Development and implementation of a training package to improve the confidence,skills and knowledge of multi-disciplinary clinicians in the use of telepractice for outpatient services

Abstract

Introduction: Telepractice is recognised as an effective and efficient medium of service delivery; however, despite this evidence, implementation has been inconsistent. Clinician confidence and perceptions are integral factors to the successful implementation of telepractice in routine care. This study aimed to develop, implement and evaluate a telepractice training package for clinicians in a single hospital service. Methods: Forty-one clinicians from Speech Pathology, Physiotherapy and Chronic Disease departments participated in a training package with a specific focus on staff skills training, access to resources and embedding telepractice models of care into organisational culture. Questionnaires were used to evaluate clinician self-reported skills and confidence at baseline, post-training and 6-months post-training. Thematic analysis of open-ended questions was used to glean a deeper understanding of perceived barriers and facilitators to using telepractice. Results: Participants’ perceived knowledge and confidence significantly increased from baseline to immediately post-training (p < .001) and increased further to 6-months post-training (p < .001). Thematic analysis revealed three main enabling themes: (a) perceived benefits to patient care; (b) training and practice; and (c) resources and support; and four main barriers: (a) staff knowledge and training; (b) staff confidence; (c) client factors; and (d) infrastructure and resources. Conclusion: The telepractice training package improved staff skills and confidence which was sustained over time. Facilitating the uptake of telepractice is multidimensional and it is integral to address all relevant factors to ensure its success.

Keywords

Telepractice confidence knowledge training

Introduction

There has been a steady proliferation of evidence supporting the use of telepractice to deliver outpatient-based clinical services across the continuum of care (Theodoros et al., 2008). Patients have identified a preference for telepractice over traditional face-to-face care models in many settings due to increased flexibility and convenience (Burns et al., 2017). This positive consumer support helped drive the establishment of therapeutic efficacy for the use of synchronous telepractice (videoconferencing) across a range of clinical areas – including the assessment and rehabilitation services provided by allied health and nursing for patients with chronic disease (Burns et al., 2017; Holland, 2013; Hwang et al., 2017; Jaglal et al., 2013; Kamei, 2013; Jones et al., 2014; Palsbo, 2007; Theodoros, 2011; Ward & Burns, 2014). Collectively, these telepractice models have demonstrated promising results related to patient satisfaction and uptake, improved service efficiency and cost savings, presenting opportunities to benefit both patients and health services alike.

Despite the documented benefits of telepractice-assisted models of care in allied health, and the advantages of their implementation, the uptake of telepractice models in clinical practice has remained slow (particularly, prior to the COVID-19 pandemic), and methods for facilitating implementation are inconsistent. Research has identified a number of potential barriers to the clinical utilisation of telepractice services by health practitioners, including clinicians’ age and experience with technology, self-efficacy, education and training, as well as operational factors such as management support, network coverage, privacy and security and resource issues (Jang-Jaccard et al., 2014; Rani Sood et al., 2016). Staff confidence and perceptions are also integral to the successful implementation of telepractice, as clinicians are responsible for promoting the use of telepractice by selecting and referring suitable patients (Brewster et al., 2014; Nicholson et al., 2013; Wade et al., 2014). To this end, it is increasingly recognised that targeting staff skills and confidence in using telepractice technology, as well as fostering a positive culture towards telepractice at the organisational level, is key to facilitating successful establishment and ultimate sustainability of clinical telepractice services (Burns & Wall, 2017; Edirippulige, 2010).

Appropriate education and training of staff has shown to be integral to the uptake of telepractice, especially for patient-related interventions (Edirippulige & Armfield, 2017; Taylor et al., 2015). Despite this, there is limited research evidence surrounding the development and evaluation of telepractice training programs and their impact on changes in staff skills, confidence and perceptions of telepractice-based services, or the uptake and/or implementation of telepractice into routine clinical care (Guise & Wiig, 2017). The aim of the current study was therefore to develop, implement and evaluate a telepractice training package for clinicians at an acute secondary teaching hospital. The ultimate objective of this work is to support and promote the uptake of videoconferencing-based telepractice service delivery models to provide services to outpatients across a variety of areas and to develop a sustainable and skilled health workforce with a positive culture towards telepractice models of care in the future.

