Impact of Virtual Care on Speech‐Language Services

ABSTRACT

Introduction

COVID‐19 impacted care delivery in rehabilitation services including speech‐language pathology. The purpose of this study was to examine speech‐language pathologists’(SLPs) perspectives on the effectiveness of virtual care delivered during the pandemic in Canada, their experiences with therapy delivered virtually and their views on future models of care.

Methods

We carried out a cross‐sectional survey with SLPs in Canada who had delivered virtual services to children during the pandemic. The survey questions were based on information collected in a previous study involving focus group interviews with SLPs. The survey elicited responses related to SLPs’ perception of effectiveness, their experiences with virtual care including perceived barriers and facilitators to implementing virtual care, and their vision for future speech‐language services. Quantitative responses were compiled descriptively, and qualitative responses were reviewed and categorized.

Results

Seventy‐five SLPs returned completed questionnaires. A majority (57.4%) reported that virtual care was very/extremely effective and 33.3% somewhat effective. The main barriers to providing virtual services were limited access to technology (family), limited workspace for the session at home, and limited availability of the caregiver for sessions. Services for children with complex developmental needs were viewed as more difficult to deliver virtually. Several positive aspects were highlighted including caregiver engagement in sessions and better work‐life balance. The majority (84%) of SLPs indicated they would prefer to continue to use virtual care by adopting a hybrid model of service, while 8% of SLPs favored virtual care only and 8% in‐person care only.

Conclusions

Most SLPs reported that speech‐language services via virtual care were effective. Practitioners indicated a preference for a hybrid model of care for post‐pandemic services. Further research is needed to better identify what components of virtual care enhance services to better adapt service models in the future.

WHAT THIS PAPER ADDS

What is already known on this subject

• Virtual care has been provided in speech‐language pathology for many years but primarily in select circumstances for children living in remote areas. Speech‐language care dramatically changed in many countries due to the required lock‐down during the COVID‐19 pandemic.

What this paper adds to the existing knowledge

• This study provides updated information about the perceptions of effectiveness of virtual care for children based on the unplanned experiences of speech‐language pathologists in Canada who were forced to rapidly implement a new service model. The findings suggest that overall practitioners adapted quickly and judged their services to be effective. Positive aspects of care included improved caregiver coaching, greater caregiver engagement and better work‐life balance for practitioners. Primary barriers included the family's access to technology and the challenges of delivering care to children with complex needs.

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

• This study supports the feasibility and effectiveness of speech‐language care delivered virtually to children. This service model may result in improvements in both caregiving coaching and caregiver engagement. Most practitioners prefer shifting their post‐pandemic services to hybrid models of care.

1. Introduction

The COVID‐19 pandemic dramatically changed the delivery of care in many health and education services for children. Speech‐language pathology services for children present the additional challenge of providing care to children who have communication difficulties. Although virtual care (also known as telepractice and telehealth) experienced growth in speech‐language pathology prior to the pandemic (Law et al. 2021; Regina Molini‐Avejonas et al. 2015), these services were implemented primarily to address access barriers to intervention for people living in remote areas (Chen and Liu 2017; Regina Molini‐Avejonas et al. 2015; Southby et al. 2022; Sutherland et al. 2019). In Canada, virtual care was not routinely used in the provision of speech‐language services prior to the COVID‐19 pandemic (Macoir et al. 2021).

Several reviews have concluded that speech‐language services through virtual care generally produce encouraging results and offer several advantages, including increased access to care and more cost‐effective services (Law et al. 2021; McCarthy et al. 2019; Regina Molini‐Avejonas et al. 2015). A number of studies comparing virtual care SLP with in‐person care specifically for children with speech‐sound disorders have also indicated that care is effective (Grogan‐Johnson et al. 2013; Regina Molini‐Avejonas et al. 2015; Thomas et al. 2018). A rapid review of 10 existing reviews on telepractice services (Law et al. 2021) for children with communication disorders suggested that the results were at least as good as in‐person care. However, the studies in these reviews were conducted prior to the pandemic, and therefore, more likely involved services where a planned decision was made to provide and/or receive virtual care.

Based on their review, Law et al. (2021) concluded that there was little information on the core elements of virtual intervention to guide practitioners in designing programs for children. An important gap identified in the review was that it was not possible to determine the value of virtual care for children with various types of communication disabilities. Subsequent studies have focused on SLPs' perspectives on this topic. For example, a survey of Dutch‐speaking SLPs found that clinicians with expertise in multiple domains of paediatric speech‐language disorders reported more added value for virtual care than those working with one specific domain (De Taeye et al. 2023). In a Canadian survey of early experiences during the pandemic, Macoir et al. 2021 reported that SLPs found virtual care to be less adequate for paediatric conditions such as swallowing disorders, hearing loss, and autism. In another survey, SLPs working virtually with children and adolescents with literacy difficulties during the pandemic reported numerous challenges, including technology, parent engagement, and the need to eliminate group therapy sessions (Furlong and Serry 2023). There was also no clear evidence from the Law et al. (2021) review on whether the severity of the communication difficulty impacts the use or effectiveness of virtual care. For example, a survey of 331 SLPs, which examined the effectiveness of virtual care with children who used Augmentative and Alternative Communication (AAC) revealed a wide range of perceptions, with most rating consulting/coaching as more effective than direct therapy services (Biggs et al. 2021). A better understanding of how various factors affect the preferences for and effectiveness of virtual care services and of how adaptations can improve effectiveness could optimise service delivery.

