J Dev Phys Disabil https://doi.org/10.1007/s10882-018-9603-3 O R I G I N A L A RT I C L E
Getting Connected: Speech and Language Pathologists’ Perceptions of Building Rapport via Telepractice Yusuf Akamoglu 1 & Hedda Meadan 2 & Jamie N. Pearson 3 & Katrina Cummings 4
# Springer Science+Business Media, LLC, part of Springer Nature 2018
Abstract Building rapport with families (parents and children) is recognized as an important feature of effective intervention. In telepractice service delivery, activities and practices that shape speech language pathologists’ (SLPs) rapport with children and families can take different forms of engagement and interaction. Identifying which SLP practices facilitate the establishment and nurturing of rapport is important and may provide keys to successful service delivery via telepractice. In this article, we present results from a qualitative study exploring SLPs’ perceptions of building rapport with the children and families they serve via telepractice and the strategies they use to establish and maintain rapport with them. Keywords Telepractice . Rapport . Speech therapy . Disabilities
* Yusuf Akamoglu
[email protected] Hedda Meadan
[email protected] Jamie N. Pearson
[email protected] Katrina Cummings
[email protected]
1
Department of Special Education and Multiple Abilities, University of Alabama, Tuscaloosa, AL 35487, USA
2
Department of Special Education, University of Illinois at Urbana-Champaign, 1310 S. Sixth St., Champaign, IL 61820, USA
3
Department of Special Education, North Carolina State University, 2310 Stinson Dr, Raleigh, NC 27607, USA
4
Department of Education, Simpson College, 701 N C St, Indianola, IA 50125, USA
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As more intervention and service-delivery occur online via telepractice, the question of how to build rapport with children and their families who receive the services becomes increasingly important. Telepractice, also referred to as telemedicine and/or telerehabilitation, is a remote delivery of services using information technology, Internet, and telecommunication systems and devices to reach a client (Hill et al. 2009; Snodgrass et al. 2017). The American Speech-Language-Hearing Association (ASHA) recognizes telepractice as an acceptable mode of expanding services from a distance while still maintaining clinician and client connections sufficient for assessment, intervention, or consultation (Cherney et al. 2011). Moreover, ASHA regards telepractice as a means to overcome service delivery barriers such as consumer distance to service locations, consumer transportation difficulties, disruption of client or family member work schedules, and limited availability of specialists and/or subspecialists in geographic regions (ASHA 2005). Rapport involves a sincere interest in others and has been viewed as an invaluable goal in education. Close, interpersonal relationships are described as a common defining characteristic of rapport. For example, Ashforth and Humphrey (1993) described rapport as Ba sense of genuine interpersonal sensitivity and concern^ (p. 96). Rapport building is important for different models of services, including direct services for children and coaching parents via telepractice. For example, researchers suggested that rapport between speech language pathologists (SLPs) and parents of children with speech-language delays or disabilities increases the likelihood of positive parent and children outcomes (Dobransky and Frymier 2004). When providing services from a distance to children with speech-language delays and disabilities and their families, activities and practices that shape service providerchild and service provider-family rapport can involve different forms of engagement, interaction, and presence (Curtiss et al. 2016). These forms might limit SLPs’ delivery of verbal and non-verbal cues, such as body language, proximity, and posture that support building rapport in traditional, face-to-face (in person) situations (Murphy and Rodriguez-Manzanares 2012). In some cases telepractice can enable the provision of services in more naturalistic contexts like the home (see Anderson et al. 2014) when it is not feasible for clinicians to travel to families’ homes (Snodgrass et al. 2017). Thus, for SLPs who use telepractice, establishing long-term relationships might require a different set of rapport-building skills. To date, the association between rapport, SLPs’ use of telepractice, and intervention outcomes for children and their families who receive these services has not been vigorously investigated.