Method

Design

Prospective mixed-method cohort study.

Participants

Clinicians from the Chronic Disease, Physiotherapy and Speech Pathology departments were recruited via purposive sampling from an acute secondary teaching hospital (Queensland Health) in Queensland, Australia. The hospital provides a variety of post-acute outpatient services to a regional metro area which also includes local islands (rural). These three departments were targeted for recruitment as the efficacy for the use of telepractice-based services in their outpatient clinics had already been established within the literature (Chan et al., 2016; Conlan et al., 2016; Keck & Doarn, 2014; Gellis et al., 2012). Participants were eligible for recruitment if they were employed by the departments at the time of recruitment (July to September 2017) and their role description involved outpatient services, home-based services or a combination of both. Participants were excluded if they were unavailable to complete the training package in full. Ethical approval was gained by the relevant institutional committee (HREC/17/QPAH/484). All participants provided written informed consent before participating.

Procedure

The telepractice training package was developed by the research team in consultation with local experts during March–June 2017 and delivered to staff across multiple in-service sessions from October 2017–March 2018. Details of the training package are provided below. Following training, participants were encouraged and supported to implement telepractice into their clinics as appropriate during a 6-month period. Implementation was driven by each department who established local processes for patient selection, scheduling and utilisation of telepractice-assisted outpatient services.

Details of Intervention

The training package was designed based on previous research which had identified crucial elements that promoted the successful establishment and sustainable use of telepractice services for outpatient services (Burns & Wall, 2017). The package involved training and/or implementation planning across three key aspects: (1) staff skills; (2) resources, infrastructure and operational planning; and (3) organisational culture. To target staff skills, all participants completed selected online training modules which included video demonstrations and written resources related to the provision of clinical services via videoconferencing.

Regarding training for resources, infrastructure and operationalisation, participants received a one-hour introductory session and a two-hour focused session on equipment setup (Cisco Jabber, The Portal and Pexip software), led by a telehealth service coordinator with expertise in establishing telepractice models across the health service. Following this, participants proceeded to simulation training which involved role-playing with mock clinical scenarios specific for each participant’s clinical caseload to provide experience in managing environmental set up, etiquette and technical issues within a controlled environment. Simulation training lasted 1–2 hours and was conducted in small groups (2–4 participants) with support provided by a clinician with telepractice experience or a ‘telepractice champion’.

Finally, to target organisational culture, strategies were employed to foster a positive team/department culture towards the use of telepractice for clinical care during the training period. This included (a) the establishment of telepractice ‘champions’ within each department to support/drive adoption of telepractice within the clinical areas; (b) regular communication/updates at departmental meetings by the research team, telepractice champions and the telehealth service coordinator; and (c) embedding the ongoing completion of telepractice training for new staff as part of each department’s strategic objectives.

Evaluation Measures

Evaluation of participants’ self-reported skills and perceptions towards using telepractice was completed in the form of written surveys at three time points: baseline, immediately post-training and 6 months post-training. The baseline and immediately post training survey consisted of 25 questions (yes/no, multi-select and Likert scale) related to participants’ demographics, clinical skills/knowledge, confidence and perceptions of the utility of telepractice (specifically videoconferencing) for outpatient care. In addition, 6 open-ended questions were used to ascertain perceived barriers/facilitators towards using telepractice for patient consultations. The post-implementation survey (6-months post-training) had an additional question related to clinician involvement with the delivery of telepractice since completing the training package. Unique identifier codes were used to match participants’ responses to questionnaires over time. Occasions of service (OOS) conducted via telepractice during the 6 month implementation period were also retrieved via review of hospital and health service statistics.

