhighlighted as a key aspect of successful implementationof telehealth interventions, and experience with tele-health has been shown to impact on such acceptance[17–20]. Thus the study aims to answer the followingquestions: 1) What are the views of healthcare workersproviding services to older people on telehealth?; 2) Arethere differences in these views between healthcareworkers providing services in rural versus urban areas?;3) What impact does level of experience with telehealthhave on healthcare workers’ views on telehealth?; and 4)What are the implications of these views and attitudesfor the successful implementation of telehealth in theprovision of services to older people? The study reportson the views of healthcare workers providing services inboth rural and urban areas, and who have a range oftelehealth experience. Normalization Process Theory,which was developed to enable examination of implemen-tation and integration processes of complex healthcareinterventions, was used as the theoretical framework.
Normalization process theoryNormalization Process Theory (NPT) [21, 22] is a middlerange sociological theory that can be used to understandthe factors that facilitate or inhibit the implementationand embedding, or ‘normalization’, of complex healthcareinterventions into routine practice. There are numerousimplementation frameworks that have been developedfor or applied to telehealth services, including NPT[12, 23–25]. NPT enables multifaceted examination ofthe complex and inter-related factors that can impactimplementation of telehealth interventions, rather thanfocusing on particular aspects [18]. It is a useful frameworkfor analysis of frontline healthcare worker experiences as it
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focuses on the work that people do, both individually andcollectively, to integrate a complex intervention into prac-tice, and contends that successful integration requires con-tinuous investment in this work. The theory proposes thatimplementation occurs via four generative mechanismswhich are affected by factors that facilitate or inhibitnormalization of an intervention. These mechanisms are:Coherence – the way in which actors make sense of
and understand an intervention. Coherence requires thatactors reach a shared understanding of how the practiceis defined and differentiated from other practices.Cognitive Participation – actors’ engagement with a
new practice. Successful integration depends on the en-rolment of actors to create a community of practice, andtheir legitimation of the practice.Collective Action – the practical work of integration.
This work is governed by two modes of interactionsbetween people: interactional workability (congruence ofinteractions between health professionals and patients)and relational integration (working knowledge requiredby users and confidence in the broader network in whichtheir work is situated). Organizing conditions that im-pact on these interactions are skill-set workability (thedivision of labour and allocation of specific tasks relatedto an intervention and the calibration of these tasks torequired skill-sets) and contextual integration (the fit ofthe intervention within existing organizational structures,systems and practices).Reflexive Monitoring – participants’ ongoing evalu-
ation, both formally and informally, of a practice and theimplementation process.
MethodsSeven focus groups were conducted with clinicians andcare workers providing services to older people in theareas of rehabilitation and allied health, aged care andpalliative care to rural and urban areas. For the purposesof this study, ‘rural’ was defined as the areas serviced bythe local rural health network, and ‘urban’ was definedas areas within the greater Adelaide (capital city of SouthAustralia) region. All focus groups were ‘natural groups’,in that they comprised of clinicians and care workerteams that already knew and worked with the other par-ticipants in the group [26]. Figure 1 provides an over-view of the study methodology, including focus groupsrecruited, number of focus groups and participants, andthe data analysis processes. Table 1 provides further in-formation about the specific services provided by partici-pants, their level of experience with using telehealth forproviding patient care and the type of areas they served(i.e., urban or rural). All participants worked for eitherState government health networks or aged care providers.As shown in Fig. 1 and Table 1, the study included partici-pants serving rural areas both with and without telehealth
experience, and similarly included participants servingurban areas both with and without telehealth experience.The experienced group provided services to both urbanand rural areas, and incorporated clinicians and residentialaged care facility staff involved in the larger telehealth trialtesting telehealth as a way of delivering rehabilitation,geriatrics and palliative care in Southern Adelaide, SouthAustralia. Both the trial and qualitative study were ap-proved by the Southern Adelaide Clinical Human Re-search Ethics Committee, reference number HREC/13/SAC/121 (203.13).The larger telehealth trial also included a quantitative
Discrete Choice Experiment and attitudinal survey de-signed to assess older peoples’ preferences and attitudesregarding telehealth. The focus group data presentedhere was collected as part of this nested study, to beused initially for development of the questionnaire [3].The quantitative survey project guided both the selectionof groups for inclusion in the focus groups (rehabilitation,aged and palliative care clinicians/careworkers who wereor may in the future provide telehealth services) and thefocus group topic guide. The topics and sampling methodswere therefore not theoretically derived. However, thesample included all groups within South Australia thatcould have reasonably been targeted for such a topic, in-cluding all clinician groups participating in the larger trial.Moreover, the content of the focus groups provided excel-lent data on clinician attitudes, and valuable insights enab-ling useful theoretical exploration of implementationfactors with regard to healthcare services for older people.On reading the NPT literature in conjunction with ourpreliminary analysis of the focus group data, there wasindeed resonation between data and theory, warrant-ing deeper analysis using NPT as a useful conceptualframework.Four of the seven focus groups (urban clinicians,
novice telehealth urban clinicians and two telehealthclinician groups) were conducted at the urban hospitalin which they worked, and one residential aged caregroup was conducted at the participating rural aged carefacility. All focus groups that were able to be conductedface-to-face were done so, however, due to logistical anddistance difficulties, it was necessary to conduct twofocus groups with rural health service providers at dis-tance (one via videoconference with a second rural resi-dential aged care facility and one via teleconference withrural allied health clinicians). The potential disadvan-tages of these synchronous technologically mediatedfocus groups, such as lack of non-verbal information inthe case of teleconference groups, were far outweighedby the key advantage of enabling these health workers toparticipate thereby strengthening the sample and maxi-mising the capture of a broad range of experiences andviews [27]. Given that in this study the participants were