Building Rapport Building rapport is not easy nor does it occur automatically after some period of time. Learning to read another person’s verbal or non-verbal cues and then act appropriately takes experience and time. Tickle-Degnen and Rosenthal (1990) asserted that rapport is not a personal trait, but rather exists through interactions. More recently, others discussed rapport as a group dynamic where group members interact with each other to build rapport. For example, Murphy and Rodriguez-Manzanares (2008) discussed how children might overcome challenges of collaborative learning with rapport building in their classroom. The authors list three phases that start with the first few meetings
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in which a low level of rapport is established and gradually builds to a high level of rapport. Eventually, children feel comfortable in the classroom and start to learn more unique characteristics about their classmates and instructors. In their descriptions of the components and characteristics of rapport, Tickle-Degnen and Rosenthal (1990) claimed that rapport is created and perceived primarily on the basis of nonverbal behaviors in interactions: Bnon-verbal behavior, as a particularly powerful medium of affective communication, would be a key element in the mediation and emergence of feeling of rapport between participants^ (p. 288). Tickle-Degnen and Rosenthal reported eight non-verbal behaviors, which are related to rapport building: smiling, directed gazing, head nodding, leaning forward, direct body orientation, posture mirroring, uncrossed arms, and uncrossed legs. Other researchers have identified verbal behaviors that can significantly contribute to the development of rapport (Freckmann et al. 2017; Tucker 2012). A few studies that have sought to isolate the contribution of specific verbal behaviors to rapport have been carried out in psychotherapeutic contexts; these studies found that the more therapists expressed reflections of emotions, restatements, and verbal reinforcements, the more their clients reported strengthened sense of rapport (Sucala et al. 2013). There are several studies that focus on delivering web-counseling and/or psychological treatments over the Internet. For instance, videoconferencing therapy (e.g., therapy via Skype), which allows real-time non-verbal communication, is more similar to conventional face-to-face therapy than text-based asynchronous e-mail therapy, in which non-verbal cues are not available. In these studies, concepts such as therapeutic alliance or therapeutic relationship are defined. These concepts are similar to rapport with regard to various characteristics such as the role therapists play and the way therapists and clients communicate with each other (Day and Schneider 2002; Sucala et al. 2013). The dynamics of face-to-face communication could be different than the dynamics of online communication (e.g., telepractice, distance education). For example, researchers argued that for teachers or therapists who work in an in person face-to-face context building rapport could be easier because they could use the above mentioned verbal and non-verbal traits during spontaneous, informal, daily interactions with their students and/or clients (Murphy and Rodriguez-Manzanares 2012). However, building rapport could take a different form during online communication. For example, Murphy and Rodriguez-Manzanares (2008) noted building rapport could be more difficult in distance education because, Be-teachers [distance education instructor] cannot see facial expressions, body language or visual clues to know if children understand^ (p. 1067). Telepractice requires the use of different forms of communication to build rapport with participants to help them better navigate the online modules or courses. Therefore, researchers in the field of telepractice suggest a variety of communication methods to facilitate rapport building in online environments (Murphy and Rodriguez-Manzanares 2012; Sucala et al. 2013). These methods include text messaging, email, phone calls, or video-conferencing and getting to know the students/clients. For example, in a study of distance education, the teachers stated, BGetting to know the children individually is important and that includes knowing how they think, how they work, what their personalities are, what they can handle, and what they cannot handle^ (Murphy and Rodriguez-Manzanares 2012, p. 175).
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Some researchers argued that building rapport in an online context might be easier. In their comparison of face-to-face, video, and audio psychotherapy, Day and Schneider (2002) argued that the distance modes lead clients to take more responsibility for the interaction than they do in face-to-face therapy, and that the distance made openness seem safer which in turn facilitates building rapport with clients. Yet, to build rapport online, technological tools must be working properly because if one of the parties does not have the necessary technology, the communication can have interruptions and this can be a disadvantage of telepractice. Given the importance of establishing rapport exploring how (or whether) rapport is achieved via telepractice by SLPs warrants attention. In this pilot study, we collected preliminary qualitative data to identify which SLP practices (a) facilitate the development of rapport and (b) are essential for positive child and parent outcomes, based on SLP perceptions; these practices may provide important implications related to successful online child and parent support practices. The following two questions guided this investigation: 1. What practices and activities do SLPs use to build rapport with the children and parents they serve via telepractice? 2. What are the perceived effects of rapport building on child and parent outcomes?