Data Analysis

Data was analysed using intention-to-treat methods. Participant demographics and OOS data were analysed descriptively. To accommodate missing survey data at the post-training time points as a result of participant attrition, mixed-effects ordered logistic regression was used to explore the impact of training (represented by time point) on participants’ knowledge, confidence and perceptions of telepractice – first at the univariable level and then subsequently in a multivariate analysis controlling for potential interaction factors. For all multivariable analyses, profession (allied health vs. nursing staff vs. other staff) and department (Speech Pathology vs. Chronic Disease vs. Physiotherapy) were forced into the model as fixed interaction effects, with participant ID entered as a random effect, to control for individual variability. Model fit was checked using the Akaike information criterion (AIC). Statistical significance was set at p < .05. Thematic analysis of open-ended responses was undertaken using plain content analysis.

Results

A total of 41 participants were recruited and consented from July to September, 2017. Eighteen participants withdrew across the course of the study as they were unable to complete all aspects of training due to staff turn-over. The mean baseline self-rating of knowledge was equal between participants who remained in the study and participants who withdrew prior to completing the structured training program (mean across knowledge domain of both groups equalled 2 on scale of 1–5). Participant demographics (n = 41) are shown in Table 1. The majority of participants were allied health professionals (62%) or nursing staff (27%), with a small number of support staff (including Aboriginal and Torres Strait Islander health workers and allied health assistants). Participant representation across the three targeted departments was proportional to department size and largely equal representation from novice to more senior staff.

Table 1.

Participant demographics (n = 41).

Parameter	% (n)
Profession
Allied health
Dietitian	2 (1)
Physiotherapy	46 (19)
Social worker/psychologist	7 (3)
Speech pathologist	7 (3)
Nursing
Nurse	27 (11)
Other
Aboriginal & Torres Strait Islander health worker	5 (2)
Allied health assistant	5 (2)

Department
Chronic Disease	56 (23)
Physiotherapy	37 (15)
Speech Pathology	7 (3)

Classification level/grade
Health practitioner (HP) level
HP3	20 (8)
HP4	22 (9)
HP5	22 (9)
Clinical nurse grade
Nurse grade 6	15 (6)
Nurse grade 7	12 (5)
Operational officer (OO) grade
OO3	5 (2)
OO5	5 (2)

Impact of Training on Skills/Knowledge and Confidence

A summary of participants’ perceived knowledge regarding aspects of telepractice outpatient service delivery is provided in Supplementary Material A. Overall, mixed-ordered logistic regression analyses demonstrated a significant (p < .001) effect of time for all clinical skills/knowledge parameters (Table 2). Specifically, participants’ perceived knowledge significantly increased from baseline to immediately post-training, with a further significant increase in perceived knowledge from immediately post to 6-months post-training. A similar trend was also observed with regards to participants’ perceived confidence in using telepractice for both clinical and non-clinical purposes. Statistically significant (p < .001) increases in perceived confidence were observed from baseline to immediately post-training, with a further significant increase (p < .001) from immediately post to 6 months post-training. Both knowledge and confidence increases were equivalent across departments and professions, with no significant interaction effects observed in the models.

Table 2.

Multivariable analysis of perceived knowledge and confidence in use of telepractice – effect of time.