Fewer studies have focused on parent/caregiver satisfaction and experiences with virtual care delivery in SLP for various types of communication disorders, yet there is clear evidence that the caregivers’ role is critical (Law et al. 2021). Findings from an early systematic review (Regina Molini‐Avejonas et al. 2015) indicate that overall, parents were satisfied with the virtual services provided. Difficulties that parents highlighted seem to relate primarily to technology issues (e.g., internet connectivity) (Chen and Liu 2017; Crutchley and Campbell 2010; Fairweather et al. 2016). Notably, these studies were generally small (5 to 10 parent participants) and were carried out several years prior to the pandemic. Even a few years can have a substantial impact on technology advancements and user familiarity.

While parents seem to be accepting of virtual care services when needed (Regina Molini‐Avejonas et al. 2015; Sweeney et al. 2020), their views on its effectiveness are less clear, as reported in recent studies. In one larger study carried out in China during the pandemic, 85 parents of children with various speech‐language disorders reported that virtual care was less effective than in‐person therapy (Lam et al. 2021). In an Australian survey conducted during the pandemic, clients, including parents, did not report virtual care SLP to be as effective as or preferable to in‐person therapy (Filbay et al. 2021). In a UK study, most parents of children with cleft palate judged virtual care to be at least somewhat effective (Southby et al., 2022). More recently, qualitative interviews with parents of children with autism who participated in a virtual version of a well‐developed program (More Than Words) showed encouraging results (Denusik et al. 2023, Denusik et al. 2024). Caregivers’ comments indicated that the program provided them with new communication strategies, allowed them to develop a support network and improved their child's functional communication abilities.

One factor that might influence caregivers’ experiences and, therefore, their perception of the effectiveness of virtual care speech‐language services is their participation. Recently, through a scoping review (DiFabio et al. 2023), identified barriers and facilitators to caregivers’ participation in speech‐language and hearing virtual care services. The primary barrier to caregiver participation was strongly related to technological challenges, followed by the environment and caregiver/child roles in the sessions. The authors highlighted that ease of use of technology emerged as the greatest barrier in the studies reviewed and stressed the need for training for caregivers.

The pandemic disrupted typical models of care in health and education services, including in speech‐language pathology. In Canada, during the early ‘lockdown’ periods, schools closed for several months in many regions, and in‐person rehabilitation services were no longer feasible. There was a forced rapid transition to virtual care in many parts of health and education (Law et al. 2021), and many SLPs were forced to quickly adapt to a new way of working across all speech‐language disorders. These experiences have nourished an increased understanding of virtual care models, with continuing attention directed to these approaches. As virtual care has become a more widespread option for SLP care, in part due to technological advancement and in large part due to necessity during the pandemic, it is important to understand practitioners’ views on this service delivery model. For many practitioners, the pandemic created the first opportunity to implement this approach. Increasing our understanding of this approach can assist programs in adapting and creating new service provision models. The purpose of this study was to examine SLPs’ perspectives on the effectiveness of virtual care delivered during the COVID‐19 pandemic in Canada, their experiences, including barriers and facilitators, with providing services virtually and their views on subsequent models of care.

2. Methods

2.1. Design and Participants

We conducted a cross‐sectional survey of SLPs in Canada who provided services to children during the COVID‐19 pandemic.

Participants. Eligibility criteria were SLPs who had delivered services through virtual care during the pandemic to children under the age of 12 years in any work setting (e.g., hospitals, schools, private practice). Participants were recruited during March and April 2022 through the Canadian professional association for speech‐language pathologists and audiologists (Speech‐Language and Audiology Canada), nine provincial/territorial professional speech‐language/hearing associations, professional social networks, and through preschool speech‐language service programs. Ontario, Canada's most populous province, makes up more than 40% of the national association membership (Speech‐Language and Audiology Canada 2023, Annual Report), which likely contributed to distribution of the survey to a much larger number of speech‐language pathologists in Ontario. Ten Canadian provinces/territories each account for less than 5% of the membership in the Canadian association.

Ethical approval for the study was obtained from the University of Ottawa Research Ethics Board (# H‐08‐21‐7078). Participants checked a box in the survey to confirm consent to participate in the study.

2.2. Procedures

Questionnaire. The questionnaire was developed based on information collected through six focus group interviews with 17 SLPs from a range of preschool and school‐age work settings (Phase 1 of this study, unpublished data). The survey consisted of 35 questions that asked practitioners about their experiences providing virtual services during the pandemic. Questions were grouped into six key areas related to: demographics, resources for service delivery, technology and barriers, types of services delivered before and during the pandemic, work‐life impact, and practitioners’ perspectives on services (e.g., confidence, effectiveness). Participants were first asked to provide a brief description of their province of employment, work setting (e.g., clinic, school), number of years of experience, and populations serviced. The subsequent questions were rated on a 5‐point Likert scale ranging from, for example: 1 (strongly agree) to 5 (strongly disagree) or 1 (very comfortable) to 5 (not at all comfortable). The survey was dynamic, in that participant responses triggered additional questions or an option for additional open‐ended comments. The final two questions were open‐ended questions inviting SLPs to share their vision for an ideal service delivery model in the future and to provide any additional comments.