Method Recruitment Participants were recruited primarily from the telepractice special interest group (SIG) within ASHA. The Telepractice SIG of ASHA has approximately 1500 members who have interest in telepractice, telespeech, or teleaudiology. The ASHA Telepractice SIG has an online community where members can share ideas, resources, and discuss topics related to telepractice. A recruitment message and a flyer were posted three times during Fall 2015 on the Telepractice SIG’s forum. In addition, individuals who participated in the study were asked to share information about the study with other SLPs they know (i.e., snowball sampling). The researchers contacted individuals who expressed interest in the study. Those who met the inclusion criteria (i.e., SLPs who provided services via telepractice for at least one year) and were interested in participating were sent, via email: (a) a consent form and (b) a Service Provider Information Questionnaire. Participants Participants included 15 SLPs who provided services via telepractice to individuals in 18 different states within the US (a few participants worked with individuals from different states). All participants were female with master’s degrees. Their years of experience with telepractice ranged from one to five years. Ten of the participants provided services via telepractice only, and five participants provided service both faceto-face and via telepractice. The participants primarily delivered telepractice services to children in schools. Some participants however, delivered services to children both at school and home settings. Very few participants delivered services to children who attended virtual schools from home (see Table 1). When telepractice was provided at
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school, only e-helpers were present. If telepractice was provided in the home environment, only parents were available for support. Participants’ ages ranged from 33 to 54 years old. The age of the children that participants reported working with ranged from 3 to 18 years old. Participants reported that they served children with (a) speech and language impairments and delays, and (b) children with disabilities including autism spectrum disorders (ASD) and Down syndrome. See Table 1 for participant demographic information. Table 1 Demographics of participants (N = 15) Characteristics
n
Age 30–35 years
3
36–45 years
5
46–55 years
7
Employment setting Private agency/company
13
Independent contractor
2
Service delivery setting School
7
Home
2
Mix (school & home)
6
Time providing services via telepractice Less than 3 years
8
3 and more years
7
Method of service delivery TP only
10
TP and F2F
5
Caseload 10 and fewer children
2
11–30 children
8
31–50 children
3
50 and more children
2
*Disability categories served by SLPs Speech and language impairment
15
Autism spectrum disorder
8
Down syndrome
1
Hard of hearing
1
Visual impairment
1
Children age group Pre-K and K-12
8
Only K-12
7
SLP, Speech and language pathologist; TP, Telepractice; F2F, Face-to-Face, in person *Most SLPs worked with children with different disabilities
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Data Collection Each participant completed the Service Provider Questionnaire, a researcher-developed tool. The Service Provider Questionnaire included 12 questions about demographic information (e.g., age, gender, employment setting, children served, etc.), two questions about advantages and disadvantages of telepractice, and six satisfaction and competency rating questions about delivering services via telepractice (see Appendix). In addition, participants completed a semi-structured interview that was conducted by the first author via videoconferencing (Skype). The interview protocol included five open-ended questions related to (a) the importance of rapport, (b) practices for building rapport via telepractice and (c) related facilitators and challenges. The first author conducted the interviews via Skype at a time that was most convenient for the participants. Each interview was audio-recorded and transcribed verbatim. The interviews lasted between 22 and 40 min. Data Analysis The research team included a faculty member, a post-doctoral fellow, two doctoral students, and an undergraduate student. All members of the team participated in data collection and analysis. The research team worked collaboratively to collect data, transcribe and verify transcripts, analyze the data, develop and verify summaries, and develop conclusions (Brantlinger et al. 2005). A constant comparative method (Corbin and Strauss 2015) was used to analyze the interview data in four phases. This method was chosen to allow the researchers to identify and compare concepts that emerged across the data, explore relations among concepts, and arrive at a deeper understanding of the phenomena under investigation. The researchers independently read each transcript and identified preliminary codes. The researchers then met face-to-face to review and verify the codes, and to discuss areas of disagreement. The discussions between the researchers resulted in a set of codes. Using these codes and categories, the first author and another team member coded, independently, each interview and met to reach consensus on the codes. Finally, team members met to review all codes and develop emergent themes to allow data interpretation. In addition, the researchers coded line-byline the Badvantages^ and Bdisadvantages^ questions in the Service Provider Questionnaire. To ensure that the data were credible and trustworthy the researchers employed data triangulation. To do this, researchers compared the SLPs’ responses to question #5 (BWhat are some advantages and disadvantages of building rapport via telepractice service delivery?^) in the interview protocol with their responses to Badvantages^ and Bdisadvantages^ to building rapport via telepractice questions in the Service Provider Questionnaire. Additionally, level two member checks were employed to confirm the accuracy of the transcript summaries and to gain support for the researchers’ conclusions (Brantlinger et al. 2005). All 15 SLPs were sent a copy of their individual analysis summary and invited to make suggestions, alterations, or additions to the summary. Ten SLPs completed the member checks and three requested changes. Change requests from the participants included correcting minor spelling errors. All participant names were replaced with pseudonyms to ensure their anonymity.
