Exploring Challenges to Telehealth Communication by Specialists in Poison Information

Abstract

The use of the telephone for providing health care is growing. A significant amount of social meaning is derived from visual information, and the absence of visual stimuli provides unique barriers to communication and increases the risks for misunderstandings and distractions. Understanding challenges to telephone communication can provide insight into training opportunities for overcoming these difficulties and improving patient care. The purpose of this research was to explore through focus groups the challenges of phone communication perceived by specialists in poison information. General types of challenges to effective phone communication included developing new communication skills to compensate for lack of visual information, difficulty assessing caller understanding, difficulty managing caller misunderstandings, maintaining distinctive assessments for routine calls, and managing the multifaceted aspects of job stress. The desire for training to enhance telehealth and cultural competency skills was also mentioned, and these findings might provide guidance for the development of training opportunities for telehealth professionals.

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Erin Rothwell, Lee Ellington, Sally Planalp and Barbara Crouch
Exploring Challenges to Telehealth Communication by Specialists in Poison Information
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Qualitative Health Research
22(1) 67 –75
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Use of the telephone for providing health care is growing,
because it improves access to health care information and
reduces costs by preventing unnecessary visits to health
care facilities (Pettinari & Jessopp, 2001; Rolland,
Moore, Robinson, & McGuinness, 2006). For example,
research has shown that telephone triage and care can
potentially decrease already overburdened emergency
department workloads (Bunn, Byrne, & Kendall, 2004).
Nevertheless, little attention has been paid to the com-
munication challenges associated with telehealth ser-
vices (Holmström & Höglund, 2007; Purc-Stephenson &
Thrasher, 2010). New communication skills are needed to
effectively provide health care over the phone, and training
opportunities would help address these concerns. Poison
control centers are one type of emergency service that
have used the phone extensively for decades and might
provide insight into this understudied area. Focus
groups were conducted with specialists in poison infor-
mation (SPIs) to explore the challenges of phone com-
munication within the context of emergency care.
Background
Poison Control Centers
More than 4 million poisoning episodes occur in the United
States each year, with hospitalization occurring in 300,000
cases (Institute of Medicine [IOM], 2004). Poisoning is
also the second leading cause of injury-related deaths in
the United States, and the nation’s 60 poison control cen-
ters (PCCs) handle the majority of all reported poisoning
cases via telephone services (IOM, 2004). During a call,
PCC specialists assess the likelihood of toxicity and
adverse medical outcomes secondary to poisonings. The
PCC specialist role is critical to achieving optimal health
outcomes because the SPIs identify individuals who can
be managed on site or refer them to emergency medical
care. In addition to decreasing poison-related injuries,
illness, and fatalities, PCCs are instrumental in national
surveillance of multiple types of events that include poi-
sonings because of marketed products, food, and illicit
substances (Litovitz et al., 1994; Wolkin et al., 2006).
Finally, each PCC serves as a regional poisoning informa-
tion source for the lay public and health care providers.
PCC services depend on accurate, rapid, and efficient
telephone communication provided by SPIs. To become
an SPI, health professionals (typically pharmacists and
1University of Utah, Salt Lake City, Utah, USA
2Kent State University, Kent, Ohio, USA
Corresponding Author:
Erin Rothwell, University of Utah College of Nursing, 10 S. 2000 E.,
Salt Lake City, UT 84112-5880, USA
Email: erin.rothwell@nurs.utah.edu
Exploring Challenges to Telehealth
Communication by Specialists in
Poison Information
Erin Rothwell,1 Lee Ellington,1 Sally Planalp,2 and Barbara Crouch1
Abstract
The use of the telephone for providing health care is growing. A significant amount of social meaning is derived from
visual information, and the absence of visual stimuli provides unique barriers to communication and increases the risks
for misunderstandings and distractions. Understanding challenges to telephone communication can provide insight
into training opportunities for overcoming these difficulties and improving patient care. The purpose of this research
was to explore through focus groups the challenges of phone communication perceived by specialists in poison
information. General types of challenges to effective phone communication included developing new communication
skills to compensate for lack of visual information, difficulty assessing caller understanding, difficulty managing caller
misunderstandings, maintaining distinctive assessments for routine calls, and managing the multifaceted aspects of job
stress. The desire for training to enhance telehealth and cultural competency skills was also mentioned, and these
findings might provide guidance for the development of training opportunities for telehealth professionals.