Distribution. The survey was distributed through REDCap, a web‐based application, used widely to collect survey data. No honorarium was offered for completing the survey. As noted, participants were recruited via national and provincial associations. The associations/networks were asked to send an invitation via email with a link to the survey in REDCap. Reminders were sent to the associations, requesting that the invitation email and survey links be resent two weeks and four weeks after the initial invitation.

2.3. Data Management and Analysis

All data were collected in REDCap, and quantitative data were subsequently downloaded into an Excel file, including the responses to each question. Participant characteristics were summarised using descriptive statistics (per cent, means and medians as appropriate).

Qualitative responses to open‐text questions were also imported into Excel, and a content analysis approach, applying the principles of interpretive description (Thorne et al. 2004), was used to systematically interpret participants’ responses. This approach is well‐suited to investigating phenomena to identify themes and patterns from subjective perceptions to generate an interpretive description (Thorne et al. 2004). Two researchers first independently reviewed the comments for each question to become familiar with the data and then met to discuss and code the comments. Through detailed discussion between the two researchers, key concepts were grouped to summarise perspectives on virtual care. To maintain rigour and trustworthiness, the researchers engaged in critical reflection on their positionality, carried out reflexive memoing and maintained field notes during the analysis process. They also met throughout the analysis to refine the final codes and themes and to select sample quotes. Qualitative comments were used to understand and support the survey responses. Direct quotes were selected to illustrate the quantitative responses collected through the survey by capturing SLPs’ perspectives in their own words.

3. Results

3.1. Characteristics of Participants

Table 1 presents information on the characteristics of the 75 SLPs who submitted completed questionnaires. The mean number of years working as an SLP was 14.6 (SD: 9.6, range 1 to 35) years. Almost one‐third (28%) reported more than 20 years of experience, and only 5% had less than 3 years of experience. There was at least one respondent from 8 Canadian provinces/territories, but the majority (77.3%) practised in Ontario, followed by New Brunswick (16.0%). As noted, Ontario is Canada's largest province with a population of more than 15 million; the large representation may also reflect the fact that the researchers worked in the same province and were members of provincial professional associations. The majority of SLPs provided services in English (94.7%), while 47% worked in other languages, the majority of these in French (42.7%).

TABLE 1.

Characteristics of speech‐language pathologists.

Characteristic	Participants a (n = 75)
Mean years in SLP (SD)	14.6 (9.6)
Practicing location, n (%)
Ontario	58 (77.3)
New Brunswick	12 (16.0)
Québec	6 (8.0)
Manitoba	1 (1.3)
Saskatchewan	1 (1.3)
Alberta	1 (1.3)
British Columbia	1 (1.3)
Northwest Territories	1 (1.3)
Practicing language, n (%)
English	71 (94.7)
French	32 (42.7)
Spanish	2 (2.7)
Cantonese	1 (1.3)
Mandarin	1 (1.3)
Other (not specified)	2 (2.7)
Practice setting, n (%)
Hospital	14 (18.7)
School board	24 (32.0)
Community agency	15 (20.0)
Health unit	12 (16.0)
Private practice	36 (48.0)
Other	3 (4.0)
Geographic area of practice, n (%)
Urban	32 (42.7)
Rural	7 (9.3)
Both	36 (48.0)
Age of children serviced, n (%)
Preschool age	63 (84)
School age	55 (73.3)
Other (adult or not specified)	9 (12)

Abbreviations: SD, standard deviation; SLP, speech‐language pathologist.

^a Proportions may exceed 100% as respondents could select more than one response for location, language, setting and age serviced.

Responses indicated that of the 75 SLPs, 70.7% worked in publicly funded health programs (hospitals, community agencies or health units), 32% in education and 48% offered private practice. Frequently, SLPs worked in private practice while holding a position in a public program. Professionals were asked to self‐identify their work settings as rural or urban. While most (90.7%) reported that they provided services in urban settings (42.7% urban and 48.0% both urban and rural), more than half (57.3%) reported delivering some services to children living in rural areas. A majority (84.0%) of SLPs provided services to pre‐school age children, with 54.6% reporting that pre‐school services accounted for more than half of their work time; only 4 reported no preschool children. Most SLPs (73.3%) had school‐age children on their caseload; 44% had more than half of their work time allocated to this age group, and only two saw no school‐age children.

