An exploration of service users’ experience of telehealth occupational therapy interventions in adult mental health services, Ireland, during COVID-19

Abstract

Purpose

The COVID-19 pandemic transformed the delivery of occupational therapy (OT) community mental health services nationally, resulting in the rapid expansion and delivery of services through telehealth. While telehealth technology and its use are not new, widespread adoption was precipitated by the cessation of face-to-face services due to the COVID-19 pandemic. Research in this field has been conducted previously; however, it is not specific to OT in the Irish context. This study aims to explore service users’ experience of telehealth OT interventions in adult mental health services during the COVID-19 pandemic.

Design/methodology/approach

A descriptive qualitative approach was used to explore service users’ experience of mental health telehealth OT services. Five service users were recruited to participate in a focus group to explore their experience of OT via telehealth. The themes identified from this focus group were then further explored via individual interviews. Four of the service users who participated in the focus group chose to complete in-depth interviews. Reflexive thematic analysis was then completed.

Findings

Two key themes emerged from the data. The theme of positive telehealth experiences included subthemes of gratitude for the option of telehealth and accessibility. The second theme of learning from experience, included subthemes of human connection, preferred platforms of telehealth methods and future considerations for telehealth interventions.

Originality/value

These findings provide a unique insight into the importance of continuing OT services via telehealth, from the service users’ perspective.

Citation

Daly, K., Isdell, E., Moynihan, L., O'Callaghan, K., O'Leary, S., Pepper, A. and Pennisi, Y. (2022), "An exploration of service users’ experience of telehealth occupational therapy interventions in adult mental health services, Ireland, during COVID-19", Irish Journal of Occupational Therapy, Vol. 50 No. 2, pp. 66-72. https://doi.org/10.1108/IJOT-02-2022-0007

Introduction

Occupational therapists (OTs) working in the mental health services, focus on maximising service users’ functional performance in everyday occupations. Traditional occupational therapy (OT) practice involves meeting service users face-to-face to carry out assessments, goal setting and complete interventions. The onset of the COVID-19 pandemic changed the way in which health care was delivered. Telehealth was used as an alternative to face-to-face interactions to maintain therapeutic input and to adhere to the requirements of COVID-19 restrictions. Service user feedback is essential to guide further development of telehealth within OT services. Service user involvement is also a core part of Irish mental health policy, sharing the Vision (Department of Health, 2020). This study aims to explore the service user experience and inform future OT telehealth practice.

The use of telehealth is growing rapidly worldwide. This digital movement in medicine began as early as 1955 when two psychiatrists developed a telemedicine studio, enabling them to complete ward rounds in rural hospitals in the USA (Hasselberg, 2020). The term “telehealth”, often used interchangeably with “telemedicine”, refers to remote healthcare-related interaction and the exchange of information, images and sound through communication technologies (Acharibasam and Wynn, 2018).

The COVID-19 pandemic has altered how health care is delivered around the world and telehealth has enabled continuity of clinical connection during this time (Wosik et al., 2020). Use of technology across all sectors and services allowed for the reduced risk of physical contact and transmission of COVID-19 (Wosik et al., 2020; Monaghesh and Hajizadeh, 2020). Telehealth has been used widely across mental health services during the COVID-19 pandemic (Marshall et al., 2020).

There is growing evidence that telehealth interventions within mental health can produce similar outcomes to face-to-face interventions (Berrouiguet et al., 2016; Hilty et al., 2013). A systematic review of technology-assisted interventions for co-morbid depression and substance use (Holmes et al., 2019), found that five out of six eligible studies demonstrated significant short-term improvement in mental health severity. According to Sanderson et al. (2020), challenges with security and risk management via telehealth need further development. Key considerations such as security, confidentiality and ease of use of technology have also been highlighted in some studies (Hilty et al., 2013; Goetter et al., 2019).

Recent research suggests mental health treatment using telehealth (Goetter et al., 2019) is a viable means of increasing access to services; however, a preference for in-person mental health visits was found for a proportion of participants. In addition, there are mixed reports on the effect of telehealth on therapeutic rapport. Some research with adults has found that a strong therapeutic alliance can be formed online and that higher alliance quality ratings predict better therapy outcomes (Holmes et al., 2019), whereas other research concluded that telehealth had an adverse effect on therapeutic rapport, as the efficient and facile nature of online interventions may be construed as superficial and too casual in approach (Hilty et al., 2013).