Keywords
communication; community and public health; emergency care; focus groups

68 Qualitative Health Research 22(1)
nurses) receive extensive training and obtain certification
based on knowledge of toxicology. No formalized commu-
nication training is conducted, despite widespread evi-
dence in multiple health care contexts that effective provider
communication improves patient outcomes (Brown,
Stewart, & Ryan, 2003; Hall & Roter, 2002). Despite
the considerable public health problem of poisoning and
the potential for PCCs to help with public health cri-
ses, telephone health care service has received limited
research attention that might provide evidence-based
guidelines for training and caller care (Purc-Stephenson
& Thrasher, 2010).
Communication and PCCs
An SPI’s principal role is to perform triage for the health
care system by guiding self-treatment if advisable, or
referring callers to health care facilities if necessary. Callers
who might have managed the incident at home but instead
use health care facilities put an unnecessary strain on
already stretched health care facilities and increase health
care costs. Conversely, improper self-treatment or unwill-
ingness to follow recommendations can put lives at risk.
Telephone triage services and advice are urgently needed
in emergency care. Reports by the Institute of Medicine
highlight the growing concern over the continual increase
in emergency room visits (IOM, 2006a, 2006b). Many
emergency departments are already exceeding their
capacity, and these problems are exacerbated by nursing
shortages (Kellermann, 2006). These problems might
be even more critical during threats of bioterrorism and
emergency preparedness. Telehealth public health services
(i.e., PCCs) might serve as one mechanism for preventing
unnecessary emergency department visits by triaging patients
to engage in self-care when appropriate (Woolf, 2004).
Findings from a handful of studies shed light on the
communication skills beneficial to SPIs. A study was
conducted on the quality of communication skills of tele-
phone triagists at Dutch out-of-hours centers (Derkx
et al., 2009). Approximately 357 calls were assessed
using a communication categorization system, and the
researchers found that telephone triagists lacked commu-
nication skills such as active listening and active advising.
Results indicated that the triagists were extremely friendly
and professional, but too problem oriented, resulting in
callers thinking they were depersonalized (“The telephone
consultation was not about me, it was about someone
with fever”; Derkx et al., p. 177). Ellington et al. (2007)
examined communication processes at a PCC using the
Roter Interaction Analysis System to capture staff–caller
dialogue. Results revealed that most of the communica-
tion was provider driven, but when SPIs utilized partner-
ship statements (i.e., soliciting involvement and actively
assessing for patient understanding throughout the
conversation) there were significant associations with
caller adherence to recommendations. It appears from the
above-mentioned studies that telehealth encounters
might demonstrate providers’ competence in medical
knowledge and professionalism, but reveal weaknesses
in communication skills.
Similar challenges to health care over the telephone
have also been documented in telenursing. A metaethno-
graphic study of nurses’ experiences with telephone tri-
age and advice from 16 studies between 1980 and 2008
revealed several challenges to providing care over the
telephone (Purc-Stephenson & Thrasher, 2010). Two of
the most prominent themes that emerged were the impor-
tance of developing new communication skills to com-
pensate for the lack of visual cues and the desire for
training opportunities to develop and maintain these new
skills. Some of the specific skills identified for facilitat-
ing telephone health care included more active advising
and active listening to compensate for lack of visual cues,
asking the same question in a different manner, and devel-
oping auditory nonverbal skills (i.e., tone, word choice,
speed of speech, background and physical noises; Holmström
& Höglund, 2007; Pettinari & Jessopp, 2001; Wahlberg,
Cedersund, & Wredling, 2003). Other challenges identi-
fied included the repetitiveness of calls, increased impor-
tance of the initial assessment, increased stress and
pressure, and difficulty with assessing caller credibility.
The most notable conclusion from Purc-Stephenson and
Thrasher’s work is that assessment skills used in face-
to-face encounters did not directly transfer to the tele-
phone. However, it is unknown if these challenges are
similar to telephone emergency triage and assessment
within PCCs. Identifying consistent challenges across
numerous settings can serve as a starting point for improv-
ing communication skills within telehealth and develop-
ing training opportunities to better prepare health care
professionals within this growing field.