Parameter		Odds ratio	Z	p	95% Confidence interval
‘I have the knowledge to’:					95% Confidence interval
‘I have the knowledge to’:					Lower bound	Upper bound
Use telepractice equipment	Time 1 versus 2	104.40	5.76	<.001	21.47	507.47
	Time 1 versus 3	148.05	5.79	<.001	27.24	804.56
	Time 2 versus 3	15456.44	6.14	<.001	711.45	335794.80
Establish clinician/patient rapport via telepractice	Time 1 versus 2	32.35	5.12	<.001	8.55	122.41
	Time 1 versus 3	70.82	5.51	<.001	15.55	322.62
	Time 2 versus 3	2291.08	5.91	<.001	176.19	29792.38
Complete an effective assessment via telepractice	Time 1 versus 2	77.44	5.51	<.001	16.47	364.02
	Time 1 versus 3	106.46	5.51	<.001	20.98	540.27
	Time 2 versus 3	8244.18	5.95	<.001	423.17	160612.10
Implement an effective intervention/management plan via telepractice	Time 1 versus 2	119.02	5.59	<.001	22.27	636.16
	Time 1 versus 3	158.12	5.69	<.001	27.67	903.66
	Time 2 versus 3	18819.34	6.00	<.001	756.36	468252.20
Troubleshoot routine equipment issues pertaining to telepractice	Time 1 versus 2	892.80	5.19	<.001	68.54	11630.50
	Time 1 versus 3	787.55	5.31	<.001	67.20	9230.26
	Time 2 versus 3	703128.20	5.39	<.001	5247.13	9.42 × 10⁷
Train and support patients to use telepractice	Time 1 versus 2	695.79	5.75	<.001	74.78	6473.57
	Time 1 versus 3	413.91	5.62	<.001	50.69	3379.61
	Time 2 versus 3	287991.30	5.89	<.001	4395.60	1.89 × 10⁷
Determine patient eligibility and suitability for using telepractice	Time 1 versus 2	43.49	6.14	<.001	13.05	144.88
	Time 1 versus 3	38.94	5.57	<.001	10.74	141.09
	Time 2 versus 3	1693.34	6.59	<.001	185.38	15467.51
If an emergency situation arises during a telepractice consultation, I am confident to manage it	Time 1 versus 2	53.88	5.65	<.001	13.50	215.02
	Time 1 versus 3	53.76	5.57	<.001	13.23	218.41
	Time 2 versus 3	2896.72	6.09	<.001	223.12	37608.20
Confidence with videoconferencing for clinical service delivery	Time 1 versus 2	119.53	5.65	<.001	22.77	627.59
	Time 1 versus 3	100.21	5.59	<.001	19.93	503.84
	Time 2 versus 3	11977.48	6.03	<.001	565.67	253612.70
Confidence with videoconferencing for non-clinical purposes	Time 1 versus 2	21.37	4.86	<.001	6.21	73.54
	Time 1 versus 3	39.67	5.05	<.001	9.50	165.68
	Time 2 versus 3	847.82	5.47	<.001	75.58	9510.66

Impact of Training on Staff Perceptions of Telepractice

A summary of participants’ perceptions of the utility and value of telepractice for outpatient services, across each time point, is provided in Table 3. At baseline, the majority of participants either agreed or strongly agreed that their clients would benefit from telepractice-based services and have better access to services using telepractice. Similarly, participants perceived that telepractice was appropriate for their clinical role and they would recommend the service to their clients. These positive perceptions were strengthened post-training and further strengthened by 6 months post-training, with a significant effect of time demonstrated at the univariable level (see Table 3). However, statistical significance for the effect of time was not maintained in the subsequent multivariable analysis, when controlling for interaction factors. Exploration of the impact of these interaction factors demonstrated a significant effect of profession on participants’ perceptions towards telepractice, as shown in Table 4. Specifically, nursing staff were significantly more likely to have negative perceptions of telepractice, than allied health staff, for all but one of the survey parameters. This finding was also observed when comparing perceptions between allied health and support staff, for two questions. No significant effect of department or group by time interactions was observed.

Table 3.

Summary of perceptions of telepractice by time point.

Perception	Baseline			Immediately post-training			6 months post-training
	n = 40 (1 non-response)			n = 33			n = 23
	% (n)			% (n)			% (n)
	Strongly disagree/disagree	Neutral	Strongly agree/agree	Strongly disagree/disagree	Neutral	Strongly agree/agree	Strongly disagree/disagree	Neutral	Strongly agree/agree
I feel that clients within my service would benefit from access to telepractice	5 (2)	23 (9)	73 (29)	9 (3)	21 (7)	70 (23)	43 (1)	22 (5)	80 (17)
I am likely to recommend using telepractice to clients within the service	10 (4)	30 (12)	60 (24)	9 (3)	21 (7)	70 (23)	0 (0)	26 (6)	80 (17)
Telepractice sessions may provide better access to clinical services for patients within our service	3 (1)	12 (5)	85 (34)	0 (0)	15 (5)	85 (28)	0 (0)	17 (4)	83 (19)
Comparable patient outcomes can be achieved when delivering services via telepractice as compared to face-to-face delivery	7 (3)	43 (17)	50 (20)	15 (5)	36 (12)	48 (16)	13 (3)	39 (9)	48 (11)
Telepractice is relevant/appropriate/applicable to my role	0 (0)	30 (12)	70 (28)	3 (1)	27 (9)	70 (23)	0 (0)	22 (5)	78 (18)

Table 4.