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motivated and engaged professionals with sufficienttechnological expertise, and that the questions andtopics covered in these groups were the same as for theface-to-face groups, we posit that the impact of differ-ences in focus group methodology on results is unlikelyto be significant.The number of participants in focus groups ranged
from two to 13, with a total of 44 participants. Eachfocus group took between half to one hour. Focus
groups with urban clinicians and novice urban telehealthclinicians included the clinical team and their manager.These focus groups were conducted at the time the teamheld their regular team meeting. All participants had thestudy described to them and were informed that partici-pation was voluntary. All present at the meeting con-sented to participate. All ‘telehealth’ clinicians involvedin the trial were invited to participate in a focus groupand consented to do so. No trial clinician declined
Fig. 1 Methodological schema
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participation. Rural allied health participants includedsenior clinicians from each of the allied health disci-plines. They were contacted through the chief alliedhealth officer for the local rural health network. All who
were contacted agreed to participate. The nurse man-agers of the residential aged care facilities who partici-pated in the telehealth trial were contacted regarding thequalitative study and asked to participate in a focus
Table 1 Focus group participants, level of telehealth experience and service provision area (urban or rural)
Participants Level of telehealthexperience in patient care
Health services provided to older people Focus group details
Participants providing services to urban areas
Urban ambulatory rehabilitation inthe home clinical team: ‘urban clinicians’
None Face-to-face physiotherapy (PT),Occupational Therapy (OT), Social Work(SW), Exercise Physiology (EP), SpeechPathology (SP), Rehabilitation Nursing(RN) in patients’ homes in southern urbanAdelaide.
Focus group 113 participantsFace-to-face aturban hospital
Urban ambulatory rehabilitation in thehome clinical team post implementationof telehealth into the service: ‘novicetelehealth urban clinicians’
Minimal Face-to-face PT, OT, SW, EP, SP, RN inpatients’ homes in southern urban Adelaide.Encouraged to provide some services atdistance via telehealth following roll-out ofthe service post-trial. Clinicians exercisedtheir own discretion regarding how muchof their caseload they used telehealth toprovide their service, with no set criteria forassigning a patient to telehealth deliveredservices.
Focus group 29 participantsFace-to-face aturban hospital
Participants providing services to rural areas
Residential aged care team: ‘residentialaged care staff’
6 months Supported residents who participated intelehealth geriatric review and rehabilitationat two rural residential aged care facilities.Review, assessments and follow-upsconducted via specialist videoconferencingequipment installed at the aged care facility.
Focus group 36 participantsFace-to-face atresidential agedcare facilityFocus group 42 participantsVideoconference
Rural rehabilitation allied health clinicalteam: ‘rural allied health clinicians’
None Rehabilitation and allied health services torural areas in South Australia.
Focus group 57 participantsTeleconference
Participants providing services to both urban and rural areas
6 months Service provision via telehealth as partof a telehealth in the home trial:Rehabilitation: Combination of face-to-faceand distant PT, OT, SP assessment,intervention and review, distant activitymonitoring. To community patients in urbanareas of Adelaide, and rural patients living inresidential aged care. Monitoring done viaprovision of ‘off-the-shelf’ (i.e., iPad)technology to patients in their homes, andspecialist videoconferencing technologyinstalled in residential aged care facilities.Activity level data was electronicallytransmitted and assessments and follow upconducted via videoconference.Geriatric review for patients living in ruralresidential aged care facilities: Specialistvideoconferencing technology installed atthe facility through which a geriatricianlocated at the hospital conducted distancereviews with the support of a ‘trial nurse’and facility staff ‘on the ground’.Palliative care to community patients:Combination of face-to-face and distantintervention, including daily self-reporting ofpatients’ symptoms via iPad provided to thepatient in their home.
Focus group 65 participantsFace-to-face aturban hospitalFocus group 72 participantsFace-to-face aturban hospital
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group with nursing and caring staff who had beeninvolved in the trial. All staff who were available at thetime of the focus group agreed to participate. The focusgroups were moderated by the researcher MK with theassistance of WS. MK was involved in the design, ethicsapproval and start-up of the larger telehealth trial. Shewas therefore known to the participants working on thetrial, but did not have a direct working relationship withthem and was not directly involved in patient care.Experienced healthcare workers discussed ‘telehealth’
with reference to their practice during the trial, as sum-marised in Table 1. Novice telehealth clinicians were be-ginning to utilise telehealth technology in the same wayas used in the trial for rehabilitation patients followingroll-out of the service post-trial. Telehealth was definedat the beginning of focus groups with inexperiencedclinicians as ‘the use of telecommunication technologiesto provide healthcare services. These services enablepassing of information in the form of voice, data andimages between patients and health professionals’. Ex-amples were provided of ways in which telehealth tech-nology can be used. All participants without directexperience indicated an understanding of telehealth andwhat it can be used for in terms of service delivery andpatient care.The focus groups were semi-structured. Topics cov-
ered included asking participants to describe their tele-health experiences, the clinical areas (if any) in whichthey have used the technology, their views on the posi-tive and challenging aspects of providing healthcare viatelehealth, challenges and requirements for the imple-mentation of telehealth services, benefits, compromises,quality of care with telehealth and any other input theyhad regarding telehealth. Probing was used to ensuretopics were sufficiently explored. Each focus group waschallenged until no more new information or percep-tions were forthcoming about the topic.Interviews were recorded and transcribed verbatim.
