Telehealth and in‐person placements: Same, same, but different. A mixed methods investigation of speech and language therapy students’ and practice educators’ experiences and perceptions

Abstract

Background

Telehealth placements in speech and language therapy provide crucial opportunities for both learning and service delivery when clinicians, students and/or clients are separated by factors such as distance or illness. While the use of telehealth placements has increased in recent times, they remain a relatively underexplored phenomenon with limited information available about the perceptions and experiences of practice educators and students.

Aims

The aim of this study was to explore experiences of telehealth‐delivered speech and language therapy services and tele‐supervision from the perspective of speech and language therapy students and practice educators.

Methods and procedures

This study used a sequential exploratory mixed methods design with a questionnaire study followed by a series of focus groups with Australian speech and language therapy educators and speech pathology students. Different questionnaires were used with students (n = 56) and practice educators (n = 27); each explored perceptions of interaction, engagement and student learning via multiple‐choice and open‐ended questions. Multiple‐choice answers were analysed descriptively; open‐ended questions were analysed with qualitative content analysis. The results informed the focus group questions. Separate focus groups were held with students (n = 17) and practice educators (n = 20); each explored student learning and development as well as educator supervisory practices. Data were analysed inductively using thematic network analysis.

Outcomes and results

Responses from both student and practice educator questionnaires indicated that students develop some different skills on telehealth placements compared to in‐person placements and telehealth placements were more suitable for some students compared to others. We constructed 12 basic themes related to student and educator practices, student learning, client care, perceptions about telehealth, and location of educator and student. These were grouped into three organising themes: processes, perceptions, place. The organising themes were summarised into the overarching theme ‘telehealth and in‐person placements: same, same, but different’.

Conclusions and implications

This study adds to the growing body of literature indicating that telehealth placements can meet student learning needs. It suggests that both educators and students need to learn new skills or adapt their current practices to engage in these placements. This paper includes recommendations for how to manage the different practices required by universities, educators and students to promote successful telehealth placements, particularly when the educator and student are not co‐located.

WHAT THIS PAPER ADDS

What is already known on this subject

• Telehealth use has increased dramatically since the COVID‐19 pandemic, both for clinical services and student placements in allied health services in general as well as speech and language therapy (SLT). Student placements conducted via telehealth are beneficial for student learning but some skills such as communication and interpersonal interaction develop differently. Placements can involve students delivering clinical services via telehealth and/ or remote student supervision (tele‐supervision).

What this paper adds to existing knowledge

• By drawing on the perspectives of students and practice educators, this paper demonstrates that the processes used for supervision, planning and clinical services are different in telehealth compared to in‐person placements. It reveals that SLT students and educators have strongly held perceptions about the value and equivalence of telehealth placements that change over the course of a telehealth placement. This paper suggests placements that combine telehealth with tele‐supervision are more complex and have fewer opportunities for incidental learning and developing professional workplace skills than placements where the educator and student providing telehealth services are co‐located.

What are the potential or actual clinical implications of this work?

• This paper will help universities, professional organisations and practice educators disentangle placements where students deliver services using telehealth from those where students also receive tele‐supervision. This work identifies common perceptions about telehealth placements that educators can use to guide discussions with students, and guide the selection of effective work practices for students and educators during telehealth placements.

INTRODUCTION

Practice placements based in workplace settings form an integral part of speech and language therapy (SLT)¹ professional preparation. Within professional practice environments, students learn to apply their knowledge and skills and develop their professional identity (Royal College of Speech & Language Therapists, 2021; Speech Pathology Australia, 2022). Given that SLT is a profession with a shortage of workers (Royal College of Speech & Language Therapists, 2022), it is important to maximise the value of professional practice placements (Allison & Thompson, 2023). One way of maximising placement effectiveness is to ensure that placements prepare students for the modern workforce (Chartered Society of Physiotherapy, 2023) where telehealth is ubiquitous (Speech Pathology Australia, 2016; Royal College of Speech & Language Therapists, n.d)

As a service delivery modality, telehealth has a long history of use in SLT. Telehealth has demonstrated equivalence to face to face services established in many areas of SLT practice (Wales et al., 2017; Weidner & Lowman, 2020) With the need for social distancing and restrictions on services in 2020 and 2021, the use of telehealth expanded significantly and there are recognised benefits in terms of convenience, costs and access (e.g., Burns et al., 2019; Shahouzaie, & Gholamiyan Arefi, 2022,) as well as enhancing some aspects of services, such as understanding the home environment, or seeing everyday interactions (Bacon et al., 2022; Sutherland et al., 2021). Importantly, research has suggested mostly good levels of acceptance of telehealth from clinicians (e.g., Sutherland et al., 2021) and patients and their families (e.g., Little et al., 2023).

Despite the documented efficacy and feasibility of telehealth service provision, less is known about the role and value of telehealth experiences in SLT students’ education. The use of telehealth in student placements was emerging prior to 2020 (e.g., Bridgman et al., 2018) but during the COVID‐19 pandemic there was a rapid rollout of telehealth placements in many settings to enable students to complete their training. This rapid rollout happened largely, as noted by Bridgman et al. (2022), “in the absence of a robust evidence base” (p. 7). Indeed, research regarding SLT telehealth placements is relatively sparse.

