3.1. Uptake of Tele-Rehabilitation amongst Rehabilitation Professionals
Over half of all respondents carried out TR with all or most of their clients during the COVID-19 pandemic. However, there were large differences between professions (Table 2
). Most PsTs carried out TR with most or all of their clients. The proportion was lowest amongst the PTs.
Based on their experiences during the COVID-19 pandemic, almost half of the professionals among those who carried out TR during the pandemic planned to use TR regularly or probably also after the pandemic. Again, there were differences between professions (Table 2
). Psychotherapists planned to use TR more often than other professions. Half of the speech and language therapists and a third of the occupational therapists and physiotherapists planned to use TR regularly or probably.
The proportion of those professionals who carried out TR with most or all clients was lowest among those with over 30 years of work experience compared to those with fewer years (Table 2
). Those who were familiar with TR before the COVID-19 pandemic carried out TR during the pandemic more often than those without earlier experience.
Therapists with the most work experience reported to be the most unlikely group to use TR after the COVID-19 pandemic. The more familiar TR was before the COVID-19 pandemic, the more common was its planned use after the pandemic.
Whether the differences between professions in carrying out TR during the COVID-19 pandemic could be explained by background variables was studied with a logistic regression model (Table 3
). In model 1, the odds ratio (OR) for occupational therapists was 3.1 and for speech and language therapists 11.8 compared to physiotherapists (the reference group). Psychotherapists had an almost 30 times higher OR to carry out TR during the COVID-19 pandemic in comparison to physiotherapists. Controlling for work experience in years and familiarity with TR before the COVID-19 pandemic did not notably reduce the differences (model 2).
The odds ratio for planning to use TR after the COVID-19 pandemic was highest among psychotherapists, whose OR was 2.6 compared to the reference group of physiotherapists (Table 4
). Speech and language therapists also had a statistically significantly higher odds ratio, whereas occupational therapists did not differ from the reference group. Adjusting for work experience and familiarity with TR before the COVID-19 pandemic explained part of the differences
3.2. Working Features and Challenges Related to TR
The qualitative data analysis produced four new themes in addition to the themes within the coding schema, producing 11 themes overall (see Table 5
). Within three of the themes, representatives of all professions had similar views. Within eight themes, the views varied between professions. However, the experiences of representatives within specific professional groups were not identical and there was plenty of individual variation. The experience of using TR is individual. In addition, the analysis revealed that the same features related to TR can been experienced as both working and challenging. The features that worked well with TR were experienced more uniformly than its challenges.
Firstly, we present the findings related to the themes where professions had similar views. After that, we will report the findings from the themes on which the views varied between professions in more detail. The number of well-working and challenging sub-themes by professional groups is presented in Table 6
(sub-themes are presented in more detailed in Table S1
The majority of therapists perceived the applicability of and the rationale for TR in a similar way and there were no distinct differences in the views of representatives of different professions, such as in age or diagnostic group of clients. No disease groups were excluded from TR. The common opinion was that the suitability of TR needs to be assessed individually, and TR is not suitable when starting therapy with a new client. The findings show that TR may not be appropriate for clients with complex diseases and health situations that require a great variety of health services. As the rationale for TR, in the context of this study, the main reason for tele-rehabilitation was COVID-19 and the clients’ need for rehabilitation.
The theme of engagement with and motivation for tele-rehabilitation
emerged and was experienced by representatives of all professions in a similar way. The findings reveal that clients and their close associates were mainly committed to TR. New methods increased motivation. However, the lack of motivation was also noted and, in some cases, the difficulty to maintain motivation during therapy sessions.
”Motivating course of action, new task types, temporally enables more frequent work with the client, parents more committed to therapy.” Occupational therapist.
The implementation of TR
included 16 sub-themes (see Table 6
). Based on the experiences of the therapists, five sub-themes were identified to work well, of which four were shared between representatives of all professions. These were the negotiations and discussions with clients, use of familiar methods and materials, use of guidance and clients’ progress in therapy. Negotiations and discussions were considered both as features that work well, as they strengthen collaboration with clients, and as a challenge because rehabilitation did not take place in daycare or school settings and some OTs and SLTs experienced negotiations in TR superficial.
Overall, there was more variation amongst professions in challenges related to the implementation of TR. One sub-theme that dealt with physical exercises and manual and concrete guidance of clients and their close associates was identified as challenging by all the professions. PTs, OTs and SLTs considered assessment and observations of a client’s activity, as well as limited methods and tasks as challenging. However, representatives of the same professions also considered diversity and new kinds of methods and perspectives as well-working features of TR. OTs identified activity modification during therapy sessions and animal assisted therapy as demanding. SLTs reported the largest number of challenges, amongst them auditive and visual accuracy during observations, tactile feeding rehabilitation and adherence to goals. Shared challenges between SLTs and PsTs were use and distribution of materials and physical exercises and activities. Both OTs and PsTs considered working with emotions challenging in TR.