Digital health and mental health in Ireland is a relatively new concept, and therefore, there is a paucity of data. However, emerging international evidence indicates the effectiveness of digitising mental health interventions, as growing consumer confidence in secure, safe smartphone technologies have contributed to ease of dissemination of mental health teleservices (Hasselberg, 2020).

Gap in literature

It is difficult to establish the benefits and the disadvantages of telehealth OT in a mental health context because data has not been systemically collected and researched prior to onset of COVID-19. There is a scarcity of research available pertaining to service users’ experiences of receiving OT through telehealth. Much of the research was found to have largely considered the clinician’s perspective, while limited data was available on service user’s experiences of receiving telehealth OT services. In addition, research is especially limited in the context of mental health OT service delivery through telehealth. This could have implications for future service development and could be explored further, in line with Irish mental health policy recommendations for increased service user involvement (Department of Health, 2020).

Methodology

This study was completed in Irish state-funded health services, Health Services Executive (HSE), within adult mental health services. This research focused on service users receiving interventions in community settings only.

An exploratory qualitative descriptive methodology was chosen as the theoretical framework for this study. As this was a new service, with little research published in this area, an exploratory study was deemed most appropriate (Green and Thorogood, 2009). In addition, a descriptive approach aligned with the aim of the research, to explore the experience of telehealth OT mental health services.

Methods

A focus group followed by individual in-depth semi structured interviews were the methods used for data collection. Focus groups were chosen to gather data and to extract the themes on service users’ experience of telehealth OT. The use of group dynamics stimulates participants’ thinking, when exploring their experiences (Flick, 2009). Individual semi-structured interviews were then used to further explore the themes found in the focus group.

Recruitment

Purposive and convenience sampling were used in recruiting the focus group participants. All service users who attended OT mental health services via telehealth were invited to participate. OTs provided details of service users who met the inclusion criteria below. A written invitation was sent at the beginning of August 2020 to each potential participant. An administrative staff member acted as a gatekeeper. In addition, posters advertising the study were placed in mental health outpatient department waiting rooms.

Five people responded to the letters of invitation, consenting to participate in the study. No participants responded to the posters. It was hoped there would be a higher rate of participation; however, recruitment was during a nationwide lockdown. This is acknowledged as a limitation of this study.

Data collection – focus groups

The focus group was conducted face to face, in late August 2020, at a community mental health setting. An independent occupational therapist/academic facilitated the focus group. An online focus group was provided as an alternative for participants unable or unwilling to attend because of COVID-19. However, participants declined this option. The focus group lasted 60 min. Focus group questions concentrated in three main areas (see Appendix):

1. Experience of participating in telehealth OT.

2. Benefits and/or challenges in engaging in OT via telehealth.

3. Preferred method of OT telehealth intervention.

Following the focus group, participants were offered the opportunity to opt-in to member check the focus group transcripts and to participate in individual interviews. The focus group was recorded on a digital audio recorder and then transcribed verbatim. The research group then completed a thematic analysis to inform the interview guides.

Data collection – individual interviews

Interview data collection took place from September to November 2020. The research team completed in-depth semi-structured interviews with four participants who opted in for the interview after completing the focus group. Interviews took approximately 30–60 min via telephone, online or face to face. As the research team were OTs currently working within the service, the external academic randomly allocated a researcher to conduct an interview. This ensured that no participants were interviewed by treating clinicians at any point in the study. All interviews were recorded on a digital audio recorder and then transcribed verbatim by another non-treating member of the research team.

Data analysis

Reflexive thematic analysis was completed using Carpenter and Braun’s six-step process (Braun and Clarke, 2012). Each member familiarised and made notes separately on the de-identified transcripts for the focus groups. Initial codes, themes and subthemes were generated in both face-to-face and online meetings as a research group. The interview questions were then modified to include the themes generated in the focus groups:

• benefits/challenges of telehealth;

• therapeutic relationship impact;

• expand on the preferred method of telehealth; and

• accessibility of telehealth.

Upon completion of the interview transcriptions, each member of the team familiarised themselves with the de-identified transcriptions. Initial codes were then generated individually. The research team used online meetings to come to discuss, review and define the agreed-upon codes; initial themes and subthemes; and final themes and subthemes.

Trustworthiness

Trustworthiness was addressed through both member checking and prolonged engagement with the data, by the researchers. Peer debriefing as well as group analysis led by an external person further addresses trustworthiness issues.