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Findings Participants completed a Service Provider Questionnaire where they rated their satisfaction and competency with telepractice services. All 15 participants rated Bsatisfied^ or Bvery satisfied^ and Bhighly competent^ or Bcompetent^ with providing services via telepractice. During the interviews participants also expressed that building rapport via telepractice was an enjoyable part of their job and rewarding for them. Following analysis, three main themes emerged from the data with respect to each of the two research questions. These themes are: (a) rapport building practices that are commonly used but are not unique or specific to telepractice, (b) rapport building practices that are more telepractice specific, and (c) effects of rapport. Table 2 highlights the themes and codes. General Rapport Building Practices When the SLPs were asked to provide examples of practices and activities they use to build rapport with children and families they serve, three codes emerged regarding general rapport building practices: (a) getting to know each other, (b) fostering open communication with parents, and (c) making personal connections with children and parents. Regarding specific examples of how they were able to build rapport, all 15 SLPs indicated that getting to know the children and families and making them feel comfortable was a primary and crucial component of building rapport. The SLPs indicated that they get to know the children and families through a variety of methods. For example, Amanda who works with children with speech and language impairments (SLI) and ASD said, Showing an interest in what interests them…this is a professional situation, but the same thing you would do in a friendship, which is to show interest in learning what interests them. And also to show them a about who I am and what I like. For Table 2 Emergent themes and codes Theme
Code
1. General rapport building practices
1.1. Getting to know each other 1.2. Fostering open communication with parents (e.g., listening, soliciting parent input) 1.3. Making personal connections with students and parents
2. Rapport building practices via telepractice 2.1. Getting to know each other 2.2. Fostering open communication with parents (e.g., listening, soliciting parent input) 2.3. Making personal connections with students and parents 3. Effect of rapport
Parent Outcomes
a. Parent outcomes
3.1. Carry over
b. Student outcomes
3.2. Buy-in 3.3. Openness and communication Child Outcomes 3.4. Responsiveness and cooperation to therapy 3.5. Improved student progress
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example, I like to ride bikes and I like to walk the dog. You know, whatever it is. Just little things so that I am a human being to them–but again more focusing on them and what are their interests. Twelve SLPs suggested that making personal connections through both children and family interests was a very useful way to build rapport. By sharing information about themselves (self-disclosing) SLPs were able to identify connections with the children and families and build relationship on these common interests. Participants highlighted (a) ways in which they connected with the children based on their personal interests (e.g., books, TV shows, action figures) and (b) ways in which they connected with parents based on their interests, needs, and experiences. Sherry who provides both telepractice and face-to-face services explained, I try to provide activities that the children are interested in and the parents love that. I have one child who likes Greek myths. So, his goal is reading comprehension and we have been doing a lot of Greek myths. He gets really excited and tells his mom how he likes that. Rapport Building Practices via Telepractice When the SLPs reported on their experience with rapport and the practices they employed to build rapport via telepractice, two themes emerged: (a) advantages of telepractice in building rapport, and (b) disadvantages of telepractice in building rapport. Additional codes emerged within each of these two themes. Advantages In regard to advantages of building rapport via telepractice, thirteen SLPs discussed the importance of online communication, beyond direct services, when building rapport. Participants indicated that they fostered open communication with parents by offering various modes of communication (e.g., text messaging, phone calls, emails), being available to parents outside session time, listening to parents’ concerns and questions, and soliciting parent input as much as possible. Rebecca who works with preschoolers through 8th graders with ASD and SLI shared the following about her communication with parents via telepractice, I actually have quite a few phone conversations with families with questions and concerns or thoughts, which has been another good way to build rapport. I try very hard in all sessions and before and after to be a very responsive communicator. Six SLPs said that the distance actually improved relationships between them and their students, and between them and their students’ parents. For example, Marva shared the following regarding her experiences building rapport with children: I really do think that [building rapport is easier via telepractice] because you are not so in their face. As an adult you are so much taller and you are bigger and they have to look up to you. On the computer they are at your same level. You are only this little tiny picture to them so I think that building rapport with the child is easier on the computer.