3.2. Virtual Care Services and Resources

Most respondents (90.7%) indicated that their primary reason for providing virtual care services was the exceptional circumstances related to the pandemic. Figure 1 illustrates this rapid transition, showing the number of SLPs that delivered various types of services virtually before and during the pandemic. As shown, 57% of SLPS reported offering no virtual care services prior to the pandemic, while during the pandemic, no SLP in our sample reported providing no virtual care at all. Less than 10% of the respondents provided any virtual assessment or direct intervention prior to the pandemic. However, 74% reported providing treatment (therapy), and the majority reported administering formal (51%) and dynamic assessments (61%) as part of their virtual care services during the pandemic. While only 14.7% SLPs reported feeling even somewhat confident providing virtual services (68% not at all confident) prior to the pandemic, 72.0% were very confident, and almost all (96.0%) were at least somewhat confident by two years post‐pandemic.

FIGURE 1.

Comparison of virtual care pre‐pandemic and during the pandemic.

Participants reported using a range of resources to provide virtual services; however, they indicated that these were not initially readily available. Overall, 88% reported the need to acquire additional resources. Difficulty acquiring resources at the start of the pandemic was most common among SLPs working in school boards (50%) and community agencies (53%), and less common for those in hospitals (35.7%), health units (33.3%) and private practice (27.8%), where overall about one‐third reported difficulty. Difficulty acquiring resources was similar for SLPs who worked in English (35% reported some difficulty) or in French (28% had difficulty).

At the time of the survey, the majority of SLPs used interactive online games (88.0%) and PowerPoint games (80.0%), and a large proportion used interactive virtual backgrounds (45.3%), a document camera (41.3%) and a green screen (36.0%) in their services. Most SLPs (82.7%) reported consulting social media pages during the pandemic to access resources and ideas for therapy, compared to only 20.0% prior to the pandemic. Most SLPs (77.3%) also reported using and adapting existing tools/materials to a virtual context some or all the time. The majority reported being comfortable using technology pre‐pandemic (70.7%), which increased to 90.7% at the time of the survey.

3.3. Effectiveness and Advantages of Virtual Care

Most respondents (57.4%) perceived their virtual care services to be very or extremely effective, and another third (33.3%) somewhat effective (Figure 2). Only 9.3% felt that their services were slightly effective. However, as illustrated in Figure 2, their judgement of how parents perceived the effectiveness of virtual care was different. Only 26.7 % of the SLPs believed that parents perceived the services to be very/extremely effective; the majority (54.6%) indicated that parents viewed care as somewhat effective. The remaining 18.6% felt that parents viewed these services as only slightly or not effective. Several comments (examples below) highlighted their responses.

FIGURE 2.

Comparison of SLP's own ratings of effectiveness of virtual care and their ratings of caregivers’ views.

Parents are sometimes skeptical that virtual SLP services will be effective, particularly if children have had negative experiences with virtual school. Once they have observed and participated in virtual therapy, they typically express gratitude and surprise. (Comment #77, Q32)

Parents are under the impression that therapy needs to be in person and more often to be successful (Comment #51, Q32)

The respondents identified several positive aspects of virtual care services (Table 2), including benefits for the child/family, efficiency of care and work‐related enhancements. A large proportion of SLPs noted that virtual care not only increased caregiver involvement (74.7%) but also helped the therapist to improve their parent coaching skills (66.7%), as illustrated in the comment below.

TABLE 2.

Positive impacts of virtual care reported by speech‐language pathologists (n = 75).

Impact of virtual care	Participants a n (%)
Caregiver involvement increased	56 (74.7)
SLPs’ parent coaching skills improved	50 (66.7)
Wider geographical area of clients serviced	52 (69.3)
Clients seen more frequently	20 (26.7)
Larger client load serviced	16 (21.3)
Work‐related travel decreased	59 (78.7)
Work schedule became more flexible	56 (74.7)
Work time saved	39 (52.0)
Collaborations with other professionals were facilitated	37 (49.3)
Other	2 (2.7)

^a Proportions may exceed 100% as respondents could select more than one response.

During the pandemic, we have held a steady caseload that has ebbed and flowed with the needs/transitions. Parent involvement through parent coaching has been a huge bonus of virtual care. It has forced me to be a better coach and modify my practice to help parents to understand why they are doing what they are doing. I thought I was an effective parent coach before virtual care, but physically removing ourselves from the child removes our ability to ‘save’ the session by stepping in. (Comment #138, Q26)

Increased efficiency of care was a notable advantage of virtual care, which translated to servicing a wider geographical area (69.3%), seeing children more frequently (26.7%), and servicing a larger caseload (21.3%), as shown in Table 2. A majority of SLPs (78.7%) indicated that an important work‐related enhancement was decreased travel time, which resulted in more scheduling flexibility and saved time. Additionally, 49.3% of SLPs reported that virtual care facilitated collaboration with other professionals.