NVivo10 qualitative data analysis software was used as adata management tool to aid the analysis. Thematic ana-lysis was undertaken to identify predominant themes inthe data. Analysis was based on the coding proceduresdescribed by Richards [28]. The researcher MK under-took the first analysis stage of ‘topic coding’, involvingline-by-line coding of each transcript to develop aprovisional coding framework consisting of 13 initial cat-egories. The initial analysis and resulting coding frame-work was descriptive rather than conceptual at thisstage, and all transcripts were analysed together, withoutexamination of the differentiation in responses betweendifferent clinician groups. In the second coding phaseof ‘analytic coding’ further, more indepth analysis wasundertaken to develop conceptual ideas. MK and WSexamined and discussed the provisional codes to draw
out and agree on nine predominant themes. In thefinal ‘coding on’ stage the themes were re-examined,with particular attention to any patterns, similaritiesand differences in responses between the differentgroups. It was found that there was a high level ofagreement within groups and some clear differencesin views between groups. Though our study includedthe viewpoints of a range of clinician groups, we didnot make specific assumptions about between-groupdifferences in our preliminary analysis. However it becameapparent through the analysis that between-groupcomparison was a fruitful method of making sense of thefactors that impact on successful implementation of tele-health services. These differences and their theoretical res-onance were reflected on and discussed, resulting in thenine subthemes collapsed into four overarching themes.These were mapped to NPT to further develop ideasregarding the implementation potential of telehealthbetween the different groups, and the likely promoting orinhibiting factors. For example, the overarching theme re-garding acceptable risk derives from subthemes outliningthe differences between experienced clinicians’ strategiesto overcome risk and inexperienced urban clinicians’ con-cerns about compromising safety with telehealth. MK andWS each worked on the development, writing up andmapping of individual themes to theoretical concepts,with regular meetings to discuss and refine their develop-ment. Though we have described the analysis in distinctstages for clarity, consistent with qualitative research ingeneral, analysis in practice was not linear but rather aniterative process, with continual cycling between codingstages and theoretical exploration.
ResultsThe four overarching themes are outlined below, withineach of which we highlight the contrasting viewpoints ofdifferent groups. Table 2 summarises each group’s pos-ition on each of the four themes. Illustrative quotes aretagged with the focus group name, number and level oftelehealth experience. Results are linked to the theoreticalconcepts of NPT in the discussion, and the implicationsfor implementation of telehealth services for older peopleoutlined.
Theme 1: Workability of telehealth: exponential growth inaccess or decay in the quality of healthcare?Both rural allied health and telehealth clinicians werepositive about the potential of telehealth and very keento explore any possibilities the technology could offerwhich might enhance and expand access to the servicesthey were able to deliver. Rural health clinicians stronglyvoiced their enthusiasm that it would support the clin-ical needs of their patients despite having little or noexperience of using the technology:
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Table 2 Health worker positions on each of the 4 identified themes
Theme Urban clinicians Novice telehealth urban clinicians Residential aged care staff Rural allied health clinicians Telehealth clinicians
Workability of telehealth:exponential growth in accessor decay in the quality ofhealthcare?
Reservations about the safetyand suitability of telehealth andthe limitations it places on whatthey can do at distance. Betterthan nothing for people in ruralareas who cannot easily accessface-to-face services
Significant portion of caseloadcould be serviced via telehealth,but similar reservations to urbanclinicians, particularly for complexcases
Positive about theeffectiveness of telehealthand saw it as justas good as face-to-face
‘Massive potential’ to expandservices and provide betteraccess to healthcare to rurallocations
Positive about the potentialof telehealth and keen toexplore possibilities thetechnology could offer toenhance and expand theirservices
What is an acceptable levelof risk to patient safety withtelehealth?
Concerned about the levels ofperceived risk with telehealth,associated with not being withthe patient to assist in the eventof an adverse advent (forexample a fall during exercise)
Revert from telehealth back toface-to-face if complications arise,but acknowledged that ongoingexperience can promote newways of managing challenges oftelehealth
Focussed on perceivedimprovements in outcomesfor aged care residents whohad received services viatelehealth, rather than risk totheir safety
Focussed on the potentialimprovements to patientoutcomes through betteraccess to services, ratherthan risk to patient safety.Telehealth is ‘safe’ and‘equivalent, if not better’ thanconventional face-to-facetherapy
Accepting and pragmaticabout risk, which theythought of as something tobe planned for and managedas an integral part of theprovision of services viatelehealth
Shifting responsibilities andrecalibrating the team
‘Risk’ problems with telehealthcould be alleviated by having asupport person ‘on the ground’with the patient.
‘Risk’ problems with telehealthcould be alleviated by having asupport person ‘on the ground’with the patient
Took on the role of ‘on theground’ support duringvideoconferences withresidents of the aged carefacilities, and through thisincreased their skill levels
Keen to forge links withurban speciality services tosupport rural clients
Adequate training of ‘on theground’ supporters isimportant
Change of architecture requiredto enable integration oftelehealth service delivery
Existing ‘traditional’organizational and systemicstructures need significantoverhaul before being ableto fully support outreachtelehealth services
Concerns about thelimitations of existingtechnological infrastructureand support. Keeping upwith rapidly changingtechnology and the requiredtechnological training andsupport will be challenging
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I think there’s a massive potential to expand thesorts of services we can provide to people in theirlocal communities by stronger partnership withmetropolitan [urban]-based specialty serviceslinking with our general clinicians to supportthe client on the ground [rural allied health clinician,FG 5, no experience].