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Similarly, Jennifer shared the following regarding her experiences with building relationships with children and parents: I feel like building rapport online is almost easier because we have what’s called session notes. So the parents are aware that their kids have a backpack [online] with the session notes and they can play games and work on their goals. I write a session note every single day… So that’s an awesome way to communicate with the parents… I see their parents and hear from them almost weekly. So I feel like I have great rapport and relationships building with those kiddos because I have all of their parents’ phone numbers, I talk to them quite frequently. One final reported advantage of building rapport via telepractice was the amount of flexibility and accessibility that is offered via telepractice. Four participants suggested that this afforded them more opportunities to engage with their students in creative ways and at flexible times. Marva explained this advantage in the following quote: I used to be like in the clinic it would be like, Bokay we have to get this done let’s get back on task.^ Now it’s like, I don’t spend as much time about getting back on task. I feel like I can have more [time]. If a child just wants to talk about their weekend or their birthday party or whatever they did, I feel like I can spend that time because I know that when I get to whatever I get to do they are so engaged. I don’t have to redirect as much. I actually feel like I have more time to build rapport than I would at the clinic because of having to redirect to a specific activity. Disadvantages Regarding disadvantages of building rapport via telepractice, twelve SLPs reported that support (e.g., aide, e-helper; a person who is present with the child during telepractice and help the child focus during the session) is needed to build rapport with certain children in telepractice. Sara, who has been working serving children via telepractice for three years, explained how support is needed to build rapport via telepractice, We do have helpers who are on the other screen so as far as redirection, I get a lot of help with that so that’s good in telepractice. If a child was in the room by himself that would be a nightmare. As far as progress being made I would feel like "I’m failing. I’m not keeping their attention" but you have the helper to bring them back. I told you that I felt like I haven't built rapport with that one child since he’s out of his seat constantly and so the helper brings him back in the chair. Twelve SLPs also reported that the level of effort and collaboration required are critical challenges in building rapport and delivering services via telepractice. Amanda shared the following regarding her experiences and the amount of effort it takes to connect with her students via telepractice: As much as I keep saying it takes effort – oh it’s the same, you know. As I’m thinking about it more, I think in terms of establishing rapport, since a big part of it for me is focusing on them, and what they care about, what motivates them, who are they, you know, when I can’t see their whole environment, or I can’t see what
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wacky things they have hanging on their backpack, or just little things to comment on, it just means that I have to work a little harder at first to learn more about them. Similar to the amount of support and effort required, a second disadvantage in building rapport via telepractice that the SLPs discussed was a lack of physical proximity to their students. Nine SLPs suggested that the lack of physical proximity to their students and their students’ parents was a barrier to connecting with their children. Amy shared the following: Well I think it is much more personal to see somebody and to be able to talk to them face-to-face and just have that eye contact and that ability to see what someone looks like. There is room for misinterpretation in a phone conversation. There is room for even more misinterpretation in an email conversation. So, I think you have the most ability to have honest open communication with parents that hopefully is going to accomplish what you want to accomplish in a face to face, in telepractice. Another common disadvantage in building rapport via telepractice that was reported by seven SLPs was disability characteristics. In other words, factors such as stereotypical behaviors and eye contact in children with autism as well as engagement and attention among children with behavior and learning disabilities had an impact on the SLPs’ abilities to develop rapport. Karen shared the following: Another difficulty I have run into [is with] children that have multiple disabilities. The types of disabilities besides the behavioral and emotional ones can cause some difficulties in building that rapport. One example that comes to mind is when I began working with one of the school districts a couple years ago. I was speaking with the administrator and he said one of the children is, just one child, is hearing impaired, visually impaired, cognitively delayed, autistic and [has] ADHD. And the children did not know how to interact with the computer. So, if they do not know how to play a video game or how to interact with somebody on the screen, it is very difficult to build rapport. Effects of Rapport During the interviews, participants were asked about their perceptions of the impact that rapport building has on both parents and children. Parent Outcomes SLPs indicated that