Scoping and rapid reviews of the literature have shown few allied health studies of the use of telehealth placements. Serwe et al. (2020) described six studies of allied health telehealth experiences, only one of which involved SLT, while Bridgman et al. (2022) identified just three studies that considered student experiences and of these, only one studied SLT student experiences. The SLT study (Bridgman et al., 2018) was a small study of six students in a stuttering service which found that student perspectives were generally positive. The authors reported some surprise that these students reported some reduction of anxiety in the telehealth condition as they could seek support in real time and better monitor their own performance.

A number of studies have considered the experiences of allied health students and practice educators since 2020. Bacon and colleagues (2022) involved allied health students (from SLT, occupational therapy, physiotherapy, exercise physiology and nutrition and dietetics), their placement and coursework educators and patients in focus groups to explore their experiences and opinions regarding services that underwent a rapid transition to telehealth. They found that while there were some challenges in transference of skills, telehealth placements allowed students to continue to develop competencies and build skills. Further exploration of the experiences of students specifically (Bacon et al., 2023) indicated that while students preferred face‐to‐face consultations, students agreed that telehealth provided high‐quality learning experiences and assisted them to improve their problem solving and clinical practice. However, with just two SLT students involved in this research, there are limitations in whether these findings can be generalised. Indeed, Krahe et al. (2021) found that SLT students reported significantly more negative experiences than students from other allied health disciplines when involved with telehealth placements. Interestingly, while the student speech and language therapists’ patients reported good levels of satisfaction, the students reported concerns that telehealth impacted on their ability to achieve session goals and clinical outcomes. It is possible that higher levels of technical difficulties, and an exclusively paediatric patient group impacted the SLT students’ perspectives of telehealth when compared with other groups. Finally, Ross et al. (2021) included seven SLT students in a qualitative study of 18 allied health students’ experiences of a rapid transition to telehealth. They reported that while students had initial concerns about telehealth, they were able to deliver quality care and reported that their skills, knowledge and confidence improved as they continued through their placements. Overall, while there is good emerging information about telehealth placements for allied health students, there is still relatively little known about SLT students in particular and very little about that of practice educators in this profession.

In addition to facilitating the remote delivery of clinical services, technology can enable real‐time student supervision in situations where the student, client and practice educator are geographically distant (Whitehead et al., 2023). Although students and practice educators have generally positive experiences with tele‐supervision (Nagarajan et al., 2016; Whitehead et al., 2023), some aspects are different from in‐person supervision. For example, following interviews with 18 SLT and occupational therapy students about a placement affected by COVID‐19 health measures, Whitehead et al. (2023) found that different logistics were required for remote supervision placements. They also found that student–educator and student–student relationships develop differently, but student competency development is similar to in‐person placements. It is important to note, however, that in telehealth placements associated with the COVID‐19 pandemic, students typically experienced both telehealth clinical services and tele‐supervision (e.g., Bacon et al., 2022; Ross et al., 2022, 2021), and it can be difficult to determine the relative contribution of telehealth service delivery, tele‐supervision, and the pandemic to the experiences of students and practice educators. Given the limitation of the extant literature—conducted during the pandemic, focused on allied health students in general rather than speech pathology students, conflating telehealth service delivery with tele‐supervision, and typically exploring either student or practice educator perspectives—further research is essential. This study aims to explore the perspectives of (a) students and (b) practice educators regarding competency development, student learning, and supervisory practices, in telehealth placements and tele‐supervision in comparison to in‐person placements and supervision. Additionally, the study aims to identify overarching themes that collectively represent both student and practice educator perspectives

METHODS AND PROCEDURES

Methodology

This study employed a sequential exploratory mixed method design (Cresswell, 2015) with two phases: questionnaire and focus groups. This design allowed the data from the questionnaire to inform the questions in the focus groups. Our final interpretation is made using data from the questionnaires and focus groups.

Participants

Participants in both phases were either (a) students enrolled in a SLT qualification degree or (b) qualified practicing speech and language therapists working as practice educators. Student participants were either enrolled in an undergraduate or postgraduate speech pathology degree at a large metropolitan university and had completed at least one clinical placement and conducted at least one session via telehealth. Clinical educators were required to have supervised at least one student on a clinical placement with services delivered via telehealth. Participants for both phases were recruited by email invitations and announcements on university web‐based learning management systems using convenience sampling.

Phase 1 (Questionnaires): Demographic information

The speech and language therapists (n = 27) who completed the questionnaire had varying years of SLT experience: 14 (52%) had <5 years’ experience, five (19%) had 6–10 years, two (7%) had 11–15 years and six (22%) had >16 years. They worked in a variety of settings: 10 (37%) worked in public health, seven (26%) in a university clinic, five (19%) in private practice and five (19%) in a non‐government organization. The majority (16, 59%) worked full‐time. Their experience as practice educators varied: 15 (56%) had 0–5 years’ experience, five (19%) had 6–10 years, two (7%) had 11–15 years and five (19%) had >16 years.

The SLT students (n = 56) were all from the same large metropolitan Australian university. In Australia, students can qualify to be speech and language therapists via a 4‐year undergraduate program or a 2‐year master's program. Nineteen students (34%) were from the undergraduate program, 31 (55%) from the master's program; six (11%) did not indicate their program. All participants had experience with paediatric clients and 24 (43%) had also worked with adult clients. Although all students had conducted at least one telehealth session, they had varying balances of telehealth: in‐person clinical placement experiences: 14 (25%) had only telepractice, eight (14%) had mostly telehealth, nine (16%) had equal telehealth and in‐person experiences, 16 (28%) had mostly in‐person; nine (16%) did not indicate their balance of telehealth: in‐person experience.