The rural allied health team indicated that tele-health technology provided ‘a whole range of othercapabilities’, and considered it ‘safe and it’s appropriateand it’s an equivalent, if not better, sort of servicethat you can provide’. They were committed to thenotion that telehealth could balance the unequal ac-cess to services across geographical locations, andwere keen to pursue innovative ways of using tele-health technologies to allow them to provide complexdistant therapy.In contrast to rural and experienced telehealth clini-
cians who were keen to utilise technology as part oftheir role and to deal with distance and isolation, urbanclinicians with no exposure to telehealth reported morereservations about the safety and suitability of providingrehabilitation through telehealth. They generally felt thattelehealth should be reserved for ‘people who are moreautonomous and more capable and … straightforward’,rather than ‘real’ rehabilitation patients with complexissues. They felt that people who required rehabilitationoften require a ‘hands on’ approach:
I like to be a lot more hands on with thosepeople, particularly when there are sensorydeficits and if there are compounding issues withcommunication and things like that, I know I wouldhave my reservations about using telerehab[rehabilitation via telehealth] in those circumstances[urban clinician, FG 1, no experience].
In addition, urban clinicians were concerned thatreduced access to the patients’ home would adverselylimit the information that they could collect and potentiallyincrease risks to the patient:
Once you’re actually there and you can see the entirehouse that gives you a much better picture. There areso many visual cues that you get from being in theroom and being in the home. Smell, cleanliness, dishes,people’s self-care, their family, social interactions[urban clinician, FG 1, no experience].
Urban clinicians perceived such risks in relation totheir own urban patients. However, with regard torural areas with limited access to services, their viewsbecame more aligned with those of rural health clinicians.
For rural patients, they considered that compared to nointervention, telehealth delivery became more acceptable:
I think in the rural sector, it’d be great, for peoplewho can’t access services … It’s probably a littledifferent in the metropolitan [urban] area[urban clinician, FG 1, no experience].
Novice urban clinicians, who had very recently com-menced utilising telehealth technology in the provisionof their services, were somewhat more accepting of tele-health than their colleagues who had not been exposed.They generally agreed that a significant proportion oftheir caseload could be serviced via telehealth, howeverthey retained reservations about the telehealth approach,particularly for more severely impaired patients:
[Telehealth] is a great way of treating functionallydeclined patients who need to improve their strengthand endurance … fantastic for them. It is probably notso good for some of the stroke hands on type manualtherapy type of … patients [novice telehealth urbanclinician, FG 2, minimal experience].
Unlike urban clinicians, staff working in the aged carefacilities which received a telehealth service were positiveabout the effectiveness of rehabilitation via telehealth andnoted many changes in residents, such as increasedinvolvement in activities and taking responsibility for theirmobility. When asked whether they would have preferredmore face-to-face input, rather than videoconferenc-ing as provided, residential aged care staff unanimouslyanswered in the negative:
I mean, of course, it is nice to have a face-to-face,but I think the teleconference was just as good. It justfelt like [therapist] was with us [residential aged carestaff, FG 3, 6 months experience].
Theme 2: What is an acceptable level of risk to patientsafety with telehealth?Discussion of ‘risk’ in the focus groups centred on therisks to patients associated with providing services atdistance. Participants recognised that things could gowrong, for example a patient falling during exercises orchoking during a swallowing assessment. Urban clini-cians were concerned at the levels of perceived risk withtelehealth, associated with not being with the patient toassist in the event of an adverse event. In contrast, theexperienced telehealth trial clinicians were more accept-ing of and pragmatic about risk. They tended to think ofrisk and patient safety as something to be planned forand managed as an integral part of the provision of ser-vices via telehealth. Rather than something that would
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prevent or severely limit what could be done via tele-health, different and alternative ways of thinking aboutand managing risk due to the absence of physical prox-imity to the patient were required. As one clinician putit, ‘it’s challenging what we previously have thought “wellyou have to be there to do”’:
You have to calculate the risk. Really youcouldn’t just decide on the spur of the moment,exercises that you’re going to do. You have to plan abit more because of that risk-taking and maybe havesome [safety] parameters in place for patients[telehealth clinician, FG 6, 6 months experience].
Novice urban clinicians showed a similar approach torisk as their inexperienced counterparts. Though opento the idea of using telehealth for patient care, theirresponse to cases in which a complication or challengearose was reversion back to conventional face-to-facetherapy:
If I chose to do the teleconferencing [telehealth],I might have to leave myself enough time and then ifsomething [a complication] came up and … I felt asthough I need to actually follow that up today ortomorrow if I had the time to go out and seethem in person [novice telehealth urban clinician,FG 2, minimal experience].
However, there was also acknowledgement in this groupthat ongoing experience can promote development of newways of practice and ways of managing the inherent chal-lenges of providing services via telehealth:
So I think ultimately, with experience we get to knowmore about maybe ways around that but there is quitea lot [of therapy] that is hands on as well [novicetelehealth urban clinician, FG 2, minimal experience].