building rapport influences parent (a) carryover, (b) buy-in and responsiveness and (c) openness and communication. These codes are interconnected but participants described them as different parent outcomes. Eleven participants suggested that when they were able to establish rapport, parents engaged in carry-over activities beyond the therapy sessions. For example, Amy said, There is a lot better carryover. Tons. I mean that is the most important thing. You see the parents are way more invested in therapy. If you set up that, it is a partnership it is a team role working together. They are much more motivated to work. I think that as a result there is a much more significant likelihood of improvement [in children]. The second emergent code related to parent outcomes was parent buy-in and responsiveness. Nine participants suggested that parent buy-in was one of the outcomes of
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building rapport. Amy highlighted the impact that her rapport-building has had on buy-in among the parents with which she collaborates via telepractice. She shared the following: I think it [rapport-building] is very important because I see at the parental level there is a much better result in therapy when you have that carry over and that buy-in from a parent. We see children for one little slice of time. We are working on eliciting certain behaviors perhaps a child hasn’t done before. Then we need that to carry over outside of the therapy session and we need partners to do that. Additionally, seven SLPs indicated that building rapport promoted open communication with parents. For example, positive feedback from parents was another effect of building rapport with them. Jennifer who works with preschool through high school students with SLI, shared her experiences with positive parent feedback: They [parents] will text me and say, BJimmy is doing such a great job I am really impressed with his speech and we have only been having this for three weeks.^ So, they are like Bthank you so much.^ So, sometimes I will get those texts where they are really happy about something. Child Outcomes For children outcomes, the SLPs indicated that building rapport (a) promoted children’ responsiveness and cooperation to therapy and (b) improved their progress in targeted skill areas. Thirteen participants suggested that children on their caseload were more responsive to telepractice therapy when they had established rapport with them. Marva who works with elementary age children who have language delays and SLI shared her experience related to children responsiveness in the following quote: I think that they [children] are such more willing to participate when you have a good rapport. And also when you make a gentle correction or you ask them to try again, they are more willing to do that when they know that you are a person that you have a relationship with. In addition to child responsiveness, nine SLPs indicated that rapport was critical to achieve improved child progress. In response to her perceptions about the importance of rapport, Stephanie said, Oh my gosh! I think it [rapport] is critical. If you don’t have a good rapport with your students you are not going to be able to fulfill any of their goals on their speech and language tasks…if you don’t have some type of the relationship outside of that small window there is going to be no gain in overall skill growth. So, you have to develop that rapport to establish trust with them.
Discussion Overall, SLPs seemed to value rapport and work towards building rapport with children and their parents who they served via telepractice. This was reflected in their ratings of high satisfaction and competency in delivering services via telepractice. Given that
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rapport is important for successful therapy it is not surprising that the participants in this study valued rapport. Participating SLPs’ orientation toward building rapport from a distance is noteworthy given that they had only been providing speech therapy via telepractice for one to five years. General Rapport Building Practices Participating SLPs highlighted the nuances of building rapport as they discussed the variety of strategies they used. Although rapport literature in the fields of psychology, medicine, and counseling generally regard building rapport as a mutual phenomenon, the SLPs in this study depicted themselves as having the responsibility of building rapport. Their perceptions of building rapport in general align with research in the fields of education and speech and language therapy, which indicates that building rapport might be service providers’ responsibility (Murphy and Rodriguez-Manzanares 2012). Participants in this study expressed that they try to get to know the children and they selfdisclose information about themselves. The method of self-disclosing to let the children know something about who the SLP is as a person is labeled variably in the online teaching literature as Bteacher presence^ and Bteacher self-disclosure.