Continuing to use VC (virtual care) allows me to see children who are difficult to schedule that are in outlying communities. Our area is geographically vast, so there are areas that I only visit one/week or once/month. These children would normally miss until the next visit, but with VC we can make this time up. Furthermore, I continue to do parent intake sessions via VC. This allows me to gather case history, etc., with just the parent at a time that is convenient for them, and when the child comes for their assessment, all that clerical work is complete.ʼʼ (Comment #92, Q26)

I see several advantages that have allowed me to make my practice and my services more accessible, and I feel that I get closer to my clients because I enter their living environment in a certain way. (Comment #72, Q26)

Work‐life balance. SLPs were also asked specifically about their views of work‐life balance in a virtual care environment. More than half (53.4%) of SLPs felt that virtual care delivery improved work‐life balance, and only 24% perceived it as having a negative effect (22.7% reported no impact). Numerous reasons were provided, ranging from practical aspects of working at home, like flexibility in managing home‐related responsibilities, to improving overall stress due to reduced travel and scheduling issues. However, 58.7% of SLPs also indicated that virtual care increased their fatigue levels.

Working from home has allowed me to improve my fitness level, attend to matters at home between sessions, and appreciate my garden as it changes between seasons (Comment #56, Q27)

Virtual [care]has improved my mood, lessened my stress, however, I find I work longer hours being at home (Comment #130, Q27)

I'm really torn here; sometimes it was more difficult due to the fact that there was no boundary between home and work. Also, it was very difficult to work with several [of my own] children attending school remotely. These have often been heartbreaking choices. Over time, my practice has become really more efficient, and I will keep several aspects of telepractice for the future (meeting with workers in remote areas, support for workers in the community, initial meeting, and reporting to families, etc.). (Comment #60, Q27)

Examples of how virtual care increased fatigue were provided in several comments.

When virtual care was 100% of the time, I felt more fatigued. I found it took more energy to engage children and keep them engaged. When we have to do that all day long, I did find I was more tired in comparison to in person. (Comment #92, Q27)

I find myself trying to overcompensate for the screen by being overly animated. I am always exhausted at the end of a session. (Comment #3, Q28)

Some respondents pointed out that it was difficult to sort out whether increased fatigue was due to the additional demands of adapting to virtual care or to situations resulting from the pandemic.

Again, there was so much to learn. I also had redeployment, and another position during the pandemic so there were many factors that impacted fatigue level—hard to determine if it was only virtual care! (Comment #144, Q28)

3.4. Experiences With Virtual Care Services

Barriers. SLPs were asked to identify technological barriers, family‐related barriers and any other factors that were perceived as negatively affecting virtual care services. They were also asked to report which children (e.g., due to types of communication difficulties or other characteristics) were more challenging when delivering services virtually. Each of these questions provided an opportunity for open‐text comments to be added. Table 3 details their responses. In the area of technology, overwhelmingly, SLPs reported difficulties with the family's internet connection (90.7%) and technological skills (68.0%). In contrast, a much smaller proportion (40%) reported difficulty with their own internet connection and/or technological skills (21.3%). The main family‐related barriers included limited access to electronic resources (72.0%), limited workspace in the home (52.0%) and caregivers unavailable to attend the online session (46.7%). The education level of the family was viewed as affecting about a third of families (34.7%).

TABLE 3.

Barriers to virtual care reported by speech‐language pathologists (n = 75).

Barrier	Participants a n (%)
Technological barrier
Clients’ internet connection	68 (90.7)
Clients’ technological skills	51 (68.0)
Sound quality	47 (62.7)
Video quality	36 (48.0)
SLPs’ internet connection	30 (40.0)
SLPs’ technological skills	16 (21.3)
Other	6 (8.0)
Family‐related barrier
Limited access to electronic resources	54 (72.0)
Limited workspace in the home	39 (52.0)
Limited availability of caregiver(s) for virtual sessions	35 (46.7)
Language barrier(s)	16 (21.3)
Education level of the family	26 (34.7)
Other	6 (8.0)
Client characteristic
Behaviour/attention	65 (86.7)
Complex developmental need(s)	55 (73.3)
Age	45 (60.0)
Other	11 (14.7)
Specific communication difficulty, diagnosis b
Autism Spectrum Disorder (ASD)	50 (66.7)
Attention Deficit Hyperactivity Disorder (ADHD)	43 (57.3)
Apraxia	36 (48.0)
Speech sound disorders	31 (41.3)
Dysphagia/feeding disorders	21 (28.0)
Developmental language disorders	10 (13.3)
Other	3 (4.0)

Abbreviation: SLP, speech‐language pathologist.

^a Proportions may exceed 100% as respondents could select more than one response.

^b SLPs were asked to identify from a list which communication difficulties or diagnoses they perceived to be challenging in providing virtual care services.

In the comments, three child‐related characteristics were identified as key factors: behaviour/attention (86.7%), complex developmental needs (73.3%), and younger age (60.0%). When asked about specific communication difficulties or diagnoses, children with autism spectrum disorder (ASD) (66.7%) and attention deficit hyperactivity disorder (57.3%) were ranked as the most challenging conditions for virtual care services. In addition, almost half of SLPs found children with apraxia and speech sound disorders to be a more difficult clientele for virtual care services. Several diverse comments illustrated some of the challenges.