Theme 3: Shifting responsibilities and recalibrating theteamThere was a sense among all groups that many ‘risk’problems associated with telehealth could be alleviatedby having someone with the patient ‘on the ground’ tosupport distance healthcare via videoconference (i.e., acarer, residential aged care staff, family member, localhealth professional):
I wouldn’t do a swallowing assessmentwithout someone in the home because I need someonethere to either be looking in the mouth or shining alight into their mouths … and to be there ifthere is a choking incident [telehealth clinician,FG 6, 6 months experience].
Residential aged care staff clearly took on supportiveroles during videoconferences with residents. This wasseen in a positive light, with these new responsibilitiesproviding opportunities to learn and upskill, and greaterjob satisfaction:
It’s really helped us to know a lot of things withmassaging them and just new ideas withexercises and using the weights [residential aged carestaff, FG 3, 6 months experience].
A service model that incorporates collaboration withlocal health professionals was considered an importantaspect of successful provision of service via telehealthamong all focus groups:
I’d be looking at a local health professional, tappinginto their view, getting them to knock on the door …Because there needs to be a collaborative thing if we’reusing telehealth to support them, we need to work withthe local people [telehealth clinician, FG 7, 6 monthsexperience].
However, telehealth clinicians recognised that suchshifting of tasks and responsibilities requires trainingand recalibration of skill-sets between telehealth providersand ‘on the ground’ supporters to enable them to under-take this role:
Neurological and physical assessments would be quitedifficult because you’d have to rely on the person or acarer at the other end to be able to move that personin a way that would give you enough information andyou get a lot of information from the way somethingfeels …You could possibly do it, but you’d have to beconfident that there’d be prior training of the carerto help with that or to give that sort of feedback[telehealth clinician, FG 6, 6 months experience].
I think it would probably need to be someone trainedthat I would feel confident could manage a chokingincident, for example, so I guess that would need to bediscussed with management, is the carer sufficient orwould it need to be someone else - just for riskmanagement [telehealth clinician, FG 6, 6 monthsexperience].
Theme 4: Change of architecture required to enableintegration of telehealth service deliveryRural health clinicians in particular thought that existingorganizational and systemic structures, which were ‘verytraditional in their approach’ would need significantoverhaul before being able to fully support outreach tele-health services to rural areas. These issues ranged from
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jurisdictional barriers, funding structures and changes toreferral pathways and follow-up procedures:
But if we’re talking about comprehensive healthcareand our patient journey and that whole follow throughof supporting people in the context in which they liveand work and all that sort of thing, then I think thereare limitations the more remote from the area of theservice. That’s not to say it can’t be done, but becauseour health services are largely jurisdictional … Therewould be some bureaucratic processes that would needto be worked through around sharing of informationand patient flows and that knowledge of expectation ofservice response if you recommended or referred - allof that sort of stuff [rural allied health clinician,FG 5, no experience].
Concerns were also raised by telehealth clinicians aboutthe quality and range of the telehealth infrastructurecurrently available to them, and the limitations this placeson what can be done via telehealth. Given access to moretechnology and support, they felt that they could furtherexpand the telehealth services they can provide:
I think we’re limited with the range of technologiesthat are available to us … There are a lot of thingsthat we can’t do at the moment, but it’s not becauseit’s not possible, it’s because we don’t have thetechnological support. For example, a second cameraor a split-screen availability to make sure that we’reshowing the person the right things [telehealthclinician, FG 6, 6 months experience].
Ongoing technical support was also raised as a factorthat could impact successful implementation of tele-health services. Telehealth clinicians felt that successfulembedding of a telehealth service requires organizationalprovision of comprehensive technical support, beyondsimple helpdesk support:
I think there has to be some sort of service that goesbeyond pure IT support around logging on/logging offtype stuff. I think there has to be maybe a new streamof either therapist or parallel to that are techniciansthat actually have a clinical focus that can actuallydrive this and I don’t think we have that at themoment [telehealth clinician, FG 7, 6 monthsexperience].
It was also recognised that rapid and ongoing advancesin technology will have an ongoing impact on telehealthservice structures and pose challenges for the mainten-ance of the working knowledge required to effectivelyuse telehealth:
We are dealing with areas that are ever-changing andrequiring support and I think that is going to be one ofour huge limitations to providing this type of service inthe future, because whilst we will all up-skill and wewill all get better at using it because we just use it inour everyday lives, I think it will then change andwe’ll get a new machine or a new game or a newprogram which we will then have to [learn] …So it’s rapidly changing and I think that is thechallenge for us all to know what’s out there andwhat’s going to help us [telehealth clinician,FG 6, 6 months experience].
DiscussionThis study contributes to the insufficiently understoodarea of how health professionals view their roles intelehealth service provision, and furthers our under-standing of the implementation potential of telehealth inthe context of care services for older people in Australia.A multifaceted examination of these issues, through theuse of NPT as a conceptual framework, has to our know-ledge not previously been undertaken. A 2014 systematicreview of studies using NPT to examine implementationprocesses found a number of studies examining tele-health/telecare/e-health initiatives, but none specificallyconcerned with the service areas of rehabilitation, aged orpalliative care [29]. Subsequent relevant NPT studies havelooked at secondary hip fracture prevention services, anddecision making for people with dementia in Australianaged care facilities [30, 31], but again, none have looked atthe specific contexts examined here. Our results show acontrast in the attitudes of rural and telehealth experi-enced healthcare workers about telehealth, compared tourban inexperienced clinicians. Table 3 summarises eachclinician group’s views on telehealth by the NPT genera-tive mechanisms. In NPT terms, there was coherence inthe way rural and telehealth clinicians defined and under-stood telehealth. They clearly differentiated telehealth as adistinct model of service that required new ways of work-ing. These clinicians were focussed on the potential fortelehealth to achieve better outcomes for patients, andwere willing to re-think and adjust their practice to pro-vide distance healthcare. In contrast, inexperienced andnovice urban healthcare workers had not yet devel-oped coherence with regard to telehealth. They didnot conceptualise telehealth as a distinct model ofservice, but rather as an adjunct to conventional ser-vices, as evidenced by their perception of telehealthservices differently for urban and rural patients. Norwere they embracing and thinking about novel solu-tions to risks and challenges in providing their ser-vices via telehealth, but rather felt that face-to-faceservice delivery is the best, and in complex cases, the onlyappropriate method.