^ However, the amount of information provided through self-disclosure may positively or negatively alter clients’ perceptions (Mazer et al. 2007). For example, when a therapist selfdiscloses certain information, such as messages from friends and family and opinions on certain topics, children or parents may perceive similarities between themselves and the therapist. Thus, therapist’s self-disclosures can improve the engagement of children in therapy sessions (face-to-face and online) as well as improve children’s sense of their teachers’ credibility (Mazer et al. 2009). However, therapists’ excessive or inappropriate disclosure of information and personal beliefs may negatively impact their credibility. The SLPs also engaged in efforts to make personal connections with children by asking about their interests, likes, and dislikes. They then use this information to build their online therapy activities and practices around children’s interests to engage them in therapy and gain their trust. As SLPs show respect for children by recognizing and prioritizing their interests and create a positive therapy atmosphere by selecting appropriate activities that engage them, they also foster the development of strong interpersonal relationships. In a study on building rapport with ESOL (English for Speakers of Other Languages) children, Nguyen (2007) noted that class instructors focused on developing interpersonal relationships with students to build rapport. Such practices seem similar to face-to-face practices; however, the SLPs expressed that they have to go the extra mile to keep children’s attention and foster motivation during telepractice sessions. Rapport Building Practices via Telepractice The SLPs identified the importance of Bgoing the extra mile^ as a means of fostering open and various modes of communication with families. Participants indicated that staying connected with children and families outside of the therapy sessions was very important for building rapport via telepractice. Therefore, many of the SLPs made themselves available by providing their personal phone numbers and email addresses to families so that parents would have an opportunity to communicate their concerns, suggestions, and/or goals for their children.
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Advantages Few participants mentioned that telepractice, itself may actually support rapport building in some cases. Furthermore, the SLPs believed that telepractice services helped them to develop a stronger relationship with children and their families who live remote areas because often times, telepractice becomes the only source of service delivery mode for these families. In addition, many of the SLPs who provided telepractice services from home, valued the flexibility of their schedules, and also the access they had to their children and their parents. That is, the SLPs had more opportunities to connect and build rapport with children and their families. Hines et al. (2015) suggested that this flexibility is Bfacilitated by being very organized and prepared for each session. Hence, clinicians had resources on-hand and available when a change of approach was needed during therapy sessions^ (p. 471). That is, being in a prepared environment like home, provides SLPs with easier access to resources that could engage their children and thus lead to rapport-building. Disadvantages The amount of support and collaboration required to establish rapport via telepractice deserves attention. Because the SLPs could not be in the school building, they often depended on e-helpers (therapy assistants during telepractice services) to discuss children’s therapy and progress. E-helpers also assisted in intervening if, for example, the children had behavior or attention or needed assistance getting to therapy on time. Therefore, e-helpers supported development of therapeutic relationships by facilitating children’s speech activities, and collaborative relationships with parents and teachers, in which the SLPs in this study considered as the essentials of building rapport via telepractice. Similar results related to the level of support needed from e-helpers were reported in a study conducted to investigate SLPs’ perspectives about their transition to telepractice (Hines et al. 2015). Hines et al. stated that, BSLPs reported that TAs [e-helpers] were often central to their management of threats to effective collaboration. Some TAs shared information on therapy progress with parents and teachers and facilitated their communication with SLPs^ (p. 471). This indicates that support from e-helpers may be an important feature of telepractice programs that not only aids in rapport-building, but also helps to improve therapy outcomes for children. The SLPs also indicated that lack of physical proximity could be a challenge to building rapport with children because they could not touch or comfort a child if he or she was having a behavior problem or struggling with sounds. They considered these instances as missed opportunities to build rapport. In the literature, challenges such as not being in the same environment to physically prompt or comfort the children was reported as a disadvantage to building a trusting relationship via telepractice (Anderson et al. 2014; Grogan-Johnson et al. 2013). This suggests that telepractice, as a delivery of direct intervention may not be suited for every children and skill. Children with certain behavior problems and/or disabilities may benefit from telepractice that is used as an indirect delivery of services, where the clinician remotely guides an adult (e.g., parent, teacher, e-helper) to deliver the intervention and has little need to interact with the child. Indirect or collaborative consultancy models via telepractice have been shown to be viable for infants, young children, and adults with more severe disabilities. Therefore, there should be certain criteria for selecting children who receive direct speech therapy via telepractice, to ensure that the needs of children who receive services via telepractice are met adequately.