Phase 2 (Focus groups): Demographic information

The SLT practice educators (n = 17) had paediatric, adult or mixed (paed/adult) clinical experiences. They were invited to provide information about their clinical and educational experience at the start of the focus group; most did so. Six (35%) had 1–5 years of SLT experience, three (18%) had 6–10 years’ experience, and four (24%) had >16 years’ experience; the remining four (24%) did not provide this information. Seven (41%) had 1–5 years working as a practice educator, five (29%) had 6–10 years’ experience and two (12%) had 16–20 years’ experience; the remaining three (18%) did not provide this information. Collectively, they had a mix of telehealth and in person clinical and supervision experience.

The majority of the SLT student participants (total n = 19) were in their final year of study (n = 18, 95%; 12 undergraduate; six master's), and one (5%) was in their second last year of study. Sixteen (84%) of the SLT students had both paediatric and adult placements; three (16%) had only had paediatric placements. All students had provided in‐person and telehealth clinical services and had supervision in‐person and via tele‐supervision.

Procedure

Phase 1 (Questionnaires)

Two anonymous online questionnaires were designed, one each for practice educators and students, and hosted through Qualtrics (www.qualtrics.com). The questionnaires, composed of 30–40 questions, included Likert scale, multiple choice, yes/no and short answer questions. Each survey had an estimated completion time of 15–20 min and was open for 6 weeks (November–December 2021). The questionnaires (a) established consent to engage with the online survey, (b) established the demographic profile of respondents, (c) investigated the respondent's attitudes, confidence and perspectives on the skill development of students for telehealth compared with in‐person placements, and (d) explored perceived barriers and challenges to implementing and attending telehealth placements. See Supplementary Materials 1a and 1b for the questionnaires.

Phase 2 (Focus groups)

Ten online focus groups were completed with the participants (five with practice educators and five with students). The focus groups were conducted by authors 1, 3–7 who were female English‐speaking speech and language therapists who had current or prior experience with practice education. Authors 5 and 6 had no prior focus group experience and were trained by author 1 and paired with experienced qualitative researchers (authors 1, 3, 4, or 7) for data collection. All focus groups were conducted and recorded via Zoom and included —three to five participants and two facilitators; no additional people were present. The focus groups occurred from April to June 2022 and had a duration of 45–60 min. Each focus group was conducted using non‐directive, open‐ended questions using a prepared question guide (see Supplementary Material 2a and b). The participants knew the facilitators through their teaching roles at the university and were provided with information about the aims of the study. The question guide was developed using findings from the questionnaire phase of this study.

Following each focus group interview, the Zoom recording was auto transcribed using Zoom, then checked for accuracy by the authors, deidentified with participant names assigned pseudonyms and returned to participants for review.

This study was approved by `The University of Sydney Human Research Ethics Committee' Human Research Ethics Committee (project number 2021/725) with informed consent obtained from all participants.

Data analyses

Phase 1 (Questionnaires)

Questionnaire responses were downloaded into an Excel spreadsheet. Data from all participants were included, including from participants with incomplete surveys. Likert and multiple‐choice questions were analysed descriptively. Open‐ended responses were analysed using qualitative content analysis (Graneheim & Lundman, 2004). In this inductive process, three authors (AP, MI, FP) analysed the stakeholder groups separately. They identified the meaning units in each response, condensed each meaning unit and assigned a code to represent condensed meaning. Similar patterns of meanings across codes within and across participants in each stakeholder set were then grouped together to form subthemes, and similar subthemes were grouped to form themes. The three researchers met regularly to iteratively discuss the codes, generating or collapsing codes as required. An example of the meaning units and codes assigned from open ended questionnaire responses is provided in Supplementary Material 3. The results of this analysis informed the development of the focus group interview guide for each stakeholder group.

Phase 2 (Focus groups)

As the focus of this study was on the collective experiences of both educator and SLT students, data from the SLT students and practice educator focus groups were analysed using network analysis (Attride‐Stirling, 2001). There are six steps in this process. Step one involved conducting inductive thematic analysis of each data set (student, educators) using qualitative content analysis (Graneheim & Lundman, 2004). The analysis was conducted by two researchers per data set (DT and EB, educators; RS and NM, students) within Microsoft Excel. Initially, the researchers identified the meaning units within each utterance. Where more than one idea was represented in an utterance, the utterance was separated into multiple meaning units. Each meaning unit was condensed, first at the level close to the text, then at a more abstract level. The idea expressed in the condensed meaning unit was then assigned as a code. Similar patterns of meanings across codes within each data set were grouped together. The two researchers analysing each data set met regularly to discuss the codes using an interactive process, generating new codes as required, and collapsing codes within similar meanings. During the process of code development, they met twice with the wider team for discussion and refining of codes.

Once the coding for each data set was complete, the whole team met for stage two of the network analysis, collation and categorisation of codes across the two data sets. This was done by identifying patterns of meaning that were represented in the codes of both data sets and assigning these as basic themes. Step three involved developing the thematic network by grouping basic themes with similar meanings into organising themes and constructing a global theme that represented the ideas of each of the organising themes. Step four involved returning to the original data to re‐explore and interpret patterns in relation to the themes in the network. In this step we selected one researcher from each data set to form a new pairing (i.e., DT and NM, EB and RS) for this deeper analysis within and across datasets. Steps five and six involved refining and summarising the thematic network and then interpreting the patterns in light of the research questions and any existing theoretical or practice‐based understandings. This process was iterative, and all team members contributed to these activities through meetings and asynchronous discussions.