Ethical considerations

Ethics was sought and approved by the Clinical Research Ethics Committee of the Cork Teaching Hospitals [CREC Review Reference Number: ECM 4 (a) 11/08/2020 COVID-19 & ECM 3 (sss) 11/08/2020] prior to commencing this study. A peer support worker was engaged during the research design process to ensure the appropriateness of questions within focus groups and interviews.

Findings

Thematic analysis of all data gathered from both focus group and interviews yielded a comprehensive overview of participants’ overall experiences of telehealth during the COVID-19 pandemic. Dominant themes and subthemes that emerged are illustrated in Table 1.

Theme 1: telehealth as a positive experience

In general, there was a sense that telehealth OT intervention had been positively received by all participants especially due to the limitation of face-to-face jhoptions at the time. Subthemes identified in the data included gratitude for telehealth options and accessibility of services.

Gratitude for telehealth occupational therapy, during COVID-19

There was a strong sense of gratitude communicated in both the focus group and the individual interviews, for the continuation of OT telehealth during the initial stages of the COVID-19 pandemic. Considering the universal sense of stress at the time due to social isolation and uncertainty, participants found maintaining a link with their occupational therapist was all the more necessary:

I would have been lost without it to be honest. (Participant D – Interview)

I was just delighted to talk to someone, I was very lonely thinking I was in this battle by myself against my own mental health. (Participant E – Focus Group)

Participants reported that they looked forward to telehealth meetings and that it was a factor in maintaining their mental health at the time. All participants viewed the provision of telehealth services as essential during this period for their mental health:

You’d have it in your head, another two days till the phone call, you’d be looking forward to it like Christmas Day. (Participant E – Focus Group)

There was clear consensus within the focus group that telehealth was particularly well received, as face-to-face OT intervention was not possible. The preference from the participants was for face-to-face OT but it was considered a good “stopgap”.

We couldn’t meet face to face, so it was like the next best option, I am grateful for that. (Participant D – Interview)

100% better than nothing, it’s totally better than nothing but for me personally it could never really be a substitute for having face-to-face sessions. (Participant B – Focus Group)

Accessibility of telehealth occupational therapy

Another subtheme identified highlighted the accessibility of telehealth. In particular, some participants reported that OT is more accessible via telehealth than in person, depending on the situation.

It doesn’t take up a whole chunk of your day either, like if I had a meeting here at 12 o’clock, I’d have to get the bus at 10.30 to walk over, get the bus back, walk home whereas if you can just use your phone, it’s grand. (Participant E – Focus Group)

Indeed, several participants discussed how telehealth facilitated attending and participating in online sessions when they possibly would not have attended face-to-face sessions because of low mood and motivation:

I still had her with me, talking me through the treatment plan, that was the best thing about it […] particularly if I had a bad day and I did not want to go anywhere, I didn’t want to be seen in public, I didn’t want to get out of bed or anything that was very very good. Just knowing that I could still access her. (Participant A – Interview)

For some, telehealth was seen as more accessible than face-to-face meetings because of reduced time and travel commitments in accessing appointments. In all, the experience of telehealth was positive; however, it was not a replacement for face-to-face.

Theme 2: learning from the experience of telehealth

The second theme to emerge was in relation to feedback service users had for researchers on methods of developing telehealth OT interventions. Participants were keen to express what they had found helpful as well as unhelpful within their telehealth experience. The subthemes here included the human connection, individual needs and considerations for the future.

Consideration of the “human connection”

The human connection in the findings highlighted the issues around rapport during telehealth. Participants voiced concerns about the negative effect telehealth can have on the development of therapeutic rapport. It was highlighted that therapeutic rapport needs to be established initially in person prior to intervention via telehealth.

It’s obviously more personal and more hands on when you have a meeting like that (face to face), but I thought the zoom call was grand like. (Participant E – Focus Group)

Personally I don’t think there is anything that you or I or anyone can do to replace that human contact, that face-to-face contact. It’s a very different interaction between screens, it’s not human. (Participant A – Interview)

Moreover, participants highlighted the importance of initiating and building rapport through in-person contact. Data indicated this was an important factor in the level of rapport. One participant suggested that had they not had that initial face-to-face contact, it would be like:

Some stranger popped up and Zoom and, I’d be like, eugh, I wouldn’t trust them at all. (Participant A – Interview)

As well as difficulty building rapport, one participant stated that they had shorter attention spans during telehealth sessions due to the lack of human connection.