It was often challenging to provide virtual services to clients with complex or behavioural needs at home because I could not structure the environment the same way that I can when I work with a student directly (low‐stimulus room, quiet environment, reduce distractions, etc.). (Comment #83, Q22)

Beyond developmental profiles, not all preschoolers have the maturity or self‐regulation to benefit from the virtual service model. And it is too simplistic to associate this challenge with a particular need (possible pathology). The interactions, manipulations and modelling for children aged 5–6 are suitable for the virtual formula, but not representative of the child's development. Need for physical and concrete manipulations, authentic interactions (no new social convention for the virtual!). Commitment is difficult for younger people. (Comment #149, Q22)

My clients are mostly aged 0–5, making virtual care of limited benefit. Goals, including social communication, phonology, AAC, oral motor skills for feeding/speech, interactive play, etc., are challenging to target virtually, especially with limited attention skills. (Comment #90, Q22)

Language support was easier to practice virtually than speech support because it can be hard to cue students for speech sounds and clearly hear articulation errors virtually. Having the parent present during sessions was helpful. (Comment #63, Q22)

Facilitators. Although SLPs provided fewer comments about the facilitators to care, several described strategies or tools that assisted with virtual therapy and how they adapted their services to mitigate difficult circumstances. The single most important facilitator for successful virtual care appeared to be the inclusion and preparation of parents. Strategies included adapting sessions to coach parents and teach specific techniques with less direct therapy provided to the child, preparing parents in advance of the sessions through telephone or video meetings and video tutorials, and guiding parents on how to structure the workspace and activities. SLPs also stressed the importance of being very well‐prepared for the sessions with multiple and varied materials to maintain interest and to be ready to adjust the therapy session. Concrete examples that facilitated virtual sessions included the use of interactive online games, PowerPoint games, interactive backgrounds, duplicate toys for the SLP and parent, and materials sent to parents in advance of the session. Many SLPs also stressed the need for shorter activities, more breaks, and even shorter therapy sessions.

For children whose needs were difficult to meet through virtual therapy, I switched to parent focused training and coaching. (Comment #77, Q22)

I would not be providing services virtually if I didn't feel I was making a difference; however, there are days when you feel like you are not making progress (as would be the case in a face‐to‐face situation). You have to be over‐prepared in case things happen. (Comment 56, Q31)

3.5. Future Models of Care

In the final section of the survey, SLPs were asked to identify their preference for future care and to provide an open‐text description of their vision for an ideal model of SLP services. There was strong support for a hybrid model (84.0%), while only 8.0% preferred virtual services only and 8.0% in‐person services only. It is important to note that the comments were sometimes influenced by the SLPs autonomy in making decisions; that is, several SLPs noted that their employer determined the service delivery model. For example, SLPs working in school boards indicated that while meetings would remain virtual, the norm for assessment and therapy was a return to in‐person services.

I will continue to use telepractice for certain aspects of my practice. Right now, I'm using virtual mode for about a third of my direct client business. I like this ratio. I will continue to use my clinical judgment to determine the appropriate mode of care for children and their families. (Comment #60, Q33)

The notion of a preference emerged in the comments for assessments and/or initial sessions in‐person, followed by virtual care sessions once the diagnosis and treatment plan were established.

Ideally, I'd meet kids in‐person to do assessment, etc. If I felt they would be appropriate for virtual (and parents were in agreement), we could switch. (Comment #75, Q34)

Ideally, I would like to see clients in person for an initial assessment. Perhaps do a few sessions in person if child needed more support or to work on stimulability (my focus is motor speech) and see if child would be appropriate to switch to virtual—again depending on certain factors—age, behaviour, severity, etc.(Comment #140, Q34)

Consistent with the tendency to identify children with speech‐sound disorders as more difficult to service, several SLPs specifically noted that these children should receive in‐person services in a hybrid model of care. Another recurring theme in the comments of 14 SLPs (in private practice or whose employers permitted virtual care) was that ideally, parents should be given a choice of in‐person or virtual care services, and many SLPs noted that virtual services should be provided when there were distinct advantages (e.g., reducing wait times, providing care to remote areas). Several SLPs indicated that intervention should ideally be provided in‐person, with parent coaching offered virtually. Overall, comments strongly suggested that SLPs recognised and appreciated the greater flexibility and the opportunities to adapt to changing child or environmental conditions, as illustrated in the following comments.

I think that a hybrid model would serve my two populations well. I work with preschoolers/early school‐age children who stutter and use primarily parent coaching with these clients. Using video feedback and live coaching has been very successful. I also work for the [XXX] Autism Program. In this program, some live face‐to‐face modelling with the families that are local would be helpful to demonstrate strategies. Coaching parents virtually or in person in their homes gives me a sense of their environment, materials available, and empowers parents to continue with home practice. (Comment #114, Q34)

A model that is flexible and takes into account everyone's reality, for example, internet availability, ability to travel, computer skills, as well as the child's family reality, such as home environment, parental collaboration and the needs of the child, so that they can fully benefit from the therapy. (Comment #60, Q34)

4. Discussion

This study examined SLPs’ views of virtual care delivered through health and education programs during the pandemic. Given that outpatient health and school services were closed for long periods in Canada, remote access was the only option to support children with speech and language difficulties, and SLPs were therefore quickly thrust into this new mode of service delivery. More than half of the SLPs viewed their virtual services as effective, another third somewhat effective, and less than 10% reported that services were only slightly effective.