Effect of interaction factors (profession) on perceptions of telepractice.

Parameter		Odds ratio	Z	p	95% Confidence interval
Parameter		Odds ratio	Z	p	Lower bound	Upper bound
I feel that clients within my service would benefit from access to telepractice	AH versus NS	0.054	−3.25	.001	0.009	0.315
	AH versus Other	0.058	−2.43	.015	0.006	0.578
I am likely to recommend using telepractice to clients within the service	AH versus NS	0.157	−1.65	.098	0.018	1.408
	AH versus Other	0.195	−1.09	.277	0.010	3.698
Telepractice sessions may provide better access to clinical services for patients within our service	AH versus NS	0.160	−2.04	.041	0.028	0.930
	AH versus Other	1.062	0.05	.96	0.105	10.770
Comparable patient outcomes can be achieved when delivering services via telepractice as compared to face-to-face delivery	AH versus NS	0.170	−2.06	.039	0.032	0.915
	AH versus Other	1.050	0.04	.966	0.111	9.918
Telepractice is relevant/appropriate/applicable to my role	AH versus NS	0.017	−3.01	.003	0.001	0.243
Telepractice is relevant/appropriate/applicable to my role	AH versus Other	0.020	−2.25	.025	0.001	0.608

AH: allied health; NS: nursing staff; Other: Aboriginal and Torres Strait Islander health worker/allied health assistant. Bold type indicates statistical significance (p < 0.05)

Experience and Use of Telepractice-Based Services Post-Training

In regards to exposure and experience with telepractice, mixed-ordered logistic regression analyses demonstrated a significant effect of time, with participants’ reporting significantly higher levels of experience with telepractice for clinical purposes from baseline to immediately post-training (Z = 3.13, p = .002) and further significant increases from immediately post to 6 months post-training (Z = 0.84, p < .001). Despite the self-reported increase in experience during the implementation period, translation to OOS was variable. The Chronic Disease department recorded 10 telepractice OOS during the implementation period (compared to five in the previous 12 months). Physiotherapy and Speech Pathology departments had nil recorded telepractice OOS during the implementation period.

Factors Affecting Implementation: Perceived Enablers and Barriers

Content analysis of open-ended survey responses revealed three main enabling themes and four main barrier themes which were identified by participants as influential to their uptake and use of telepractice. Exemplar responses are shown in Tables 5 and 6.

Table 5.

Effect of training program on staff reported experience in use of telepractice.

Parameter		Odds ratio	Z	p	95% Confidence interval
Experience – clinical	Time 1 versus 2	7.163829	3.13	.002	2.090959
	Time 1 versus 2	7.163829	3.13	.002	24.54398
	Time 1 versus 3	15.83036	3.59	<.001	3.497484
	Time 1 versus 3	15.83036	3.59	<.001	71.65158
	Time 2 versus 3	130.9161	3.84	<.001	10.87221
	Time 2 versus 3	130.9161	3.84	<.001	1576.406
Experience – non-clinical	Time 1 versus 2	9.840705	4.12	<.001	3.313863
	Time 1 versus 2	9.840705	4.12	<.001	29.22253
	Time 1 versus 3	20.78467	4.62	<.001	5.735956
	Time 1 versus 3	20.78467	4.62	<.001	75.31484
	Time 2 versus 3	40.3598	4.10	<.001	6.883024
	Time 2 versus 3	40.3598	4.10	<.001	236.6566

Table 6.

Content analysis of perceived enablers to telepractice.

Theme	Subtheme	Example participant quote
Perceived benefits to patient care	Improved access to services	‘Bay island residents are being increasingly referred to our service. For these patients, their geographical location is a huge barrier to attending therapy in person. I believe an increase in the number of Bay Island referrals will facilitate the use of telepractice’
Training and practice	Previous experience	‘Taking part in a telehealth research study at PAH’
	Training package	‘Training has helped with knowing what resources and equipment is available’
	Simulation/practical	‘The simulation sessions were very helpful, especially when the technology was problematic and we had to figure out how to “fix” things on the spot’
Resources and support	Experienced staff	‘Having an experienced person to help me’
	Infrastructure	‘Having equipment and resources already available” ‘Phone support line – excellent support’
	Support from management	‘Encouragement from management’

Enablers

Enablers for telepractice uptake/implementation centred around (a) training and practice; (b) perceived benefits to patient care by improving access; and (c) resources and support.