Shulver et al. BMC Medical Informatics and Decision Making (2016) 16:131 Page 10 of 15
Rural and telehealth experienced healthcare workersalso demonstrated cognitive participation in clearly view-ing telehealth as a legitimate way to expand their services
and showing a willingness to engage with it, and establisha community of practice by working together and for-ging links with other services and clinicians. Cognitive
Table 3 Summary of views on telehealth by participant group and NPT generative mechanisms
Clinician group Coherence Cognitive participation Collective action
Urban clinicians Low. Perception of telehealth did notcohere with that of other groups ofclinicians. Perceived the servicedifferently for rural than forurban patients.
Low. Do not see telehealth as alegitimate model of service for‘real’ rehab patients (particularlyurban patients).
Interactional workability – low. Onlysuitable for high-functioning or remotepatients (who have no option for face-to-face consults). Patient-therapist interactionswould suffer due to narrowing of thescope of what can be seen and done viavideoconference.Relational integration – low. Focussed oncurrent patients rather than wider servicedelivery limitations
Rural allied healthclinicians
High. Clearly defined, differentiatedand understood telehealth and itspotential
High. Willingness to engage withtelehealth as a model of service;viewed telehealth as a legitimateway to expand their services;looking at ways to create acommunity of practice utilisinglocal health professionals.
Interactional Workability – High. Promisingway to provide access to services forrural patients who lack local services.Relational integration – High. Clearunderstanding of the wider health networkand could see opportunities for usingtelehealth to link urban and rural servicesContextual integration: Low Considerableorganization, systemic and technologicalinfrastructure barriers
Novice telehealth urbanclinicians
Developing. Telehealth stillconceptualised as an adjunct totraditional model of service.
Developing. Burgeoning acceptanceof telehealth but retained concernsabout the efficacy of telehealth formore severely impaired patients.
Interactional workability – low to moderate.Agreed that a significant proportion of workcould be done via telehealth but still feltthat it was not suitable for significantlyimpaired patients.Relational integration – low. Conventionalmodel of service seen as ‘core business’,with telehealth incorporated at theirdiscretion, rather than embracing novelways of working using telehealth.
Telehealth clinicians High. Clearly differentiatedtelehealth as a distinct modelof service that required newways of working.
High. Engaged with the serviceand were thinking about ways toexpand its scope and make it work
Interactional workability – moderate. Carefulplanning and improvements in technologyrequired to maximise what can be donevia telehealthSkill-set workability – questionable. Concernedthat on the ground supporters ofvideoconferences adequately trained.Relational integration – moderate to highConcerns about keeping up with rapidlychanging technology to maintain workingknowledge; forged supportive networks withresidential aged care facilitiesContextual integration – ModerateTechnological infrastructure and techsupport requiredReflexive monitoring – High.Re-conceptualised telehealth as a distinctmodel, rather than an adjunct to traditionalmodels. Thinking about ways in which theycould improve, expand and respond tochallenges in providing their services viatelehealth
Residential agedcare staff
High. Positive about theimpacts of telehealth as anew service not previouslyavailable to their residents
High. Embraced the service andcollectively enrolled.
Interactional workability – High. Positiveoutcomes for residents. Teleconferenceas good as face-to-face.Relational integration – High. Establishedlinks with urban rehabilitation andgeriatric services.Skill-set workability – High. Displayed theskills to support interventions; increasedtheir skill-set through doing so.
