OCCUPATIONAL THERAPY HOME SAFETY

INTERVENTION VIA TELEHEALTH

LORI E. BREEDEN, EDD, OTR
SCHOOL OF OCCUPATIONAL THERAPY, COLLEGE OF HEALTH SCIENCES, UNIVERSITY OF INDIANAPOLIS,
INDIANAPOLIS, INDIANA, USA

ABSTRACT
Photography can be an effective addition for education-based telehealth services delivered by an occupational therapist. In
this study, photography was used as antecedent to telehealth sessions delivered by an occupational therapist focused on
narrative learning about home safety. After taking photographs of past home safety challenges, six participants experienced
three web-based occupational therapy sessions. Sessions were recorded and transcribed. Data were examined using
content analysis. The content analysis identified the following themes: the value of photos to support learning; the value of
narrative learning related to home safety education; and abstract versus concrete learners. Procedural findings are included
to support future endeavors. Findings indicate that within a wellness context, home safety education for older adults can be
delivered effectively via telehealth when using photography as a part of an occupational therapy intervention.

Keywords: Home safety, Older adults, Photo-elicitation, Telehealth

According to the workforce survey by the American  How does the use of digital photography facilitate
Occupational Therapy Association (AOTA, 2010), most narrative learning and impact individuals’
occupational therapists, approximately 55.4%, work in a awareness of safety challenges in their home?
direct style of service delivery wherein a therapist provides
One of the many challenges in occupational therapy is
one-to-one treatment in a medical setting. Given the current
a lack of adherence by older adults with regard to home
trend in health care toward shorter hospitalizations, and
safety. This is especially challenging when working with
recent reform legislation, occupational therapists are
community dwelling, independent older adults whose range
exploring different models of service delivery. In telehealth,
of performance is decreasing but who are otherwise
a new type of service delivery for many occupational
functioning well. They may not see a reason to change their
therapists, the methods and quality of client education can
environment or habits when they have not yet experienced
be important factors in determining successful client
difficulties with safety. These clients can be very resistant to
outcomes.
recommendations from health care practitioners about
Patient education in a clinical setting is often guided by safety in their homes. Helping older adults anticipate their
an occupational therapist’s understanding of activity changing function by balancing knowledge of past
analysis, use of adaptation, and the structuring of tasks that functioning with a realistic view of their future may increase
provide the best challenge for patients (Dahlin-Ivanoff, their openness to suggestions for home safety.
Sonn, & Svensson, 2002; Schemm & Gitlin, 1998). These
Involving these clients in decision-making processes
methods provide a client with opportunities to learn through
can facilitate adherence. Clemson, Cusick, and Fozzard
practice with a skilled clinician present. Telehealth practice
(1999) stated, “the ownership of ideas and exerting control
can challenge occupational therapists to use different
within the context of an individual’s environment and life
methods of client education that do not rely on hands-on
experiences strongly influences acceptance and follow
assistance or practice. There is a lack of evidence to
through of recommendations” (p. 539). Additionally, these
support educational strategies in telehealth practice. To
researchers recommend “joint decision making and
address this gap, this multi-case study examines the
negotiation” (Clemson et al., 1999, p. 539) as being most
experience of educating older adults about home safety via
likely to result in changed home environments. Radomski
telehealth using photography as an antecedent to narrative
(2011) recommends that adherence is a function of the
learning.
client, the provider and the recommendations set within the
The central research questions were as follows: environment; and that adherence is a process of client and
provider decisions rather than recommendations.
 What is the process of home safety education with
older adults as delivered via telehealth?
 Does the combination of digital photographs and
narrative learning impact home safety as scored by FALL PREVENTION
the Safety Assessment of Function and the
Of great concern when working with community
Environment for Rehabilitation-Health Outcome
dwelling older adults are the physical and psychological
Measurement and Evaluation, version 3 (SAFER-
injuries that accompany a fall. The Centers for Disease
HOME v. 3)?

