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Using video in clinical practice
We have been lucky enough recently to meet with Speech and Language Therapists, who are experts in working with people living with Parkinson’s and neurorehabilitation. This is as part of a project generaously supported by a public engagement bursary from UCL Engagement to help us understand:
the current barriers to implementing Better Conversations with Parkinson’s as an intervention
what our next steps in research should be
One topic that has come up when talking with these highly experienced SLTs is the myriad of challenges associated with using, and worse – storing, videos in clinical practice.
As someone who spent over a year navigating various hurdles to lend out iPads to NHS patients, I understand barriers to using technology and storing identifiable information in an organisation that, quite rightly, prioritises the safety of patient data and confidentiality. Therapists raise challenges such as:
how to take videos
how to store videos
transfer of videos
reluctance from the patient or family member
patient or family member not familiar with technology
therapist not feeling confident in using videos
The difficulties faced will be very dependent on the patient, the therapist, the clinical setting, and the associated information governance / IT systems. However, in a bid to motivate people to keep chipping away at these barriers, here are some reflections on the value of using video in clinical practice, and some tips for using it in practice…
Why use video?
1. It's a fantastic tool for observation
As speech and language therapists we are above all interested in how people’s communication and conversations work in everyday life. We want to know about impairment and function, but also how this is going to impact on participation. Conversation is a notoriously difficult thing to measure and it can be difficult to piece together what is actually happening.
Video provides a really useful tool for the therapist and the people involved to see what is going on in conversation. It allows access to the home environment, without the potentially interfering dynamics of having a therapist in the room. It is a close second to directly observing the kind of conversations that happen every day when the therapist is not around.
2. It facilitates effective self-reflection
People living with Parkinson’s in our advisory groups really emphasised the importance and value of using video. They felt that seeing things for yourself was the most effective way of bringing something home.
Research shows that self-monitoring behaviour and self-monitoring outcomes of behaviour are ‘active ingredients’ in interventions that encourage behaviour change (Michie et al., 2013). Increased awareness of one’s own behaviour, and changed expectations of behaviour’s impact are key mechanisms of conversational behaviour change in conversation therapy (Johnson et al., 2017).
"video is the most powerful way to encourage self-monitoring and monitoring of outcomes"
Better Conversations with Parkinson’s recognises that seeing yourself on video can be confronting and difficult for some people, in particular with a neurodegenerative condition. The programme therefore suggests back up activities to encourage self-monitoring and reflection. Consensus amongst our advisory group, however, is that video is the most powerful way to encourage self-monitoring (for example identifying what strategies you are using that are helpful or get in the way of a good conversation) and monitoring of outcomes (seeing for yourself what the impact is on conversation flow). Seeing your own conversations also allows individuals to set their own personalised, meaningful goals – therefore implementing principles of self-management and efficacy (Yorkston et al., 2017).
3. It allows the therapist to provide non-judgemental feedback
Other active ingredients in therapies that encourage behaviour change are feedback on behaviour and feedback on outcome(s) of behaviour (Michie et al., 2013). Giving feedback on what is going well, and less well, in everyday conversations can be a delicate business – how we communicate, after all, is what makes us human and defines us as individuals.
Video is an extremely useful means of the therapist describing what they see without judgement.
The therapist can show the person living with Parkinson’s and or a conversation partner (together called the 'dyad') short video clips, repeatedly if needed. The clips are there to facilitate discussion about conversation – what may be seen as a ‘barrier’ by the therapist, may in fact be nothing of the sort to the dyad concerned. The dyad therefore become much more active members in receiving and responding to feedback, and can be coached by the therapist to identify goals that are really meaningful to them.
How to use video?
In the Better Conversations with Parkinson’s approach, the therapist currently videos everyday conversations between a ‘dyad’ - someone living with Parkinson’s and their ‘conversation partner’ (a family member or friend). The therapist records a conversation for approximately 15 minutes – this allows time for those talking to become used to the video recording equipment, and ease into the conversation. If needed, we provide broad options for conversation topics (e.g. holidays, television programmes).