Statement of rigour

Several strategies were used to ensure trustworthiness, credibility and reflexivity (Baillie, 2015). To ensure trustworthiness, all analyses were conducted over multiple occasions with groups of authors. At author meetings, differences in opinions on the themes were discussed and resolved. To facilitate credibility of the participants’ views, a series of steps were completed. Firstly, the authors wrote field notes to summarise the participants responses after each focus group and reviewed these notes during the analysis. Secondly, the authors reviewed the transcripts against the audio recordings. Thirdly, the focus group transcripts were returned to research participants for checking. One student participant requested minor changes to the transcript to further safeguard their anonymity; no other changes were requested. The last step was the selection of participants quotes by the authors for inclusion in this publication to share the participants’ insights and considerations.

The authors’ own beliefs and biases (reflexivity) were impacted by their professional backgrounds as speech and language therapists. All authors were female, and the group represented a diverse ethnic and cultural background. All authors were employed in a university setting and were experienced practice educators and academics. Although we tried to minimise the power imbalance by allocating facilitators who were not directly known to participants, student participants may have been aware of facilitators’ roles and this may have affected what the participants felt comfortable to say. Regular research team meetings were held from study design, data collection through to data analysis and write up stages. Extensive dialogue across the team allowed for both consensus and challenging notions to be equally discussed.

RESULTS

Phase 1 (Questionnaires)

Practice educators

Most educator respondents² (19/24, 79%) agreed that students who experience telehealth clinical placements develop different skills to those who have in‐person placements (2/24 disagreed; 3/24 were unsure). Educators (14/24, 58%) also indicated that telehealth placements were more suitable for some students compared to others (4/24 disagreed; 6/24 were unsure). Educator respondents had mixed perceptions about whether they changed their supervision in telehealth placements compared to in‐person placements (9/24 changed their approach, 9/24 did not and 6/24 were unsure). Sixty percent of respondents (13/22) indicated that telehealth supervision requires the same amount of time as in‐person supervision (but 5/22 indicated it requires less time, and 4/22 more time). Some respondents (9/24, 37%) felt that their engagement with students in a telehealth placement was the same as an in‐person placement, though this was not the majority; some felt more engaged (3/24, 13%), less engaged (6/24, 25%) and 6/24 (25%) were not sure.

Students

Most SLT students (34/42, 81%) indicated that they learn different skills in telehealth compared to in‐person placements (2/42 did not, and 6/42 had not yet experienced an in‐person placement). Students also agreed (21/42, 50%) that telehealth clinical placements were more suitable for some students compared to others (however, 9/42 disagreed and 12/42 were unsure). Compared to educators, fewer students (10/42, 24%) considered that being educated via tele‐supervision required the same amount of time as in‐person supervision. Instead, 64% (27/42) felt that tele‐supervision was less time consuming, and 9.5% (4/42) felt that it was more time consuming. Most students (24/42, 57%) felt that their engagement with their practice educator in a telehealth placement was the same as an in‐person placement while 33% (14/42) felt less engaged, 1/42 (2%) more engaged, and 3/42 (7%) were not sure or had not been supervised in‐person.

The results of the qualitative content analysis of responses to open ended questions within the questionnaires for SLT students and practice educators are available in Supplementary Material 4a and 4b, respectively.

Phase 2 (Focus groups)

During our network analysis of the focus group data, we constructed 12 basic themes that were grouped into three organising themes: processes, perceptions and place (Figure 1). The organising themes were summarised in the global theme: ‘Telehealth and in‐person placements: same, same, but different’.

FIGURE 1.

Thematic network showing themes from SLT students and educators.

Abbreviation: SLT, speech and language therapy.

An explanation of the three organising themes is provided here. Pertinent quotes are provided in the text. Further participant quotes are available in Supplementary Material 5.

1. Processes

The organising theme of processes was constructed to reflect the students and practice educators’ perceptions about the work practices they engaged in during telehealth placements and the ways in which these were similar to and different from in‐person placements.

Supervision looked different but was still effective

Educators and students agreed that the essence of supervision remained the same, regardless of the modality of the student's placement:

“I wouldn't say [my supervision] would be much different, I would say it's you still giving feedback on like what they've done, what their goals were, how they, how they manage the client, what they achieve.” (educator Penny)

“I think the interaction was pretty similar. The CEs, whether it was telehealth or whether its face to face; they're really supportive.” (student Stacey)

However, educators used some different supervision methods and explicitly taught some different content in telehealth placements. For example, educators provided explicit teaching about aspects of students’ interactions, such as their facial expression and animation during telehealth sessions. They used additional technology such as the ‘chat’ function in the telehealth platform and computer screenshots. Students had mixed feelings about educators’ use of the ‘chat’ function during sessions, with some valuing the covert feedback but others finding it distracting. Student Jeanette found it unhelpful: “I've had like CEs messaging me on the Zoom and that it is so confusing to see, because you're trying to do something with the client, and then you've got messages coming in that you have to read at the same time, and then implement that into what you're doing”; however, student Hannah felt live chat messages were positive: “It's way less disruptive when you receive feedback over telehealth than in‐person when you're given real‐time feedback”.

Educators expressed less confidence in their supervision ability via telehealth compared to in‐person, and as a result, provided closer supervision in this medium that was newer to them. They requested (‘demanded’ [educator Monica]) more detailed planning from students, spent longer with their students, and felt they didn't have the same ability to recognise patterns about when students required additional support. Educator Barbara admitted “I still was not entirely sure that I figured out how to do the supervision online really, confidently”.