At the post-training survey, the most frequently cited enabler for clinicians to use telepractice was the training package itself (n = 11). Participants (n = 5) specifically commented on the positive value of the simulation training to ‘role play’ and ‘troubleshoot’ in a practical scenario to improve their skills and confidence.

Across the three surveys, participants also reported that improving access to services for patients, including reduced travel time, was a motivator to offer telepractice services. They commented that the ability to increase the intensity of treatment and improve treatment continuity justified the use of telepractice. Finally, participants reported that a range of support mechanisms assisted the implementation of telepractice services. Access to experienced clinicians/champions available for support was perceived as valuable, as was printed resources and support via the Statewide Telehealth Service Desk. Comments were also made about the support and encouragement from management being an enabling factor.

Barriers

Barriers to successful implementation were related to (a) staff knowledge and training; (b) staff confidence; (c) client factors; and (d) infrastructure and resources. At baseline, participants reported a lack of training (n = 15) and experience (n = 8); however, encouragingly, by the post-training surveys, the number of respondents nominating training/experience as a barrier had reduced (n = 2 and n = 3 respectively). Similarly, participants (n = 8) initially reported their confidence in the use of telepractice as another limiting factor to implementation. As per their knowledge and training, a lack of confidence was reported by nil participants immediately post-training; minimal to no participants as a barrier to using telepractice post-training.

Participants (n = 6) reported difficulty in identifying suitable patients as a barrier to using telepractice in clinical care. Low throughput of eligible patients reduced motivation to implement the service more broadly. Unlike the first two barrier sub-themes, the client factors did not reduce as a perceived barrier post-training. Participants also reported that infrastructure/resources for both patients and staff including patient access to the internet/appropriate hardware (n = 5) and clinicians’ own connectivity issues (n = 3) were barriers to telepractice uptake. Seven participants reported staff capacity was a barrier post-implementation, primarily associated with the time to set up the telepractice equipment and lack of administrative support (Table 7).

Table 7.

Content analysis of perceived barriers to telepractice.

Theme	Subtheme	Example participant quote
Staff knowledge and training	Training and education	‘Not knowing processes to follow, equipment patients need to provide service, forms to complete’
Staff knowledge and training	Experience	‘No experience in telepractice; Equipment needed; issues with technology/internet; will patients actually use it?’
Staff confidence	Confidence	‘Lack of confidence in the use of technology, lack of experience in clinical service delivery of telepractice. Lack of understanding regarding the expectations regarding “do I set it up? Do I need to train the patient in the use of the software?” This seems intimidating!!!’
Client factors	Patient suitability	‘Finding appropriate patients, having elderly patients willing to use technology’
	Patient preferences	‘Discrepancy between patient perceived level of computer literacy and clinician expected literacy to use telepractice’
	Patient knowledge/confidence	‘Patient confidence and familiarity with IT’
Infrastructure and resources	Patient access	‘Clients lack of access to internet, hardware’
	Staff access	‘Lack of opportunities to utilise videoconferencing’
	Staff capacity	‘No time to review resources to then ascertain client requirements (e.g., correct software)’
	Technical limitations	‘Some older and remote areas have low internet speed and service’

Discussion

This study demonstrated that a comprehensive telepractice training package can improve staff skills and confidence in the use of telepractice. The training package has been shown to be applicable to a range of disciplines working across a spectrum of outpatient services – yielding significant increases in knowledge and confidence across departments and professions that were sustained up to 6 months post-training. It can be hypothesised that knowledge and confidence may be intrinsically linked, and that knowledge even without real-world application does increase confidence in the use of telepractice. This is further confirmed by the work of Honey and Wright (2018) who found initial use of telehealth, hands-on training, specialty experience, mentorship and technological know-how as important factors in nurses’ self-assessment of telehealth confidence. This appears to have wider implications for telepractice training package design and highlights the importance of building on this body of evidence.