Conceptual Framework
This research was part of a larger study that used a multi-
disciplinary and multimethod approach to identify and
develop an inventory of communication challenges and
training needs for North American poison centers
(Planalp, Crouch, Ellington, & Rothwell, 2009). The infor-
mation generated by our research will be used to help
develop a Web-based collaborative communication train-
ing program. The theoretical framework guiding the
larger study is social cognitive theory (SCT). According
to SCT, human functioning is viewed as a product of recip-
rocal determinants in which personal factors (cognition,
affect, and biological events), behavior, and environment

Rothwell et al. 69
influence, inform, and alter subsequent behavior (Pajares,
2002). In SCT, efficacy beliefs (personal factors) are the
foundation for human agency and provide guidance for
interventions by increasing efficacy beliefs (Caprara, Rega lia,
Scabini, Barbaranelli, & Bandura, 2004). The development
of a communication program that targets communication
confidence and skills can increase a sense of efficacy and
satisfaction with performance (Bandura, 1986, 1997).
Identification of barriers through the use of focus groups
was the first step to gain an in-depth understanding of
challenges that could be targeted through training.
Methods
Three focus groups were conducted at the annual North
American Congress of Clinical Toxicology (NACCT) in
October, 2007. Institutional research board approval was
received from the corresponding university. Participants
were recruited prior to and during the conference using
flyers and email list servs. Gift cards were provided to
compensate participants for their time. Each discussion
lasted approximately 90 minutes and was held in a private
room in the conference hotel. Before the start of discus-
sion, consent was obtained and each participant provided
demographic information by completing a brief question-
naire. Only individuals who worked exclusively as an SPI
were included in the focus groups, and participants were
also excluded if they served in management roles in their
respective PCC. There are approximately 1,150 SPIs in
United States and Canadian Poison Control Centers, and
approximately 181 attended the conference (L. J. Sandler,
personal communication, October 4, 2010). This resulted
in 16% of the targeted population available for recruit-
ment, and of those who attended the conference, approx-
imately 14% volunteered for this study.
The goals and objectives of the focus groups were
explained at the beginning of the each session. First author
Erin Rothwell, who is experienced in focus group research,
moderated two of the groups, and another experienced
moderator was hired to conduct the third. Open-ended
questions were presented that invited participants to iden-
tify and explain communication challenges (see below).
The moderators used nondirective probes to seek addi-
tional detail and description from the participants (Frazier
et al., 2010). Each discussion was audio-recorded and tran-
scribed by a professional transcriber. A member of the
research team verified all transcription work by listening to
the recordings and reading the transcripts. ATLAS.ti com-
puter software was used to help analyze, retrieve, and review
all coded data (ATLAS.ti, 1999). The following questions
were included in the semistructured interview guide:
• Can you tell me about general types of commu-
nication issues that you experience in answering
calls?
• Are there different communication challenges for
life-threatening vs. non-life-threatening phone
calls?
• What skills and strategies have you developed
to handle challenging calls as you become more
experienced?
• Are there specific types of callers that are more
difficult, or easier?
• What would help you communicate better?
• What do you think are the biggest barriers or
challenges to developing telephone skills?
• How you do handle people who appear to not
be happy with the outcome of the call?
• How do you handle it when you suspect you
are not meeting the needs of the caller?
• What do you do to make the calls more satisfy-
ing to you?
• What kinds of calls leave you with a lingering
dissatisfaction?
A qualitative content analysis was used to analyze the
data. A distinguishing feature of content analytic approaches
is the use of a consistent set of codes to designate data
segments that contain similar material (Morgan, 1993).
Consistent with ours and others’ work (Kondracki &
Wellman, 2002; Rothwell & Lamarque, 2010), the codes
are generated from the data, and rather than using search
algorithms, careful readings of the data are performed
to generate the codes. Then the codes are systematically
applied to the transcripts, with the ability to add codes
that might have been missed with the initial development
of the codebook (Morgan, 1993). After coding was com-
pleted, the codes were summarized to identify the most
frequently reported challenges across and within each of
the groups. We then returned to the transcripts and recon-
textualized the data for development of themes (Tesch,
1990). Reviewing and recontextualizing the data was the
most significant and time-consuming aspect of the analy-
sis (Morgan, 2010). This process also allowed us to assess
data saturation. The frequency of codes was not used to
assess data saturation but rather the content of the data
(Morse, 1995). Repetitive data emerged, and no new
codes were generated from the third focus group, indicat-
ing data saturation (Crabtree & Miller, 1992; Krueger &
Casey, 2009; Miles & Huberman, 1994).