I found myself constantly distracted by the glare of the screen (Participant A – Interview)

Individual needs differ in preferred mode of telehealth

The data indicated that participants could not agree or identified if there was one preferred mode of telehealth, whether via telephone, video calls or just text messages. One participant had used telephone calls with his occupational therapist and found this mode of telehealth supportive:

Other people would prefer the video calls but I just like the telephone, I think the telephone is enough. (Participant D – Interview)

This person had found video calls difficult:

In zoom calls, yeah, it’s totally different, I don’t know it didn’t really suit me […] yeah I just wouldn’t really be comfortable with that. (Participant D – Interview)

Other participants had found video calls more helpful than telephone calls. Participants reported less distractions on video calls and reported having a face onscreen was more personable.

Like definitely the phone is incredibly hard to do anything, I don’t know if that’s my own personal experience.

No, I’m the same, when you’re on the phone you could be watching telly, you could be looking at fruit, you’re not there like. (Participants B and E – Focus Group)

Considerations needed for future implementation of telehealth occupational therapy

Participants did see an opportunity for telehealth to be continued in the future, with some changes. Participants suggested that the privacy and security of both the therapist and the service users need to be considered. Specifically for the therapist, both a private environment and a secure connection was essential.

If we’re to go down the internet route, the therapist has to have a solid internet connection and a place where they are not interrupted or that doors are going to be opening and closing or there might be a radio in the background. (Participant B – Focus Group)

For the service users, privacy and confidentiality were concerns. Some participants reported having difficulties accessing private spaces in their own homes. They highlighted concerns about being overheard, which impacted on how and what they could share:

I was at home and I live with both my parents and for me it was the thing of, I didn’t want them overhearing certain things that I wanted to say. I think it’s great having a safe place that you can talk freely and not be concerned about other people overhearing you. (Participant B – Focus Group)

I live in an apartment jowl to cheek with my housemate and it’s very difficult to get away from him. There’s not a lot of places I can sit so that was always a bit of a concern… so privacy was a big issue. (Participant A – Focus Group)

In terms of security, there was some concerns that conversations could have been overheard or recorded. Suggestions were made that the HSE have its own secure platform:

I think it’s hugely important, you can’t be relying on external platforms for something such as this. If it’s something that is going to be happening going forward the HSE needs some platform and it needs to be good and user friendly. (Participant B – Interview)

All participants in this study appeared to have the technical skills and ability to set up and join video calls; however, one participant having been involved in a group video call discussed the need for the provision of technical support and advice on online etiquette to those who may not have those skills and abilities.

That’s something I saw kick in, on different group calls that I was on, was people not knowing what to do in terms of how to actually use the technology. (Participant B – Interview)

Discussion

The findings of this study have provided useful information on mental health services users’ experience of telehealth OT, which can be used to guide future practice.

The findings of this study build on existing evidence (Marshall et al., 2020; Nissen & Serwe, 2018; Hilty et al., 2013) that telehealth interventions can produce similar positive outcomes to face-to-face contact. Gratitude emerged as a strong theme in these findings and has not been clearly expressed in existing literature regarding telehealth interventions. It is reasonable to speculate whether the gratitude for telehealth was stronger because of the lack of alternative options during the early stages of the COVID-19 pandemic and the nationwide lockdown during 2020. Gratitude was expressed for the ongoing support received from occupational therapists. At a difficult time, this allowed service users to feel connected. The findings of this qualitative research indicate that service users had positive experiences of telehealth OT because of its ease of accessibility. Similar to previous research undertaken (Hasselberg, 2020; Holmes et al.,2019; Sanderson et al., 2020), there are positive implications for access to OT when telehealth is offered; as participants reported, it was more convenient and time efficient. Telehealth can reduce barriers to care, particularly for those with competing commitments or those with social phobias (Hasselberg, 2020). Our findings demonstrated service users were likely to commit online appointments than face-to-face. One cannot conclude from the findings of this study whether this may have implications for poor attendance or “DNA” rates but the findings warrant further exploration to discover if there are cost saving implications for offering telehealth more regularly.