Student learning on telehealth placements was similar but distinct from in‐person placements

Educators and students considered that the core aspects of student learning are achieved regardless of the modality of the placement.

“I was providing therapy online or in person but my aims – of, for example, reasoning and assessment, like, the goals—are necessarily the same. Like, I need to do an assessment on a child, it's just the way I'm doing it is different … In terms of the competencies and getting there, I never really saw it as too different, because it's just like our aim to become clinicians, so I didn't feel like it changed being in‐person or on telehealth.” (student Valerie)

Educators and students described how each placement modality facilitated the students’ learning of different skills and competencies. For example, in‐person placements facilitated the development of behaviour management and professionalism, while telehealth placements facilitated the development of sophisticated communication skills, caregiver coaching, technical skills, and critical thinking about the relationship between goals and activities. Student Margo explained “I learn more about behaviour management in in‐person versus online”.

Telehealth helped students to think critically about their goals and consider the most effective means for achieving those goals, as explained by educator Nareen: “I think [telehealth] challenges [students] to think a little bit more dynamically about how they could deliver health in a format that wasn't face‐to‐face, so working more so on the communication and thinking about other ways to teach online”. Via telehealth, the most effective means of facilitating change for the client was often to coach the caregiver, and students therefore learned to coach caregivers and thoughtfully consider who was the agent of change for the client: “On telehealth I think they really learned how to empower the parent as the agent of change, and how to build that into their everyday practice really quickly. I think potentially a bit more quickly than in in real life” (educator Clare). Students noted the need to work with carers in their telehealth sessions, as explained by student Jeanette: “I think also with telehealth…it's also about training Mum to understand what I'm teaching, and to give me feedback on how he's performing”.

Students noted that their clinical learning progressed in both modalities and valued having both telehealth and in‐person placements. Student Ivy explained, “So I think there's[sic] definitely skills that you learn in either. But I feel like it's been very beneficial for me to have experience in both telehealth and in‐person because I feel like I'm more well‐rounded now”. The practice educators, however, noted higher student anxiety about in‐person sessions when students had previously only had telehealth sessions. When talking about her students who had previously had only telehealth experience, educator Molly said ‘‘Both of them said ‘this is my first time I'm going to see a real client and then the parent is in the room, and like they're watching me and they're just sitting right there, looking at me … one of them was literally shaking … she's like ‘I'm shaking. I'm so scared. I don't know how's it going to go’.

Telehealth required multitasking and more thorough preparation

Both educators and students noted that telehealth sessions required more multitasking than in‐person sessions and this was seen to have both benefits and limitations. In terms of benefits, students felt they were more able to view their notes without their client's knowledge, and this made them feel more confident and facilitated data collection. “I had, you know, half my screen with the client and half my screen with the script of what I was going to say, and what my session plan was as well. So that was really nice” (student Fatima). However, the multitasking associated with telehealth “put a whole extra layer of difficulty on the session” (student Ivy). This was explained by educator Monica “The cognitive load for the students in terms of managing the technology and being on track with what they're doing in a telehealth session and then having to monitor themselves—what non‐verbals and facial expression they're giving—I think that's quite high for students. I think that whole technology just adds this extra layer”. To successfully manage the perceived complexity of telehealth sessions, students planned their telehealth sessions in more detail than their in‐person sessions: “the students are a lot more prepared for their sessions, and I believe that's because when you're preparing a digital presentation and you're combining different AV materials, you need to” (educator Jenny). The detailed preparation in telehealth session plans improves student confidence, as explained by educator April: “things were really thoroughly explained…, so I think, in the end it allowed them to feel super comfortable and flexible and confident”.

Some attributes and prior experiences made adapting to telehealth easier

Students and educators noted that there were some personal skills, knowledge and attributes that students possessed that were beneficial in telehealth placements. These included strong non‐verbal communication skills, organisational ability, independence, prior telehealth experience, and confidence with technology. For example, when describing student factors associated with success in telehealth, educator Shannon said “organisation was a huge one … on telehealth you have to be very prepared and I think you need to be adaptable and flexible” and student Rachel said “I didn't find [telehealth] difficult but I am an older student and I've taught online before in my previous job”. Educators noted that interpersonal skills were even more important in telehealth than in‐person “because you don't have the value of proximity … [and] students who could put on a bit of pizzaz … [were] much more successful in telehealth” (educator Clare). Telehealth sessions were more structured than the in‐person equivalent and were considered to better suit less‐experienced students. “With telehealth, it seems that most of the activities that can be developed are somehow more structured as opposed to face to face… for some students, that may be easier to start off with, so they have a clear plan” (educator Molly). Although educators felt that specific attributes were helpful, they noted that clinically strong students adapted better to telehealth than weaker students; likening telehealth to any other variation students may experience during their placement. This was explained by educator Chris: “When you're a strong student, I think you can adapt to those situations and whatever kind of modality of therapy it is, a lot easier and quicker … If they're weak, they struggle with, like, parent in the room versus no parent, you know, and that sort of throws them off, but if they're strong, none of that stuff matters. The ones that struggle with telehealth also struggle with just therapy in general”.