We addressed trustworthiness and rigor of the data to
maintain data integrity during the analysis through meth-
ods of credibility and auditability (Lincoln & Guba, 1985;
Morrison-Beedy, Cote-Arsenault, Feinstein, 2001; Polit
& Beck, 2004; Sandelowski, 1986). Upon completion of
the coding, all coded data were queried by the codes and
reviewed by the research team. This allowed reviewing,
verifying, and auditing the coding schema and associ-
ated data. We followed the qualitative research approach
of reflexivity to minimize the influence of our own beliefs

70 Qualitative Health Research 22(1)
on the data analysis (Mason, 2002). Our personal beliefs,
assumptions, and roles were continually discussed by the
team during the analysis to prevent premature interpreta-
tions of the data and to recognize assumptions (Miles &
Huberman, 1994).
Results
Twenty-five participants took part in three focus groups.
Most participants were women (76%); 68% indicated
that they were nurses, and 24% were pharmacists. PCCs
throughout North America were represented, with over-
representation from the central United States (40%), pos-
sibly because the conference was held in this geographical
area. Years of experience working as an SPI ranged from
2 to 32 (mean = 12.9). The average age of the participants
was 46 years. Below we discuss themes that emerged from
the group discussions related to challenges faced by SPIs
in their telehealth communications.
Development of New
Communication Skills
The most common challenge discussed by SPIs was com-
municating with no visual cues. SPIs indicated that phone
communication requires more detailed questioning to
ensure that all necessary information is collected. The fol-
lowing are examples of comments that support this
theme: “You do have to ask a lot more questions than
would otherwise be necessary. . . you don’t have a visual
image.” “You just have to ask so many more questions
than you would if the person was actually there in front
of you.” “Being physically removed from the actual scene
makes it very difficult.”
Participants also indicated that the more detailed ques-
tioning required increased control of the conversation.
For example, SPIs also noted that they relied heavily on
closed-ended questions to gather specific information
when no visual cues were available. They often avoid
asking open-ended questions because they were concerned
that callers would provide lengthy answers and unneces-
sary information. SPIs have to prioritize gathering infor-
mation quickly and accurately in case immediate action
is needed. For example, one SPI said, “You can’t ask an
open-ended question, [such as] ‘What happened?’ You’ll
be on the phone for 20 or 30 minutes.” Encouraging call-
ers to talk about their concerns in a general, open format
was not viewed as conducive to efficient communication
in this setting.
Communicating over the phone without visual cues
requires not only more questioning and closed-ended
questions, but SPIs also noted that they could not ask the
same type of closed-ended questions as they could in
person. One participant stated, “You have to also approach
from different ways, ask the same question different ways.”
Four participants (P) in one of the focus groups shared a
common challenge faced when asking a typical closed-
ended question:
P1: How many have asked, “Is this a normal, healthy
child?” and the mother answers, “Yes.” “Does your
child take any medicines on a day to day basis?”
[Laughter]
P2: And they’ll go, “Let’s see, phenobarbital, Tegretol
[carbamazepine], Dilantin [phenytoin] . . . ”
P1: Exactly.
P2: And you’ll go, “And what’s all this for?” “Well,
he’s got . . . ”
P3: Or Seroquel [quetiapine], or
P4: spina bifida.
P1: But he’s healthy.
Difficulty Assessing Caller Understanding
SPIs mentioned that it was often difficult to discern the
level of caller understanding and education. One partici-
pant stated that it was a challenge to “get a sense for the
other person on the other end, and what level you need to
keep your language at, and the questions you ask.”
Developing a rapport to help with this barrier was not
always perceived as possible because of the need to assess
the situation as efficiently as possible to determine if
immediate emergency care is needed. It was also difficult
at times to adapt quickly to the wide range of caller educa-
tion and capacity for understanding. SPIs not only answer
calls from the public; they are also a resource for health
care professionals. A few examples of participant com-
ments about this include: “If they’re calling with very poor
education, speak to them on a 4th-grade level, and the
next call, bam, I’m speaking to a physician on his or her
terms.” “I really don’t know if they got it [understanding
of the recommendations].” There were also several com-
ments about how callers’ “words are not the same as what
our words are,” and “different words [are used] for differ-
ent things.”