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Effects of Rapport via Telepractice When telepractice involves building rapport, it has the potential to improve access to services as well as quality of services for children who show a preference for telepractice for speech-language services (Parette et al. 2010). By having access to their children’s therapy notes and witnessing their speech progress, the families feel more empowered to support their children’s speech goals (Snodgrass et al. 2017). This type of indirect interaction between the SLPs and families may serve as a catalyst to build rapport between the two parties. Implications and Limitations A few limitations of the current study should be noted. First, the brevity of interviews might have impacted the depth of understanding conveyed. Although participants described the impacts and outcomes of the use of telepractice for parents, children, and the SLPs themselves, further research should explore ways to measure and evaluate these potential outcomes. Additional research is needed to guide future practices and policies pertaining to telepractice, particularly the rapport dimensions of SLP-child relationships. Second, participating SLPs provided telepractice services to children in home and/or school settings. Future research should delineate findings by these two settings. Third, the SLPs who participated in this study reported on the benefits of rapport in telepractice. Thus, additional empirical evidence regarding the relations between rapport and telepractice outcomes is needed. Future research should investigate relations between rapport-related skills, knowledge, and attitudes among SLPs who provide telepractice and retention. Another limitation of the study is that the Service Provider Questionnaire lacks validity and reliability and was used only as a supplement to the interview data. Lack of evidence for validity and reliability might have an impact on the validity of the results. It is recommended that in the future researchers use valid and reliable questionnaires to provide strong evidence of their results. Lastly, efforts should be made to operationalize rapport building and identify best practices for implementing rapport-building in telepractice. Finally, SLPs’ dedication towards rapport-building practices is particularly admirable and demonstrates the feasibility and advantages of telepractice services. Acknowledgements We would like to acknowledge the contributions and mentorship of Dr. James Halle at the University of Illinois at Urbana-Champaign. Funding This study was partially funded by the Department of Special Education at the University of Illinois at Urbana-Champaign. Compliance with Ethical Standards Ethical Approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed Consent
Informed consent was obtained from all individual participants included in the study.
Conflict of Interest We declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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Appendix Service Provider Questionnaire Please tell us about yourself Service Provider 1. Name ______________________________ 2. Gender (please circle): Male
Female Other (__________)
3. What is your age? __________ 4. What is your ethnicity? ___________________________________________________ 5. Which state do you work in? _______________________________________________ 6. What is your highest degree received? ________________________________________ 7. What is your current occupation? ____________________________________________ 8. Do you work as an independent provider or for an agency? _______________________ 9. How long have your been working in your current position? _________ 10. How many children and families do you serve? _____________ 11. How long have you been serving families via telepractice? _______________ 12. Do you provide services only via telepractice or via both face-to-face and telepractice? __________________________________________________________ 13. On average, how often do you provide services via telepractice? ____________________ 14. How do you decide whether provide services via telepractice? __________________________________________________________________ __________________________________________________________________ ____________ 15. What do you believe are the advantages for providing services via telepractice?
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__________________________________________________________________ _________________________________________________________________ 16. What do you believe are the barriers for providing services via telepractice? __________________________________________________________________ __________________________________________________________________ ____________
17. Please rate your satisfaction with using telepractice to provide services. Very Satisfied
Satisfied
Neutral
Dissatisfied
Very Dissatisfied
18. Please rate your satisfaction with the relationships you have with the child/family when using telepractice to provide services. Very Satisfied
Satisfied
Neutral
Dissatisfied
Very Dissatisfied
19. Please rate your competence in providing services via telepractice. Highly Competent
Competent
Somewhat Competent
Not Competent
20. Please rate your satisfaction with providing services in person, face-to-face. Very Satisfied
Satisfied
Neutral
Dissatisfied
Very Dissatisfied
21. Please rate your satisfaction with the relationships you have with the child/family when providing services in person, face-to-face. Very Satisfied
Satisfied
Neutral
Dissatisfied
Very Dissatisfied
22. Please rate your competence in providing services in person, face-to-face. Highly Competent
Competent
Somewhat Competent
Not Competent
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