Making, finding and tailoring telehealth resources was time consuming

Educators and students identified challenges with developing resources for telehealth intervention. Students tailored their resources to the individual more in telehealth than in‐person: ‘‘Our client really likes dinosaurs…. I made him an animation with things like baby eggs and things; and dinosaurs hatching out and stuff, and all of that was to engage him and keep him on the screen.… It was really great, but they were very specific to that client, so they are not really something I can really use for another client. They were very time consuming to make (student Stacey).

Students explained that they wanted engaging resources because they felt less connection with the client via telehealth. Student Hannah felt: “I am just a picture on a screen. So you're trying to, uh, you know, bridge that gap with something that's more alluring, whereas in‐person, you can make an activity out of nothing”. Educators noted concerns about the sustainability of the students’ resource development practices: ‘‘They send the slides, data sheets, incredible session plans but it's I mean it's hours and hours and hours and it's not commercially viable (educator Jane).

2. Perceptions

The organising theme of perceptions was constructed to reflect the students’ and practice educators’ thoughts and feelings about telehealth placements and the ways these were similar to and different from in‐person placements.

Perceptions of telehealth placements were initially negative but changed over time

Upon hearing that their placement would be via telehealth, many students experienced negative emotions such as disappointment and anxiety. These stemmed from preconceived notions that telehealth placements were inferior to in‐person placements and students said they initially felt that they had been ‘robbed’ (student Hannah), given the ‘second best option’ (student Karen), or that they ‘missed out’ on opportunities available in‐person (student Carrie). A small number of students were positive about having a telehealth placement. For example, student Anne said “I was quite excited. I think the thought of doing something new was really exciting”.

Students had more positive perceptions about telehealth placements after they had experienced this modality. This was described by student Hannah: “I spoke about my negative initial impressions. It was amazing how that changed … it was a good learning experience and everything. All the notions that I had, about how it was going to be fruitless, and, you know, impossible, whatever, that turned out to be, not as true as I thought”.

Telehealth placements were considered by educators and students to be more challenging than in‐person placements. Educators noted that supervising a student placement via telehealth “is a completely extra layer” (educator Shannon) that can lead the educator to experience overwhelm. Students, too, felt telehealth placements were more challenging: “I felt prepared for an in‐person placement, because I survived the telehealth one, you know” (student Hannah).

Telehealth placements are valuable but not equivalent to in‐person

Educators and students believed that students should gain experience with telehealth on placements, as telehealth was “here to stay” (educator Monica). Educator Molly explained: “I think that it's, like, important to have both to have face‐to‐face and telehealth, I think that one should not override the other. I think the world is changing, that we need to have competencies in both”. Telehealth placement experience, however, was not viewed as identical to in‐person, and in‐person client experience was considered by educators and students to be essential. “I think it would be hard if they got to graduate and they never had a face‐to‐face client. I think they'd struggle a lot in that first year they'd probably need quite a bit more supervision” (educator Jenny).

Client engagement in telehealth felt different from in‐person

Students and educators felt that it took more effort for students to engage their clients via telehealth than in‐person. Students perceived a “barrier” (student Shannon) or “separation” (educator Bree) between themselves and the client. Educators felt students were not as attuned to the client's emotional state as they may have been in‐person. Students had fewer ways to engage their clients via telehealth and felt they therefore needed to be more “exciting” (student Ruth), animated or “a bit more over the top” (educator Bree) to maintain their client's attention.

“With telehealth … they only see this part [gestures to head]…. So you just use different ways of doing therapy, using more prosody. Yeah. So you're way more aware of how you look on screen; what they see.” (student Lyn)

“If a client is looking dissatisfied or frustrated or upset that's sometimes a bit more difficult for students to respond to online rather than in‐person. You know, when you're in a room with someone you can actually make eye contact with them, get a sense of whether it's appropriate to pat their hand or give them a cup of tea. You can't do any of that online, and I also think because students are in the safety of not having the real person right in front of them, it almost relieves a bit of responsibility, because they're just going to close the laptop afterwards.” (educator Katie)

Students found it more difficult to manage their clients’ behaviour online than in‐person and, despite their best efforts, their paediatric clients sometimes walked away from the screen. Students said it was not uncommon for paediatric clients to be left without caregiver supervision, and this made their work harder. One example of this was provided by student Alison: “The behaviour control is so difficult. One of the little kids, and he was six or seven, I think, and when his mum had to leave, you know, he'd just get up and start jumping on his bed. And what can you do? His mum wasn't in the room so she's not helping with it”.

Not all clinical tasks transfer easily to telehealth

The final perception was that some clinical tasks were not easily transferable from an in‐person context to telehealth. Educators and students expressed concerns about students managing some clinical situations via telehealth such as clients under 3 years old, clients with dysphagia, adult clients with tangential communication, and clients with complex communication needs.

“But really little ones that are like three and four and five that sort of need that the room and they kind of need to be bouncing off the walls … For those, I feel like an in‐person session works better.” (student Stacey)

Although there were situations where educators perceived telehealth would not be appropriate for a student on placement, there were others where they perceived that telehealth improved client care. Educators and students noted that telehealth was more convenient for their clients, facilitated generalisation and enabled the clinicians to see the client's home context. This was explained by educator April: “Assessing little ones via telehealth was good, because [the students] got to see the child in a different environment so … they were able to observe the client in a different light and a different perspective to what they see in a clinic session”.

3. Place

The organising theme ‘place’ was constructed to reflect that the location of the student, relative to the educator and the clinic, made a difference to educator and student experiences of the placement. When the student was not co‐located with the educator at the clinic for their placement (i.e., the placement had tele‐supervision in addition to telehealth), students had fewer incidental learning opportunities, additional educator effort was required, and professional workplace expectations were not learnt in the same way.