We have been using videos as a ‘before’ and ‘after’ outcome measure, and recording strategy use according to the Better Conversations Facilitators and Barriers Observation Tool (see for more details later this year). Storage on notes systems can, however, be complicated. You may therefore agree to store the videos purely for the purposes of the therapy, and delete them immediately afterwards.
The therapist spends (let’s be honest, a reasonable amount of) time looking through the videos, in order to understand how the dyad’s conversation is currently working, and identify possible facilitators and barriers to conversation. The therapist is then well armed to take some example video clips to the dyad, which are used to stimulate discussion and set goals. The clips don’t need to be long at all...
30 seconds can be adequate to demonstrate what is working well or less well, and the impact of this on the flow of conversation.
We used video editing software (e.g. OpenShot Video Editor is free) to ‘snip’ short video clips, and then uploaded these to a PowerPoint presentation… the therapist could then share the videos via the presentation in the therapy session, and navigate with ease between different examples of conversation behaviour. This was really helpful, for example, when contrasting something that helped in conversation (e.g. leaving a long pause) with something that might act as a barrier (e.g. asking questions one after the other without pauses).
Videos allow the dyad to watch clips of their conversation repeatedly, and form their own judgements about what conversation behaviours are helpful or not for them. In Better Conversations with Parkinson’s, this reflection is then followed directly by goal setting. The dyad use the Goal Attainment Scaling framework (Turner-Stokes, 2009) to set individual, personalised goals for the next 4 weeks of therapy.
"our advisory group emphasised how important it is to familiarise people with the process of video recording"
As part of recording videos, and then showing video clips to the dyad in therapy, our advisory group emphasised how important it is to familiarise people with the process of video recording. Some might need to practise the process of video recording, and we give all participants the option of deleting a recorded video and recording again if they choose (for example if they don’t want the topic they talked about to be watched by the therapist). We educate the dyad about why video is important, choose a ‘neutral’ video where the therapist is talking with the dyad to reflect together on how it feels to watch yourself on screen, and carry out practice videos until the dyad feel confident enough using video to focus on the content and reflect on their own conversations.
7 steps for using video
But what about storage and transfer?
We made various decisions, in agreement with the information governance team and ethical committee, to ensure identifiable information is handled effectively, securely and in accordance with the Data Protection Act 2018.
We use a remote platform (Zoom) to video record participants. The therapist sets up a video appointment, explains the process, turns off their camera and puts themselves on mute, and directly records the dyad’s conversation to their encrypted laptop. This allows direct collection of the video to a secure location, and avoids transfer via web or USB.
If participants choose to send videos to the therapist (e.g. videos of them practising certain conversation strategies), they were given the option of sharing this via their own device (through shared screen within the therapy session), or sending the video through WeTransfer. WeTransfer has dual authentication, is encrypted, and uses Transport Layer Security during transfer. Verbal consent is sought each time that it is used, following a discussion about the increased risk of data breach (for example by interception of the email with a link to the videos) with the participants. Steps such as password protection are put in place to minimise this risk.
Videos are stored on an encrypted work laptop and on Data Safe Haven (a secure portal for storing, handling and analysing identifiable data). Videos that need analysis are stored on an encrypted, password protected laptop, and shared between the team only as necessary via an encrypted external hard-drive.
Consent is sought for how long videos are stored, and videos are deleted as soon as no longer needed.
Inevitably, one system will not work for all situations, and a fair amount of effort may well be needed to overcome local or unexpected barriers, in particular if implementing a new way of working. We would say that it is well worth the effort in terms of the rewards gained: service users are able to gain a huge amount of insight into how their conversations work, and reflect on what they would like to do more or less of. This allows them to generate their own, individualised, personalised goals, which are directly related to strategies occurring in everyday conversations.
Video is a tremendous coaching tool for the therapist and empowers service users to take control of their own reflection, goal setting and therapy.
So, let’s make the most of technology and systems available to us, and make 2023 the year of (lights) camera action…
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