Perceptions towards the use of telepractice for clinical care was not impacted by training but was significantly impacted by profession. Specifically, analysis of interaction factors in the multivariable modelling demonstrated that nursing staff were significantly less accepting of telepractice than allied health professionals. This is the first known study to compare and find these disparate perceptions, specifically between nursing and allied health staff. Brewster et al. (2014) investigated staff acceptance of telepractice and found that nursing staff in particular were concerned about the impact of telepractice on their relationships with patients, as well as the nature of their caring role. It was suggested that these factors are likely to impact on clinical autonomy and credibility, especially where staff do not view telehealth as necessary or sufficiently beneficial. Greenhalgh and colleagues (2017) also suggested additional challenges with chronic disease nursing role or task complexity impacting on telepractice implementation. Although the simulation sessions in the current study were discipline-specific, the introductory sessions and written resources were multidisciplinary in nature, which may have contributed to nursing participants feeling less prepared or willing to convert their outpatient services to a videoconferencing-based model. Further investigation into the relative contribution of profession on long-term telepractice uptake and the causes of profession-specific barriers is warranted.

This research also provides further insight into the complex nature of telepractice uptake and associated behaviour change beyond that of highlighting the importance of training. Whilst the varied methods of training employed in this study helped to address some barriers to telepractice implementation (specifically knowledge and confidence), it did not directly correlate with improved telepractice uptake across the 6 months post-training. This stands in accordance with Edirippulige and Armfield (2017) who stated that despite a growing literature base, substantial financial investment and policy changes within governments, the integration of telehealth into routine clinical care has been limited. It is acknowledged that the follow-up window for recording telepractice OOS (6 months) may have been too short to be responsive to instigating clinical practice change in complex clinical settings. Investigating longer term uptake (>12 months following training) was not within the scope of the current study, however is warranted to explore factors underpinning the delayed time between knowledge consolidation and telepractice implementation.

Limitations and Future Directions

A number of limitations to the current study are acknowledged. Firstly, the sample size of participants decreased throughout the study period from 41 to 23 (56%), chiefly due to standard staff turnover rates across the three departments. This demonstrates the recurring challenges associated with maintaining effective training of the clinical workforce. Additionally, clinicians noted difficulty in identifying suitable patients for telepractice, which did not improve post-training or implementation. This was further confounded as clinicians reported a low throughput of eligible patients which reduced motivation to implement the service. Clinicians also reported infrastructure challenges which did not improve post-training, including patient access to the internet/appropriate hardware and clinicians’ own connectivity issues. It should be acknowledged however, that at the time of writing this report, the health service has changed dramatically with a large-scale uptake of telepractice in response to the COVID-19 pandemic (current study conducted prior to COVID-19). It can be hypothesised that this is likely to have increased the throughput of eligible patients (through increased technology literacy), increased patient-led demand and overall acceptance of telehealth. Whilst we acknowledge that connectivity (especially in rural areas) remains a challenge, technology is likely to be rapidly upscaled to meet the demand.

Other departments within the health service also increased utilisation of telepractice in response to the COVID-19 pandemic. Because staff within these other departments had not participated in a structured training package, in order to respond to the urgent need for change, staff were required to learn how to deliver services via telepractice as they were delivering care via this modality. There may be benefit in future studies to compare the difference in effect on confidence, skills and knowledge when completing a structured training program versus an immersive learn-as-you-go model.

Conclusion

In summary, this study provides valuable insights into the impact of a multidisciplinary telepractice training package in improving knowledge, skills and clinician confidence. This study also provides further evidence to support the use of complex and varied strategies to support sustainability across these domains. Furthermore, supporting and maintaining a positive telepractice culture within organisations as well as addressing real and perceived client factors appear integral to telepractice uptake.

Footnotes

Acknowledgement

We would like to acknowledge Dr Clare Burns for her expert consultation in the development of training resources.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

ORCID iD

Denis Morton

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