Difficulty Managing
Misunderstandings of Callers
When asked to identify communication barriers, partici-
pants responded that many of the challenges to communi-
cating effectively over the phone result from caller
misunderstanding of the situation and the role of the SPI.
Callers might misconstrue what is life threatening, believ-
ing that a substance is life threatening when it is not, or
vice versa. Example comments about this include: “There
are times they don’t understand the gravity of the situa-
tion.” “They call you and their level of anxiety is way up

Rothwell et al. 71
there because they’re scared to death [even when the situ-
ation is not life threatening].” It was also mentioned that
callers are sometimes misinformed based on information
they read on the Internet. One participant stated, “And
they’ve just read that it’s horrible, and you’re trying to tell
them that it’s not quite so horrible as they’ve read.” Callers
are reportedly sometimes unaware of what information to
provide, and do not understand that SPIs must ask specific
questions because of time constraints and the lack of visual
cues. SPIs mentioned some of the questions they get from
callers, such as “Why do you need that [information]?”
and “Why are you asking me so many questions?”
Staying Vigilant With Routine Calls
Participants reported that another barrier to communicat-
ing effectively was falling into a routine assessment with
more common calls, which could prevent effective spe-
cific assessments. One participant said, “It’s easy to fall
into the spiel. . . . I know every time there’s a plant inges-
tion I can almost mimic them and know exactly what
they’re going to say. They do it every time.” Despite
acknowledging that it was easy to jump to conclusions,
focus group participants stressed it was still necessary to
follow procedures and thoroughly assess the situation to
make sure there were not additional factors that could
alter the assessment. SPIs also mentioned that although
they found this type of call routine, each situation might
be novel and frightening to the caller, and treating it in a
routine fashion might result in poorer customer service
and satisfaction. An SPI commented, “To that person
that might be the first time they’ve called in ever, and
they’re anxious, and I’ve taken lots and lots of calls [like
this], but I have to go back to the initial, what the caller
needs.”
Stress
SPIs shared that the stress associated with their work
impacted their ability to communicate effectively. Their
stress stemmed from several sources related to telehealth:
concern that they were not getting full and accurate infor-
mation from the caller, never knowing what each call
would be like, pressure to respond accurately and
quickly, additional demands to be friendly and courteous,
and perceived work overload. With regard to the accu-
racy of the information collected over the phone, one
participant mentioned it was what health care providers
face in any situation with a patient, and stated, “You have
to take it at face value. I guess it’s like anything else with
patients—people lie all the time.” Another participant
said, “You are relying on them to tell you the right infor-
mation.” Still, without visual cues, SPIs have to rely
more on the caller correctly understanding the questions
and providing accurate answers to those questions.
Another contributor to stress voiced by participants
was uncertainty about what the call might entail. For
example, one SPI said, “You have no idea of what’s on
the other end of the phone, and it is scary.” SPI worries
were, in part, influenced by working without visual cues,
but also by never knowing what to expect when answer-
ing the phone, and the reluctance of some callers to give
all the needed information. Also, the possibility of facing
an emergency call that they had not dealt with before
increased their perceived stress. One participant expressed
it as, “Omigod, I haven’t had one of these yet! Nobody’s
told me anything about this!” According to the SPIs, the
stress associated with a new type of toxic exposure also
stems from pressure to respond correctly. A few com-
ments that support this view include: “I don’t want to
screw up.” “You could really screw up your reputation
by having an ineffective phone call, one that gets
misunderstood.”
An additional stressor mentioned by SPIs was the dif-
ficulty in striking an optimal balance between the need to
be friendly and the need to be direct. They made state-
ments like the following: “I think we’re wearing different
hats all the time.” “There’s times, though, that you have
to really redirect the person on the line, because it’s an
emergency line, and you have to, and they want to talk
about other things, or they want to be your friend.” “You
have to be able to reassure the person and cut them off at
the same time.” Individuals from each of the focus groups
noted that this was especially challenging for new SPIs.
Another challenge to communicating effectively was
stress caused by work overload: a high number of calls,
and pressure to complete a call in an effective and effi-
cient manner. Comments supporting this included:
“Unfortunately, how busy you are, too, makes a difference.”
“Again, so many calls.”