Shulver et al. BMC Medical Informatics and Decision Making (2016) 16:131 Page 11 of 15
participation is less developed among inexperiencedurban clinicians with respect to urban patients asmany do not see it as a legitimate service model for‘real’ patients (i.e., those with complex issues). Simi-larly, novice urban clinicians, whilst more open to theprospect of increasing utilisation of telehealth thanthose with no experience, still perceived these samelimitations.There were also differences between rural and tele-
health clinicians and both novice and inexperiencedurban clinicians in terms of collective action. In particu-lar, urban clinicians were concerned that telehealth com-promises interactional workability. They did not believethat telehealth is an appropriate substitute for face-to-face interactions with patients who they would otherwisesee in person and felt that the patient-therapist inter-action and its outcomes would suffer due to a perceivednarrowing of the scope of what they can see and do overvideoconference. By contrast, experienced telehealthclinicians and residential aged care staff demonstratedsuccessful interactions between clinicians and patientsvia telehealth, though telehealth clinicians felt that theycould further improve interactions with access to bettertechnology. Rural allied health clinicians and residentialaged care staff perceived an interactional advantage oftelehealth in its potential to accomplish improved dis-posal of work and access to healthcare for the rural pop-ulations they served. Aged care facility staff saw nocompromise to interactional workability, believing thatvideoconference interactions were equal to face-to-face.Telehealth clinicians and aged care facility staff were
able to establish relational integration of the telehealthservice by gaining the knowledge required to supportthe service and forge links between urban based rehabili-tation and geriatric services and rural aged care facilities.Rural allied health clinicians had a clear understandingof the wider health network in which they practiced andthe limitations of existing services, and could see op-portunities to maximise relational integration of servicesby using telehealth to link urban and rural healthcareservices.The willingness to engage and utilise other health pro-
fessionals shown by all groups, in particular experienced,rural and residential aged care participants, holds prom-ise for cognitive participation, the enrolment of otherstowards the development of a telehealth community ofpractice, and relational integration towards an integratedteam of clinicians and carers working at distance. How-ever, this study highlights the importance of monitoringthe skill-set workability of such a network. Residentialaged care clinicians did not experience difficulties adapt-ing their skills to enable them to support rehabilitationand geriatric assessment videoconferences on the ground.They felt, in fact, that their skills were enhanced through
their participation in the trial. Nevertheless, the skill-setworkability of ‘on the ground’ supporters was raised bytelehealth clinicians, who recognised that telehealth mayrequire enlisting new sources of support and recalibrationof skills in order to achieve effective telehealth services.As argued by Mort et al., through telehealth, ‘responsi-
bilities in care networks are shifted and delegated in newways’ [32]. Reliance of others ‘on the ground’ to supporttelehealth service delivery has the effect of shifting theburden of care work and re-allocating tasks and respon-sibilities. With traditional models of service, family andcarers may transport a patient to a clinic appointment.With telehealth, they may instead be asked to fulfil someof the therapist’s role assisting with exercises or assess-ments at home. Local health professionals supportingtelehealth consults may also necessitate taking on someof the roles usually performed by specialists. Conversely,new responsibilities may also be required of specialists,who may need to train, advise and assist local people onthe ground in order to enlist their support. It is import-ant for successful integration of the model that attentionis paid to the existing skills of those who will be calledon to undertake new tasks, and training provided wherethere is a lack of calibration between tasks and skill-sets.Telehealth and rural allied health clinicians raised con-
cerns about a number of contextual integration barriersto normalization of telehealth services. The latter in par-ticular strongly felt that telehealth services do not cur-rently fit well within existing health service structures,and identified numerous organizational and systemicbarriers that would need to be overcome if telehealth isto be successfully integrated into existing mainstreamhealth services. Telehealth clinicians also raised techno-logical infrastructure as an issue that may inhibit con-textual integration, including the challenges of dealingwith rapidly changing technology and provision of on-going technical support. Telehealth clinicians recognisedthat rapid and ongoing advances in technology will im-pact on relational integration and skill-set workability,posing challenges for the maintenance of the workingknowledge required to effectively use telehealth. Lack oforganizational support, jurisdictional constraints andincompatibilities across different organizational entitieshave also been recognised in the literature as barriers toimplementation of telehealth [12, 13]. ‘Leadership sup-port’ from health service decision makers and managershas been identified as a key factor in achieving broadimplementation of telehealth, as such support is essentialfor addressing such contextual integration barriers raisedby the health workers participating in this study [33].This study indicates that both location of service
(urban versus rural) and level of experience with telehealthdo impact on health worker attitudes, and therefore theimplementation potential of telehealth in the context of
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care for older people. As shown in Table 3, residentialaged care staff working in rural facilities demonstrated, inNPT terms, high coherence, cognitive participation andcollective action. In addition, their urban-based partnerswho provided the service, experienced telehealth practi-tioners, also showed that they engaged with and perceivedthe model to be a legitimate way of providing their service.These factors are likely to support embedding of this newmode of health delivery in the unique context of reha-bilitation and geriatric outreach services to older peopleliving in residential aged care.Rural health practitioners’ attitudes regarding tele-
health met many of the constructs outlined in NPT asnecessary to successful implementation of new servicemodels, despite these clinicians not having used thetechnology in the provision of their services. We arguethat their awareness of the unmet healthcare needs ofmany in rural areas drives their engagement with the po-tential of telehealth and holds promise for integration ofa rural telehealth service. However, our results also showthat clinicians working in urban areas that are more eas-ily able to see their patients face-to-face can also findtelehealth models of service acceptable and willingly usethe technology.In contrast to urban clinicians with no experience of tel-