Incidental learning less when student is off‐site

When the student was not co‐located with the educator there were fewer incidental student learning opportunities. For example, students were not able to note “all the sensory things going on, when you're meeting [an acute patient] for the first time … what tubes are going in and out, what they're looking like” (educator Jane). Students had fewer informal interactions with their educator: “When you're in‐person you do have more just casual conversations” (student Lyn); and when students are not at the clinic “you don't do the non‐work stuff, right? Like, you don't exactly share a cup of tea” (educator Clare). This lack of incidental interactions led some educators and students to feel less connected. Educator Melanie said, “I was definitely less present as a CE online, um, I think because there was [sic] no incidental conversations…” and educator Fea's student “wrote a reflection saying ‘I felt quite isolated just not being in the same building as my educator’”. Interactions with members of the multidisciplinary team were harder too, when students were not at the clinic, as noted by educator Sam: “being able to connect with the wider just multi‐disciplinary team was more challenging when you're online … there weren't really lots of opportunities, or if there were it had to be created, it couldn't happen spontaneously”. Student Jeanette also expressed that connecting with team members is harder in a fully online placement: “face‐to‐face communication with the teachers and professionals is definitely much easier”.

Additional educator effort required when educator and student are not co‐located

When students completed placements remotely, educators used different teaching methods between sessions, and found these to be more time and effort. For example, educators noted they needed to plan the placement in more detail and produce daily schedules that outlined the activities for each student and educator which “felt really formal… [and] added a sense of pressure to me as a CE as well as the students” (educator April). Additional resources were needed when the student was located remotely, such as technological solutions that enable students to access resources and client information. However, there were some benefits associated with telehealth placements when the student was not on‐site. These included greater student organisation, independence, time management, and higher quality peer and educator meetings. “I found that over Zoom you could schedule meetings where you got really good quality feedback, and you really got the CE. I just felt like you could schedule more time to really talk about, you know, the details, the nitty‐gritty what worked, what didn't work, whereas in person it was always a bit of ‘ah there are too many things.” (student Hannah).

Professional workplace expectations aren't learnt in the same way when student is off‐site

Students found it more challenging to learn professional workplace expectations when they did not attend the clinic. Educators noted that students’ interactions with clinical and administrative staff members were less appropriate, students’ choice of clothing were not always suitable, and student engagement was lower in these contexts. Educator Angela and educator Molly reflected on telehealth placements when students didn't attend the clinic: “it was a little bit too comfortable. They will be wearing T‐shirts to their sessions so the professionalism … stuff goes out the window” (educator Molly); “I think there's been less learning around professionalism and professional communication. So even talking to the reception staff and…understanding some of those in‐person, in‐place kind of work habits, like how to organise the resource cupboard … I think telehealth and doing everything by telehealth may have impacted” (educator Angela).

DISCUSSION

This study explored experiences with telehealth placements and tele‐supervision compared with in person placements and supervision from the perspective of both SLT students and practice educators. Data from the questionnaire phase highlighted that both students and practice educators felt that telehealth placements were valuable, facilitated the development of different skills compared to in‐person placements, and that telehealth placements better suited some students than others. Thematic network analysis combined educator and student perspectives to construct three organising themes: processes, perceptions and place, and a global theme of ‘Telehealth and in‐person placements: same, same, but different’. This global theme highlights that both educators and students perceive telehealth placements and tele‐supervision have many similarities to in person placements and supervision. However, some important differences need to be managed by students, educators and universities to ensure graduates are ready for SLT practice. These include differences in the learning opportunities, educator and student experiences in telehealth placements, which are magnified when the student and educator are not co‐located.

In the theme of Processes, educators and students similarly perceived that a range of fundamental knowledge and skills could be developed in students whether placements and services were online or in person. This is consistent with the established benefits of placements in health professions and confirms emerging evidence for telehealth placements (Bacon et al., 2022; Bacon et al., 2023; Bridgman et al., 2018). However, shifting to online required additional thought, planning and effort by both educators and students to manage new technologies, plan and resource sessions to ensure quality person‐centred care. Given many educator participants were highly experienced as both clinicians and educators, this raises questions about why the move to telehealth was effortful. It may be that the experienced educators used the knowledge and skills developed through their previous supervisory experiences (“routine expertise”, Cutrer et al., 2017), but had limited capability to transfer their practices to an online context. For students still developing competency, their existing attributes and capabilities may have become magnified during online placements; for example, one of the core competencies for telehealth, communication skills (Anil et al., 2023), is known to be linked with difficulties demonstrating clinical competence on placement (Davenport et al., 2018).

In the theme of Perceptions, educator and student views about telehealth and tele‐supervision impacted learning experiences as well as client service delivery. Both educators and students perceived it to be more challenging to engage clients online than in person, which aligns with previous findings in the United States (Overby, 2018). This seemed to contribute to each stakeholder group viewing this as a limitation of telehealth placements, and to the belief that telehealth experiences should be supplemented with in‐person experiences before graduation. However, our finding that negative perceptions changed over time is consistent with an SLT study in Ireland (Lyons et al., 2021) and suggests that once educators and students have experienced online placements, they can recognise the transferrable skills that students develop as well as the value of telehealth for client care. Nevertheless, it is still important to acknowledge any increased sense of burden for educators in telehealth placements or using tele‐supervision. SLT educators already perceive that students take time (Bourne et al., 2020) and universities need to guide educators in implementing efficient and effective practices in these less familiar supervisory contexts.