The impact of delivery of services through telehealth on therapeutic rapport has been researched extensively (Berrouiguet et al., 2016; Hilty et al., 2013; Holmes et al., 2019; Goetter et al., 2019). Some studies have suggested that a strong therapeutic alliance can be formed online, whereas a study on occupational therapists’ perspectives in the USA (Dahl-Popolizio et al., 2020) indicated that telehealth can have a negative effect on the therapeutic relationship. Findings from this research suggest that service users were able to continue to build rapport with their therapist via telehealth, when they had met their therapist face-to-face initially. Participants did, however, note that there were difficulties in building a therapeutic rapport online, if there had been no prior face-to-face interactions. It was clear that participants did not view online input as a replacement for face-to-face intervention. As indicated in similar studies (Holmes et al., 2019; Goetter et al., 2019), participants did value the supportive nature of therapy through telehealth, provided the initial therapeutic rapport was already established through traditional means.

The challenges of the specific communication skills required to engage in online OT intervention require further exploration. The loss of some communication during telehealth sessions was noted both in previous studies and through this research (Hasselberg, 2020). The necessity for guidance and training on communication skills required in a telehealth era appear to have been overlooked by health professionals within Irish mental health services. Further training in this area may allow health professionals to acknowledge the difference in communication with service users prior to commencing telehealth, particularly in group interventions where there are many variables involved.

The preferred mode of telehealth differed within our small sample group. Different platforms for telehealth OT have not been researched extensively prior to the COVID-19 pandemic. This is an area that requires further investigation. When developing telehealth, OT services should consider the service users preferred mode of telehealth. Again, this may be dependent on their own personal and environmental factors.

Privacy and confidentiality issues arose within our sample group, similar to previous studies (Hasselberg, 2020; Hilty et al., 2013; Goetter et al., 2019; Dahl-Popolizio et al., 2020). Participants reported challenges, such as interruptions from other people within their environment. They also expressed concerns regarding the recording of sessions. However, the finding of ensuring therapists’ environments are private and non-distracting is an important takeaway message for therapists.

Strengths and limitations of the study

A limitation of the study is the potential bias of practitioner-researchers, including OTs who were currently providing treatment within the service. Respondent bias was addressed, ensuring no participant was interviewed by their treating therapist. Possible researcher bias was addressed in part with the data analysis being completed by the research team, and ongoing meetings and reflections with the external academic OT (Robson, 2007; Byrne, 2021). In addition, a limited response rate was achieved, with 25 service users being contacted, via the gatekeepers. With only five participants, a 20% participation rate was less than anticipated; however, it was a reasonable uptake in comparison with other similar studies (Renda and Lape, 2018). There may be a positive bias as only service users who took up telehealth options were recruited; however, this should be considered in research planning in future.

Conclusion

The COVID-19 pandemic drastically changed the way mental health-care services could be delivered in Ireland. Because of social distancing requirements, face-to-face OT input was limited between March and October 2020. The findings of this study suggest that telehealth OT was appreciated and valued as it facilitated the continuation of care. The findings indicate that service users do not believe telehealth can completely replace face-to-face input; however, it can be more useful at times as it is more time efficient and accessible. There were potential negative implications of telehealth OT on therapeutic rapport, communication and on privacy and security. The findings of this study illustrate the benefits of telehealth OT and areas that could be further investigated if telehealth OT is to continue to develop.

Table 1

Themes and subthemes

Theme	Subtheme	Codes
Telehealth as a positive experience	Gratitude for the option of telehealth in the absence of face-to-face options	• “Better than nothing” • Sense of stress • Something to look forward to
	Accessibility of occupational telehealth	• Time • Travel
Learning from the experience of telehealth	Consideration of the human connection	• Rapport • Distractibility
	Individuals differ in preferred method of telehealth	• Telephone or video call
	Considerations for future implementation of telehealth	• Communication skills • Privacy and security • Online etiquette

Inclusion criteria	Exclusion criteria
• Experience in attending Occupational Therapy services via telehealth in 2020. • Service users of mental health occupational therapy services. • Adults over 18 years of age • Ability to converse in English	• Under 18 years of age • Currently experiencing an acute episode of mental illness

Appendix. Focus group questions

Service users’ experience of occupational therapy delivered through telehealth – focus group interview guide

1. Describe the experience of receiving occupational therapy through Telehealth?

2. How would you compare the experience of occupational therapy through Telehealth to the traditional face-to-face delivery?

3. Were there any challenges to participating in occupational therapy via Telehealth?

4. Were there benefits in engaging in occupational therapy via Telehealth?

5. How do you think the use of Telehealth impacted on the therapeutic relationship with the occupational therapist?

6. What was your experience of discussing sensitive information via Telehealth?

7. What would be your preferred method of Telehealth and why? – e.g. telephone, text message, online, social media or other platforms.

8. How accessible is a Telehealth service?