ehealth, the experienced telehealth clinicians in this studyhad significantly developed coherence, cognitive participa-tion and collective action. They had re-conceptualised theway in which they provide their services through the lensof telehealth, rather than as a mere adjunct to conven-tional face-to-face therapy. They also had sufficient experi-ence to develop insightful reflections on telehealth inrehabilitation, demonstrating reflexive monitoring in NPTterms. They were able to reflect on how they can furtherextend telehealth services and respond to challenges, byaccessing and improving available technologies and pre-emptively managing risk. The telehealth clinicians wererecruited to work on the telehealth trial from the cohortof urban clinicians, which supports existing evidence thatexperienced healthcare workers perceive telehealth ser-vices in a more positive light than those without telehealthexperience [17, 19, 20].However, it is possible that the clinicians who applied
or were nominated to work on the telehealth trial haddifferent characteristics from other staff. This study sug-gests that increasing exposure to the technology and ex-perience providing telehealth may be beneficial but notsufficient to significantly enhance normalization po-tential. Novice providers of telehealth services dis-played a burgeoning acceptance of telehealth, howeverthey still conceptualised it within the bounds of con-ventional practice, rather than a distinct model of ser-vice. As put by Asch ‘The innovation that telemedicinepromises is not just doing the same thing remotely that
used to be done face-to-face but awakening us to themany things that we thought required face-to-face contactbut actually do not’ [34]. We posit that a key differencebetween experienced telehealth and novice clinicians wasthis difference in conceptualisation, or in NPT terms, lackof coherence about telehealth on the part of novice clini-cians. Hinging on this was a difference in expectationabout how and the degree to which these clinicians willuse telehealth. The former, by virtue of their involvementin a trial specifically evaluating telehealth, viewed tele-health as their core business. By contrast, novice cliniciansperceived conventional face-to-face therapy as theircore business, with telehealth incorporated at theirdiscretion.It remains to be seen whether these novice clinicians
will further embrace and legitimise telehealth as theirexperience lengthens. This research suggests that inaddition to exposure, attention needs to be paid to rela-tional integration of the service. Researchers havehighlighted the importance of understanding how tele-health dovetails with conventional services [14]. Analysisof the implementation of the Whole System Demonstratortrial in the UK, one of the largest trials of telehealthservice provision, has demonstrated the challenges inachieving ‘whole system’ change and complete integrationof telehealth services. Support of front-line healthcare staffis important to this process [35]. Wade et al. argue thatclinician acceptance is the most crucial factor influencingsuccessful and sustained implementation of telehealthservices. Such acceptance can be enhanced by promotionof the efficacy, safety and normality of telehealth, focus-sing on relationship building within telehealth networks,disseminating evidence of the acceptability of tele-health, a comprehensive change management planand adequate training and support [8, 13, 18, 36]. Weposit that, as suggested by other researchers, accept-ing and enthusiastic clinicians will use the technologywillingly [18]. However a comprehensive implementa-tion strategy should also include development of aservice framework, which explicitly defines the scope,position and use of telehealth within it, which shouldbe clearly communicated to healthcare workers expectedto use it.
LimitationsAs for qualitative research in general, the study is highlycontext specific. Further research in a range of rehabili-tation, aged and palliative care contexts may highlightnot only contexts in which clinician attitudes align withthose found in our study, but also contexts in which cli-nicians attitudes and beliefs about telehealth may differ.Such research will help to further our understanding ofthe normalization of telehealth services in these healthservice areas.
Shulver et al. BMC Medical Informatics and Decision Making (2016) 16:131 Page 13 of 15
The sampling approach and topic guide developmentused in this study were not originally designed for the pur-poses of analysis of implementation factors, or a NPTframework, but rather for the development of a relatedquestionnaire on telehealth attitudes and preferences.Though the sample and topics covered in these focusgroups were highly relevant to these areas, a morepurposefully sampled study and theoretically derivedinterview guide may have produced more focussedresults.
ConclusionsTelehealth delivery approaches in the context of agedcare services may be more readily normalized in areaswhere existing services are rationed or not accessible,such as rural areas. In this study, rural health cliniciansand residential aged care staff were enthusiastic aboutthe potential of telehealth to enhance healthcare accessfor their clients.Experience and exposure to telehealth technology ap-
peared to aid normalization, particularly among healthworkers providing services in less-rationed urban areas.However, changes in the way new interventions are con-ceptualised and perceived in relation to existing, conven-tional services may be more critical to attitudinal changeand the normalization process. It will be important toshow that telehealth is a feasible alternative to moretraditional service delivery if we are to achieve wide-spread coherence and cognitive participation among staffexpected to facilitate implementation and embedding ofnew telehealth services. The attention paid to necessarychanges to organizational, systemic and technologicalinfrastructure, as well as training and skill recalibrationare also highlighted in this study as important factors tosuccessful normalization of telehealth services in rehabili-tation, aged and palliative care.
AbbreviationsEP: Exercise physiology; NPT: Normalization process theory; OT: Occupationaltherapy; PT: Physiotherapy; RN: Rehabilitation nursing; SP: Speech pathology;SW: Social work
AcknowledgementsWe would like to thank all of the health workers who participated in thefocus groups for this study.
FundingThis research was supported by a Flinders University, South Australia project‘Telehealth in the Home: Aged and Palliative Care in South Australia’, aninitiative funded by the Australian Government.
Availability of data and materialsProvision for participants to consent to making the data publiclyavailable was not included on the approved consent forms. Therefore,as participants have not given their consent to make the data publiclyavailable, we are unable to share the full focus group transcripts forthis study.
Authors’ contributionsWS and MK undertook the focus groups and qualitative analysis. WS, MK andMC were involved in the study design, ethics submission and contributed tothe interpretation of results, conceptual ideas and manuscript preparationand revision. All authors read and approved the final manuscript.
Competing interestsThe authors declare that they have no competing interests.
Consent for publicationNot applicable.
Ethics approval and consent to participateThe study was approved by the Southern Adelaide Clinical Human ResearchEthics Committee, reference number HREC/13/SAC/121 (203.13). To ensureinformed consent was obtained, all participants were provided with theapproved information sheet and the study was verbally explained toparticipants at the commencement of each focus group. All participantssigned the approved consent form prior to participation in the study.
Author details1Rehabilitation, Aged and Extended Care, Flinders University, Daws Road,Daw Park, Adelaide, South Australia, Australia. 2Rehabilitation and Aged Care,Repatriation General Hospital, Adelaide, South Australia, Australia.
Received: 12 April 2016 Accepted: 7 October 2016
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