Support for Training Opportunities
Participants in the focus groups mentioned several times
that providing health care over the telephone is different
from anything else they have done within the clinical set-
ting, and it requires a new set of skills that could be devel-
oped or sustained through training opportunities. Although
they indicated they get training in toxicology, there appears
to be no formal training in developing the additional
auditory and verbal interpersonal skills needed for tele-
phone encounters. Some comments that exemplified this
included: “I’d love to have something that we could
incorporate, whether it’s either online or tapes that we
could use in PCCs as part of the orientation.” “I think it’s
[training] definitely got to be incorporated.” “We needed
to learn how to communicate without the visual cues of
communication.”
Participants also mentioned the need for improved
cultural competency. The most common barrier mentioned

72 Qualitative Health Research 22(1)
by SPIs was their inability to speak the language of the
caller and having to rely on an interpreter. They mentioned
that the number of callers whose native language was not
English was increasing. With increased awareness of the
PCC hotline, especially among diverse cultural groups,
SPIs expressed a desire to learn more about the cultural
backgrounds and health care practices of callers in their
geographical jurisdiction. One participant summarized
this growing need by stating that in the geographical
area of the SPI’s PCC they had a
very large population from Asia, and so the prod-
ucts in their home and what they eat and things like
that are totally different. For example, culturally
they forage for a lot of mushrooms. We had a lot
of problems with poisonous mushrooms.
Discussion
PCCs are an essential part of the public health infrastructure
and disaster response, and are a challenging work envi-
ronment. First, SPIs provide information on poisoning to
both lay persons and health care providers. Second, SPIs
provide emergency services by determining caller toxic-
ity, triaging individuals who can be managed at home, and
referring those who might need emergency medical care.
Third, SPIs document calls to build valuable sources of
data about public health issues. Not only are SPIs expected
to be knowledgeable in toxicology; they are also expected
to be effective communicators under pressure. It is clear
that SPIs need a rich array of communication skills to do
their jobs effectively, but little is known about the com-
munication challenges they face.
To our knowledge, this is one of the first studies to
document barriers to communication over the telephone
specific to emergency telehealth, and to provide prelimi-
nary data on barriers that might be addressed through
communication training opportunities. Challenges iden-
tified from this study are similar to those found for
telenursing (Purc-Stephenson & Thrasher, 2010), and these
similarities might be consistent with barriers to telehealth
communication in general. However, additional research
is needed to validate these findings.
One of the most prominent themes in the literature
about challenges to telehealth is the importance of devel-
oping new communication skills to make up for the lack
of visual cues. Without visual information it is more dif-
ficult to interpret callers’ meaning, convey social pres-
ence, and develop a supportive and collaborative
relationship to reach common goals (Turner et al., 2003;
Turner, Thomas, & Reinsch, 2004; Wilson & Williams,
2000). Consistent with findings in the telehealth literature,
SPI participants voiced their concerns about not having
visual cues to respond to caller concerns. Strategies SPIs
used to confront the barrier of no visual information were
mainly verbal in nature (e.g., use of closed-ended ques-
tions, repeating and rephrasing questions and information).
No mention was made of nonverbal strategies. Auditory,
nonverbal skills are essential in conducting an assessment.
Numerous articles in the literature indicate the importance
of tone, breathing rate, volume, background noises, word
choice, and speed of speech for making complete and
accurate assessments (Holmström & Höglund, 2007;
Pettinari & Jessopp, 2001; Wahlberg et al., 2003). Without
visual information, these factors were not only necessary
for conducting a patient assessment but also for communi-
cating concern and friendliness (Wahlberg et al.).
Of all the challenges identified by the participants, the
impact of work stress was the most detailed. Clinician
stress and burnout has been found to negatively impact
patient care (Shanafelt et al., 2005). Little research has
been devoted to the effects of stress and burnout on inter-
personal health communication (Epstein & Street, 2007).
The perception of high stress is well documented within
the literature for similar telehealth encounters (Car &
Sheikh, 2003; Purc-Stephenson & Thrasher, 2010),
and addressing challenges to telehealth through training
opportunities can help alleviate some of the concerns
(Planalp et al., 2009).