As highlighted by Southby et al. (2022), it is important to consider that these data were collected at a time when most SLPs were forced to offer services virtually, and it can be challenging to disentangle the benefits of access to any services from those specific to virtual care. It is also important to note that our study captured practitioners’ lived experiences about midway through the pandemic (approximately two years after the start), after they had acquired considerable experience with virtual care.

The views on effectiveness from SLPs in our study, while encouraging, are not entirely aligned with the overall positive findings from a recent rapid review (Law et al. 2021). The review of 10 existing reviews conducted at the start of the pandemic in 2020 concluded there was evidence to suggest that, for the most part, tele‐practice service results were comparable to standard in‐person care. However, the authors did note that there was little information on the perspectives of parents or children themselves about their experiences. It is also important to note that the reviews included in the rapid review were conducted prior to the pandemic, when it is likely that remote care may have been a planned service or at least a choice for most parents, versus the forced rapid transition to a new service delivery model for SLPs in our study.

In contrast to their own perceptions that virtual care was effective, SLPs in our study appeared less confident about parents’ views of the benefits of virtual care. Just over a quarter of SLPs judged that parents perceived care as effective, while three‐quarters of the SLPs felt that parents viewed it as only somewhat, slightly, or not at all effective. In our study, the open‐text comments from SLPs appeared to support their overall perceptions of how most parents viewed virtual care. It is important to consider that the SLPs in our study were making judgements about the perceptions of caregivers whose children had received in‐person services prior to this new involuntary intervention model. A UK study that examined the satisfaction of 140 parents with services for children with cleft palate during the pandemic reported remarkably similar results to the views of SLPs in our study (Southby et al. 2022). In the study, two‐thirds of parents (66.0%) reported SLP services to be somewhat effective and 7.6% not at all effective. An Australian survey of individuals who received telehealth services, including parents of children with a range of communication difficulties (Filbay et al. 2021) found that 42% judged it as somewhat effective. In the Filbay et al. (2021) survey, 8% also reported services to be very/somewhat ineffective, and the overwhelming majority (76%) indicated that they preferred standard in‐person services. It is difficult to tease out how much of parents’ concerns are related to the actual intervention in a virtual format versus the perception that virtual sessions do not work well because of the many barriers that may be encountered during online sessions. As reported in a recent scoping review (DiFabio et al. 2023), barriers, particularly related to technology, remain a challenge for online intervention sessions. This is an important component which may contribute to caregivers’ impressions of the effectiveness of virtual care.

In keeping with reports in the literature, SLPs in our study clearly indicated that virtual care is not a panacea and that it is not an appropriate replacement for standard in‐person services for all children. In particular, our findings revealed concerns about the benefits for children with complex needs, notably with ASD and with ADHD, as well as children with speech sound disorders. However, in a study examining parents’ satisfaction with services offered during the pandemic to children with cleft palate, Southby et al. (2022) found that having an additional developmental disability did not seem to influence parents’ views on the effectiveness of virtual care services. In their review, Law et al. (2021) reported there was insufficient evidence to date to determine the value of tele‐practice for groups of children with different types or severity of communication difficulties. Many of the studies related to virtual care in reviews may not necessarily address care models that were specifically designed to be delivered virtually. During the pandemic, many services were quickly adapted to respond to an unprecedented and unplanned situation. Denusik et al. (2033, 2024) reported positive findings from interviews with caregivers of preschool children with autism who participated in a specifically designed intervention that taught caregivers strategies to facilitate their child's communication development. In addition to the concerns about children with complex needs, SLPs in our study also identified the age of the child and child behaviour as factors that may present greater challenges in a virtual care model. Filbay et al. (2021) found that parents reported difficulty maintaining their child's attention during virtual interventions. However, in their parent survey, Southby et al. (2022) did not find a relationship between the child's age and parents views of effectiveness. Comments from SLPs in our study suggested that they learned to adapt their care to include more parent coaching, and some SLPs did not view younger children as more difficult because parents were more engaged in the intervention sessions.

Although our findings were mostly positive, SLPs identified numerous barriers which need to be addressed to enhance the consistency, equity, and effectiveness of virtual care. Key challenges were related to technology, particularly families’ access to internet or adequate computer equipment. Almost all SLPs reported that the family's internet connection presented a barrier, and more than two‐thirds raised concerns related to the family's comfort level with technology. Through the SLPs comments, it became evident that once the initial technology hurdles were worked out, this barrier was largely related to socioeconomic status of families, and occurred in homes where resources appeared limited, often because of a larger number of children in homeschooling. Similarly, another important barrier was the limited availability of some families for the intervention session. In their review, Law et al. (2021) also emphasised the critical role of caregivers in virtual care and noted that evidence about their role and views of the process remains relatively limited. The authors also highlighted the need to consider inequities, particularly related to technology access. Recent studies conducted during the pandemic also emphasise that technological barriers interfere with users’ satisfaction (De Taeye et al. 2023; Filbay et al. 2021; Macoir et al. 2021; Southby et al. 2022). As noted, based on their scoping review, DiFabio et al. (2023) reported that technology issues and more specifically ease of use was a major barrier to caregivers’ experiences with virtual care services. The tremendous impact of the pandemic on creating more virtual health and education services, coupled with advances in technology and government investment in infrastructure, may result in technology issues being less problematic in the future.