In the theme of Place, participants observed that student learning experiences and outcomes were different if students were not co‐located with their educator and other team members. Interestingly, identified differences align with key areas of work readiness in SLT (Attrill et al., 2022), including strengths in independence and attitude (e.g., administration and time management) but limitations in teamwork capabilities. In relation to educator experiences, administrative challenges and time implications when students were not co‐located are consistent with previous tele‐supervision studies in allied health (Nagarajan et al., 2016). Services and universities should plan in anticipation of these constraints to ensure educators are well positioned to supervise using online modalities.

Suggested guidelines for maximising effectiveness of telehealth placements

Given that telehealth is a valuable form of clinical service delivery, it is important for students to develop capabilities in this modality (Royal College of Speech and Language Therapists [RCSLT], n.d.; Speech Pathology Australia, 2016). Informed by the findings of this present study, we propose the following guidelines for universities, educators and students to maximise the effectiveness of telehealth placements (Table 1).

TABLE 1.

Suggested guidelines for stakeholders to maximise effectiveness of telehealth and tele‐supervision placements.

Stakeholder	Guideline	Example
Universities	Prepare students for telehealth placements	Highlight the skill transfer that can occur across contexts (Bourne & Bell, 2024). Include telehealth examples in academic as well as clinical units, not just in the context of rural and remote services. Provide video examples of telehealth, and consider incorporating telehealth in some assessments. Equip students to discuss the evidence base for telehealth, in the same way as for other service delivery options Teach students telehealth competencies (Anil et al., 2023; Overby, 2018).
	Prepare educators for telehealth placements	Discuss telepractice and telesupervision in practice educator training programs. Explicitly teach about routine versus adaptive expertise (Cutrer et al., 2017) and support the development of ‘adaptive expertise’ to facilitate flexibility in new teaching contexts such as telehealth placements. Provide resources for maximising effectiveness on telehealth placements (e.g., RCSLT, n.d.)
	Ensure students have a range of placement experiences, ideally with both telehealth and in‐person across their degree	Include detail about placement modality in placement tracking systems. Consider telehealth placements for students early in their degree, when student benefit from detailed planning
Educators	Plan for telepractice placements	Allow more time when supervising in a new modality, particularly if it includes tele‐supervision ○Plan ways for students to engage with other team members ○Build in structured ways for the student to receive feedback Provide students with video models of telehealth sessions, and where possible, have student use modified simulated telehealth patients (Thomas et al., 2023)
	Explore the diversity of student learning and work practice preferences	Discuss student preferences within telepractice sessions (e.g., educator to have camera on/ off when entering sessions; use of ‘chat’ use during sessions)
	Support students in learning about ethical care	Encourage students to consider confidentiality, caregiver support, and efficacy of care in addition to client convenience (Anil et al., 2023; RCSLT, n.d.)
	Support students in acquiring and developing resources	Direct students to digital resources they can use or adapt; negotiate the level of detail required in plans for telehealth sessions
Students	Monitor verbal and non‐verbal communication skills in telehealth sessions	Maximise the use of facial expression and intonation. Review recordings of sessions and engage in reflective practice (Dunne et al., 2019).
	Strive for efficiency in resource development	Consider ways that resources can be re‐used for different clients.
	Provide ethical practice	Discuss expectations with clients and families (e.g., involvement of caregiver) and raise any concerns with educator
	Continue open conversation with your educator	Advocate for meetings with educator, particularly if not co‐located. Don't assume educator knows how you are feeling.
	Be aware that attributes such as communication skills, organisation, and confidence are helpful in telehealth placements	Take opportunities to refine your communication skills. Set up systems to manage clinical tasks in a timely manner. Utilise peer support

Limitations

Although the students and practice educator participants in this study each described their experiences with telehealth and in‐person placements, they were not describing the same placements. The participants in this study were all from Australia, and the student participants were from one university, limiting the generalisation of the results. Phase 2 demographic details were collected within the focus groups and not all participants provided the requested demographic information. The data analysis and findings may have been influenced by the composition of the research team, which consisted of female speech and language therapy academics; no students or non‐university employed practice educators were involved in data analysis.

Future Directions

Given the central role of telehealth in the practice of speech and language therapy, it would be beneficial to consider the impact of the guidelines (Table 1) on the perceptions and outcomes of students and educators with telehealth placements. Future research could also consider the update of telehealth placements across speech and language therapy sector and explore uptake through an implementation science framework.

CONCLUSION

This study suggests telehealth placements can meet student learning needs but both educators and students may need support to transfer their skills to this learning context, particularly when the practice educator and student are not co‐located. This study includes recommendations for universities, educators and students to promote successful telehealth placements.

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Thomas, D.C. , Sutherland, R. , Munro, N. , Ibric, M. , Pacey, F. , Purcell, A. , Bourne, E. et al. (2025) Telehealth and in‐person placements: Same, same, but different. A mixed methods investigation of speech and language therapy students’ and practice educators’ experiences and perceptions. International Journal of Language & Communication Disorders, 60, e70009. 10.1111/1460-6984.70009

DATA AVAILABILITY STATEMENT

The data are not available because, as part of the original study design, participants were not asked to consent to the inclusion of their data in a public registry, and ethical approval for such dissemination was not granted. Deidentified data are available from the corresponding author upon reasonable request.