Some findings suggest that clinicians are generally
dissatisfied with their performance in encounters with
patients over the phone (Car & Sheikh, 2003). In other
research, dissatisfaction by clinicians with telephone-
based care was related to the absence of visual cues,
potential risk to miss a serious condition, and inability to
confirm diagnosis with an examination (Car & Sheikh;
Foster, Jessopp, & Dale, 1999). Opportunities for tele-
health providers to practice and learn new communica-
tion skills promise not only to improve the efficacy of
services, but can also improve job satisfaction (Car & Shei kh;
Ellington et al., 2007; Newes-Adeyi, Helitzer, Roter, &
Caulfield, 2004). For example, an evaluation of a com-
munication training program found increases in satisfac-
tion with job performance that paralleled increases
in communication competency (Newes-Adeyi et al.).
Providing training that enhances competency and con-
fidence for telephone-based care might address some of
the barriers found in this study and other concerns asso-
ciated with telehealth (Car & Sheikh; Derkx et al., 2009;
Planalp et al., 2009).
Trainings that provide opportunities to practice and
have successful experiences with skill development are a
powerful source for increasing efficacy beliefs. In the con-
text of this study, self-efficacy refers to the confidence that
an individual has in her or his ability to communicate
effectively over the telephone. Unless a person believes
that she or he can accomplish a desired task, then that per-
son has little motivation or incentive to act (Bandura,

Rothwell et al. 73
1977, 1986, 1997). Increasing efficacy beliefs is also asso-
ciated with reduced stress and increased satisfaction with
one’s performance (Bandura, 1986, 1997). Identifying
challenges to communication over the telephone and pro-
viding training opportunities to develop the skills to over-
come these challenges is an effective behavioral
intervention for increasing efficacy beliefs and improving
targeted behaviors (Bandura, 1986, 1997; Pajares, 2002).
Findings from this study also suggest that SPIs are
likely to be receptive to the idea of improving their skills;
they made numerous comments that support the need for
a communication training program. This is consistent with
studies in which other telehealth providers were open to
and supportive of communication training opportunities
(Derkx et al., 2009; Ellington et al., 2009; Purc-Stephenson
& Thrasher, 2010). It appears that a communication train-
ing would be most helpful before actually engaging in
telehealth services, to be supplemented by periodic train-
ings to help strengthen and sustain telephone communica-
tion skills (Purc-Stephenson & Thrasher). For example, it
might be necessary to develop general training opportuni-
ties prior to beginning telehealth encounters, so providers
can practice communicating without visual cues.
However, more research is needed to identify strategies to
help overcome telehealth challenges and to identify for-
mats of acceptable training opportunities to practice these
skills. In addition, finding additional strategies for enhanc-
ing telephone cultural competency will be essential as
health care increasingly uses advanced telecommunica-
tions (Wakefield et al., 2008)
Limitations of this study include that only three focus
groups were conducted, which is the minimum number of
groups recommended by Krueger and Casey (2009). In
addition, the groups were comprised only of SPIs who self-
selected to participate, and only those who attended the
conference. Conducting additional focus groups from a
larger sample of available SPIs would help to strengthen
these results, as would the use of other methods, which
could include observing telephone calls or interviews.
In summary, in a world that relies increasingly on tele-
communication, it will be essential to match technologies
to patient needs and assess the skills of health care provid-
ers to effectively communicate with patients (Wakefield et
al., 2008). Given that evidence on telephone health care is
in its early stages, it is likely that extensive training and
institutional support is not yet available to guide health
care providers. Providing communication training unique
to communicating over the phone might help overcome
some of the barriers unique to this emerging field of health
care.
Acknowledgments
We thank Kelly Teemant for her assistance on this project.
Declaration of Conflicting Interests
The authors declared no conflicts of interest with respect to the
authorship and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support
for the research and/or authorship of this article: This research
was funded by a Health Resources Services Administration
(Grant #U4BHS08563).
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Bios
Erin Rothwell, PhD, is an assistant research professor in the
College of Nursing, University of Utah, Salt Lake City, Utah,
USA.
Lee Ellington, PhD, is an associate professor in the College of
Nursing, University of Utah, Salt Lake City, Utah, USA.
Sally Planalp, PhD, is a professor in the School of
Communication Studies, Kent State University, Kent,
Ohio, USA.
Barbara I. Crouch, PharmD, MSPH, is a professor in the College
of Pharmacy, University of Utah, Salt Lake City, Utah, USA.