JCPSLP Vol 23, Issue 1 2021

was voluntary and would not affect their employment with BUSHkids before being invited to take part in the research. A list of managers who directly or indirectly supervised the SLPs (clinical supervisor, line manager, clinical area manager, and executive managers) was provided by BUSHkids. The IT manager was also included in recruitment given their involvement in telehealth technology training and support. All managers were provided with detailed verbal and written information about the research by the first author, in person, via email and/or phone. They were assured that their participation was voluntary and would not affect their employment with BUSHkids before being invited to take part in the research. All child clients had been identified by BUSHkids for unidisciplinary SLP care and were on the waiting list for the two SLPs. This meant that they had met the BUSHkids eligibility criteria of being aged birth to end grade 1 (approximately age 6), not receiving individual speech-language services elsewhere, and referred for mild-moderate concerns with fluency, language, speech, voice or multi-modal communication, excluding severe presentations and feeding and swallowing concerns. In addition, to be eligible for research, the SLP judged that parent and child were able to attend to therapy, were medically stable, and had carers over 18 without severe health condition impairing capacity to consent to research. SLPs contacted parents via phone to offer either in-person or telehealth service. Families residing in the same town as the BUSHkids clinic were offered in-person service. Families residing outside town were offered the telehealth service. Three families declined the offer of the telehealth service, compared to nil families declining the offer of in-person services, raising the possibility that parent attitudes to telehealth affected uptake. Research participation was discussed at the end of the first therapy session. Treating SLPs provided eligible clients with detailed verbal and written information about the research. Parents were assured that participation would not impact on their service with BUSHkids. If parents declined research participation they continued to receive the therapy, but no data was collected. One telehealth family declined research participation, with no reason given. No in-person All data was collected by the first author, an SLP and PhD student but not a treating SLP in this study. In-person therapy was observed before the SLPs started telehealth. Telehealth therapy was observed at three time points to determine whether SLP and parent practice changed over time (day 1–2, day 6–7, and day 12–13). The researcher took detailed observation fieldnotes using a form to guide which included sections about the people involved and their roles, processes and practices happening throughout the session, and objects used in the session. Ten in-person observations (mean length 48 minutes, range 32–63) and 12 telehealth observations (mean length 42 minutes, range 19–62) were conducted. To reduce the burden on each family, each family was observed once only. SLPs were also interviewed in their offices prior to telehealth delivery, after each observation, and after six months of telehealth delivery. An open-ended interview guide was used to explore SLPs experiences of delivering telehealth. Eight interviews were conducted (mean 41 minutes, range 23–77). Managers were interviewed in their offices six months after telehealth began to understand families declined research participation. Data collection and analysis

changes made by the organisation to implement telehealth (n = 6, mean 57 minutes, range 42–86). All interviews were conducted using interview guides developed by the authors and were recorded and transcribed verbatim. To identify key themes in the case, an adapted inductive thematic analysis method was used (Braun & Clarke, 2006). The first author read and re-read transcripts and observation fieldnotes and noted initial impressions. She developed a coding protocol which was discussed with the remaining authors and feedback given to improve the reliability of coding. The coding protocol was composed of practices across four domains (scenes and actions, people, processes, objects) (domains adapted from Emerson et al., 2011), with telehealth and in-person data coded separately under each domain. Author NH checked raw data was coded to appropriate codes and reassigned data in discussion with the first author. All other authors then refined the coding protocol and coding process. The first author then identified and mapped themes that described important focal points for differences in practice between telehealth and in-person. Further discussion took place with the remaining authors to refine the themes. A report of themes and exemplars was produced and this was edited until consensus was reached among all authors. Results Two major themes emerged from thematic analysis of the interview transcripts and observation fieldnotes: extending parent roles and preparing and adapting resources . See Table 1 for further explication of these themes and associated extracts. Theme 1: Extending parent roles A major theme that was revealed was that parents’ roles shifted from an observer role in-person to a co-therapist role via telehealth, although this shift was not a complete transition in all families. In in-person therapy, parents observed therapy and occasionally verbally encouraged children to complete a therapy task: In-person observation fieldnote: [Child has a cat toy]. Clinician: “Now put him under the table”. The child gets it wrong. Dad says “under the table”. (In-person Family 2, C2). In contrast, in telehealth therapy parents presented stimulus and task instructions to children, delivered physical, gestural, and verbal cues, supported the child’s posture and judged whether children were producing speech sounds accurately: Telehealth observation fieldnote: Mum is asking child if he hears a short sound, or a long sound (sound discrimination). Mum places the flash cards on the visual aide ... Mum does a big swing with the child [in her arms] for “long sound” making him giggle. Modelling the sound into his ear three times while making him laugh. (Telehealth Family 1, C1) Telehealth observation fieldnote: “I wish I had lots of fish in my fish tank” (As the boy is talking and says “wish” and “fish”, [target sound “sh”]) I can see Mum nodding, then the clinician nods back, they appear to have established a partnership where Mum shares non-verbally information about correct productions. (Telehealth Family 8, C2) However, not all parents took on these aspects of the therapist role (presenting stimuli and instructions, cues, supporting posture, and judging speech sound accuracy)

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JCPSLP Volume 23, Number 1 2021

Journal of Clinical Practice in Speech-Language Pathology