“If activities planned for therapy are not enough, for example, tasks are completed faster than usual or not succeeding at all, coming up with extra doing has been challenging for me.” Occupational therapist.
included 13 sub-themes (Table 6
). Of the six sub-themes related to working features when initiating TR, only one—clients’ commitment, positive attitude and motivation towards TR—was shared between representatives of all professions. In addition PsTs named as well-working features shared challenges in the uptake of TR, collectively agreed schedules and procedures and therapists’ positive attitude. Two sub-themes out of eight relating to challenges in initiating TR were common for representatives of all professions. They were learning new ways to work and prejudices towards TR. OTs, SLTs and PsTs considered additional procurements for TR challenging, whereas OTs and PTs identified that lack of skills and knowledge challenge initiation of TR. PTs and SLTs named motivating clients to try TR as a challenge. SLTs considered that licensure and legal liability as well as confusing administrative instructions make TR demanding.
“In the beginning, time and money went into learning and taking over platforms. This also creates additional costs.” Physiotherapist.
Within the theme of support during TR
none of the nine sub-themes (Table 6
) were shared between all professions. PTs, OTs and SLTs identified support provided for the professionals and clients’ skilled personal assistance as features that support well-working TR. However, these features as well as personal assistance for the client were considered both as well-working and as challenging feature depending on their availability. Lack of support was identified as a challenge by PTs and OTs, and lack of interpretation services, by OTs and SLTs. OTs, SLTs and PsTs identified challenging the therapist’s role as technical support for client.
“The client has had no access to an assistant and movements cannot be executed independently or the assistant has not had sufficient competence in the situation.” Physiotherapist.
The representatives of all professions experienced technology
quite consistently (see Table 6
). Seven sub-themes were identified within the theme of technology. The sub-theme of technology and bandwidth was shared between all professions, both as well-working and challenging, depending on its’ functioning and reliability. In a similar way, availability or lack of appropriate and easy to use equipment and applications supports or challenges TR. PTs, OTs and SLTs identified that poor video and audio quality as well as poor device positioning and lightning conditions challenge TR. Information security was considered as a challenge by OTs and PsTs.
“Not everyone has suitable device at home other than a smartphone. On that it’s hard to see shared tasks or otherwise establish good contact.” Speech and language therapist.
The context of TR practice
includes nine sub-themes (Table 6
). One of the four sub-themes that work in a TR context, flexibility in planning and carrying out TR, was shared between the professions. However, PTs, OTs and PsTs experienced flexible schedules also as a challenge, as longer workdays and changing schedules caused burden and mixing home and work affairs. In a same way PTs, OTs and SLTs identified that TR practice supports efficient use of resources and on the other hand planning and preparing sessions was considered as a time consuming challenge. None of the five sub-themes of challenges related to TR were shared between professions.
“No cancellations due to illness or fatigue.” Speech and language therapist.
The following three themes are additional to the pre-defined coding schema and emerged during data analysis.
The professionals’ well-being at work during TR
includes seven sub-themes (Table 6
). Only SLTs and PsTs expressed sub-themes that work in TR, which were their development in ways guiding clients, learning new and decreased emotional strain. Representatives of all professions shared one of the four sub-themes that deal with challenges. They felt that TR burdens and exhausts more than face-to-face rehabilitation. In addition, OTs and SLTs pointed out experiences of loneliness at work. Concern about clients for OTs and additional challenges at work for PTs were also challenging.
“It’s been actually interesting and challenging, it’s been great to find out it works like this as well”. Physiotherapist.
Interaction during TR
raised plenty of views (see Table 6
). Two of the six sub-themes that work in interaction during TR, fluent and intensive interaction and clients’ active engagement, were shared between representatives of all professions. Two sub-themes, clients’ better possibility of controlling interaction and the opportunity to focus on essential issues in therapy sessions, were identified only by PsTs.
From 11 of the sub-themes of challenges related to interaction during TR, representatives of all professions shared three: differences and intensity of interaction, no shared environment and a therapeutic relationship. Two sub-themes, work with emotions and clients’ preference for personal presence, were expressed only by PsTs. PTs, OTs and SLTs identified misunderstandings in communication, difficulties in guiding interaction between the client and close associate and lack of physical contact as challenging. OTs, SLTs and PsTs again named understanding nonverbal and visual cues as challenging.
“In telerehabilitation one is more tied to what’s spoken; observing the mood of the meeting and the gestures and state of the client is a little more difficult.” Psychotherapists.
TR in the everyday life environment
includes 15 sub-themes (Table 6
). Of the five sub-themes that work, two were shared between representatives of all professions. The analysis brought up that during TR therapists can learn more about their clients in their everyday life environment, and they are able to apply therapy within everyday life. In addition, they consider it easier for clients to participate in therapy. Furthermore, PTs, OTs and SLTs considered that everyday life environment is good for participation of close associates, and PTs, OTs and PsTs noted that it is safe for the clients.
“It’s been amazing to get into the clients’ own environment” Psychotherapists.
The number of sub-themes related to challenges was much greater. Encountered challenges were connected to the physical environment (for example, lack of space or therapeutic equipment, no quiet and calm place for meetings). PTs and OTs noted worries about the safety of the home environment. Part of the experienced challenges at home were connected to other persons, such as lack of peaceful space and lack of privacy. Different profession groups expressed varying views about the everyday life context. Psychotherapists expressed only three challenges. Participation of close associates was identified as challenging by PTs, PTs and SLTs as it does change interaction.