Despite the reservations discussed above, when asked about their vision for future care, the overwhelming majority of SLPs indicated that a hybrid service was the optimal model of care for the future—only 8% preferred to continue with in‐person care only. Through SLPs’ comments, it also became clear that many felt that ideally assessment and initial intake sessions to determine the diagnosis should ideally be provided in‐person, followed by virtual care sessions for intervention. Similarly, Macoir et al. (2021) found that in Quebec, Canada, more than half of respondents felt that virtual assessments were not as valid as in‐person assessments. However, it is also important to highlight that the study was conducted only four months after the shutdown period (an important difference) when fewer virtual assessments were available, particularly for SLPs working in French. Essentially, the findings of our study indicated that the advantages of virtual care outweighed the disadvantages and challenges. DiFabio et al. (2023) also noted that hybrid models of care will likely become the preferred options in pediatric health.

Consistent with other reports on telehealth (Kruse et al. 2017; Law et al. 2021), key advantages of virtual care reported in our study included efficiency in care and savings in travel time, which translated to improvements in wait lists and access for children in remote areas. Three quarters of the SLPs also commented on the increased flexibility in their schedules, and more than half felt that virtual care contributed to a better work‐life balance. Another notable advantage was the increased opportunity for caregiver participation and coaching, regardless of the age of the children served. Law et al. (2021) also concluded from their examination of multiple reviews that virtual care facilitates active parent participation in sessions, permitting them to gain greater insights into their child's communication difficulties. It is important to note that virtual care was not part of standard services provided in most Canadian programs, and this was the first experience for 9 out of 10 SLPs in our survey. In their survey conducted in Quebec, Canada, just four months into the pandemic, Macoir et al. (2021) found that 82% of 85 SLPs felt positive about delivering services virtually. The notion of ‘making it work’ was also prominent in our study through SLPs’ responses and comments. Many even expressed some surprise at how well virtual care worked when both practitioners and caregivers were motivated to adopt this new service.

A strength of our research was that the survey was conducted almost two years after the start of the pandemic. Therefore, we captured SLPs views as they were living the day‐to‐day adaptations associated with this new service delivery model, but after they had experience working out the initial technology kinks. We also collected the views of SLPs working in multiple programs, including both private and publicly funded programs. SLPs reported mostly positive experiences and a high degree of willingness to provide virtual care. However, it is important to underscore that this survey was conducted when virtual care was the only option for care in much of Canada; that is, they were forced to provide this service delivery model. One important limitation is that we did not collect family perspectives, which would have provided helpful insights into the benefits of virtual care. We attempted to capture a very limited snapshot of clinicians’ views on how the families perceived virtual care. While clinicians’ views on how parents value their services may affect how they invest in or deliver virtual care, parents’ perspectives cannot be interpreted through the lens of the providers. Given that these clinicians were providing the intervention sessions, this clearly introduces potential bias and does not necessarily reflect caregivers’ experiences. It is particularly important to continue to learn from the subset of families who face barriers due to technology and other needs. Our study also had limited representation across the Canadian provinces; therefore may not be transferable to some parts of Canada and elsewhere.

5. Conclusions

Most SLPs in this study were thrust into offering a new model of service delivery without preparation. Clinicians’ reflections on their virtual care experiences and their perceptions of the advantages and effectiveness are encouraging and should be considered in designing programs of care. The ‘forced’ learning now provides an opportunity to integrate and improve hybrid options, which can be of benefit for SLPs and families. While previously used for very remote areas, the findings of this study suggest that other benefits, including servicing more children, reducing wait lists, improving flexibility and more family engagement in intervention, should be considered in planning future services. As virtual care can be expected to become an important part of the care model, ongoing research is needed to systematically examine how it can be most beneficial and to implement the appropriate hybrid models for different disorders, populations and circumstances. Further study of how to overcome barriers to improve virtual care delivery will allow for a more planned approach to service.

While not a replacement for in‐person intervention, our study suggests that virtual care has many potential advantages and should be carefully considered in partnership with families and program decision‐makers when planning SLP services for children. The wealth of experience gained during the pandemic means that SLPs are more confident in their skills and are in a better position to offer and tailor care using this new tool for families.

Ethics Statement

The research received ethics approval from the University of Ottawa Research Ethics Board, Study #H‐08‐21‐7078

Conflicts of Interest

The authors have no conflicts of interest to disclose.

Supporting information

Supporting file: jlcd70145‐sup‐0001‐SuppMat.pdf

Fitzpatrick, E. M. , Grant A. C., and King T.. 2025. “Impact of Virtual Care on Speech‐Language Services.” International Journal of Language & Communication Disorders 60, no. 6: e70145. 10.1111/1460-6984.70145

Data Availability Statement

The datasets presented in this article are not publicly available because data are not available outside of the research team as per Research Ethics approvals. Requests to access the dataset should be directed towards the corresponding author.