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Control and Prevention (CDC) (2010) reported that $19 experience and to mentally construct a perspective of the
billion was spent in 2000 on treating the elderly for the event that creates its meaning. As we listen to an individual
adverse effects of falls. It is estimated that this equates to telling his or her story, we witness learning in real time as
$30 billion in 2010 dollars (CDC, 2010). Relevant to the narrator relates the experience. Personal narratives are
occupational therapy, injury from a fall can slow a way to structure and make meaning of daily lives and can
occupational performance at home as well as on the facilitate a transformative and critically reflective
worksite and can contribute to other fall-related costs to understanding of those experiences (Clark, 2010).
individuals, families, and organizations such as lost time on
Schank and Berman (2006) note how much of the
the job, inability to perform household activities, and
educational process is comprised of telling stories, even
decreased quality of life (CDC, 2010). Fleming (2002),
though most listeners do not retain what they hear:
identified falls as the leading cause of death among people
65 years and older. In the year 2000, non-fatal falls It is rare that we learn from others’ stories, but stories
accounted for 19 billion dollars in health care expenses play a key role in our day to day conversation. Why do
(Stevens, 2006) we tell stories if others will not remember them? The
answer is that we like to hear ourselves talk, and
The definition of a fall varies by institution; however, a
actually, we learn from hearing ourselves talk. So we
common element seems to be unintentionally coming to the
(pretend to) listen to others to get them to listen to us.
ground, floor, or other lower level (Tinetti, Baker, Dutcher,
We are not consciously pretending, but we also are not
Vincent, & Rozett, 1997). Effective interventions to prevent
really gaining much from what we hear. (p. 220)
future falls assume falls are not the result of random
accidents but rather result from the presence of numerous Applying this notion, telling clients how to be safe at
risk factors and a compromised medical condition (Tinetti et home may not be as effective as having clients tell clinicians
al., 1997). It is therefore essential to help community how breaches in home safety occurred. When clients listen
dwelling older adults examine their environments and to suggestions and advice regarding home safety, that
improve home safety. One clinical strategy that therapists advice may not be heard; yet when clients themselves
use when working with a client who has fallen is to ask the explain, even a flawed process, they likely derive benefit.
client to recreate the fall. This process is often used to help
a therapist appraise past performance; an additional benefit
is that the client uses narrative learning to examine his or
her safety. PHOTOGRAPHY
In this study participant-generated digital photographs
were employed as an antecedent to participants’ narrative
NARRATIVE LEARNING learning about home safety. The photographs, used as an
archival record, allowed participants not only to share a
The use of a personal narrative is a way people reason, visual image representing the past safety challenge but also
and make meaning out of an event. Through the process of to provide a basis for the description of their experience.
telling the stories of their lives people reason about cause Harper (2002) defined photo elicitation as “the simple idea of
and effect. Clark (2010) stated, “we learn from telling inserting a photograph into a research interview” (p 13).
stories. When we hear, we are the receiver; when we tell, Collier and Collier (1986) described taking notes during a
we are the actor, the one putting all the details together and traditional interview as something that would “block
making the experience coherent for ourselves and for conversation” (p. 106). Additionally, the authors described
others” (p. 6). Learning via narrative is an integral part of the use of a tape recorder as something that would “bring all
adult learning theory. Lindeman (1989) offered, “Adult conversation to a stop” (p. 106). Collier and Collier (1986)
education is a process through which learners become were supportive of the use of photographs; using them
aware of significant experience. Recognition of significance seemed to focus all discussion toward the photograph.
leads to evaluation. Meanings accompany experience when Furthermore, neither note taking nor recording seemed to
we know what is happening and what importance the event bother participants when conversation was centered on a
includes for our personalities” (p. 109). For a client photo instead of the participant. As Collier and Collier
recovering from illness or injury, the process of organizing (1986) explained:
thoughts and crafting the story of one’s experience helps to
evaluate the process and assign meaning. Photographs sharpen the memory and give the
interview an immediate character of realistic
Clark and Rossiter (2008) position narrative learning reconstruction. The informant is back on his fishing
within constructivist learning theory, which “understands vessel, working out in the woods or carrying through on
learning as construction of meaning from experience. The a skilled craft. The projective opportunity of the
fundamental principles of narrative underlie this type of photographs offers a gratifying sense of self-expression
learning because the meaning construction is done as the informant is able to explain and identify content
narratively” (p. 63). Narrative learning occurs because of and educate the interviewer with his wisdom. (p. 106)
the processes that individuals must use to organize their
thinking such as highlighting the relevant points of the One reason that photo elicitation could support both
experience and building those relevant points into a reflective and critical reasoning skills is that examining a
narrative. This process helps the person to both solidify the photo allows for a perspective on a point in time from which

30 International Journal of Telerehabilitation • Vol. 8, No. 1 Spring 2016 • (10.5195/ijt.2016.6183)

the photographer is removed. Allowing the participant to older adults were contacted by phone. Each agreed to
reflect on a situation from a more objective, even safe point participate in the study and were scheduled for an initial
in time can support critical reflection of past accidents. meeting. All participants were retained for the duration of the
study.
Latz (2012) discussed the unintended results of a study
using photovoice to elicit critical consciousness in
community college students. The author illustrated how
participant-generated photographs in research elicited not
only critical consciousness but reflective consciousness as
MATERIALS
well. Latz (2012) noted: “Photovoice for reflective The SAFER-HOME v. 3 (Chiu et al., 2006) was used
consciousness may be used as a tool for inquiry as well as pre- and post-intervention. This is a 74-item assessment
personal development” (p. 50). This article is relevant to the that scores individuals as having no, mild, moderate or
current study in that participants were asked to use severe safety concerns based on interview or observation of
reflective consciousness, elicited by the photographs, to household tasks. The SAFER-HOME v. 2 is reported to
develop their understanding of home and community safety. have “high internal consistency with a coefficient alpha value
of 0.859, indicating that the 97 items all contributed to the
As occupational therapists employ telehealth, it is
measurement of one dimension (home safety)” (Chiu &
important to understand the educational tools that are
Oliver, 2006, p. 140). SAFER-HOME v.3 is the current
available and how the educational process can influence a
version and has fewer items, less categories and a change
client’s outcome. In this study, photography and the
in weighting of categories to better capture more severe
accompanying client narrative construct a learning
problems. These changes, based on expert reviewer
experience about home safety. Using photographs to
feedback have made the tool more responsive to change
promote narratives could help the occupational therapists
over version 2 (Chiu, et al., 2006).
guide home safety education toward specific issues that the
older adult has deemed relevant. Three weekly telehealth sessions were performed using
the VSee software program (VSee, 2013). VSee is a web-
based video technology currently recommended for
telemedicine because of its ease of use and security.
Tsuboi noted, “As far as privacy concerns, VSee uses end-
METHODS to-end encryption.” (2013, para. 4). This process ensures
Subjectivism respects that older adults have an intimate that data being transmitted is not decrypted on a remote
understanding of their homes and how they function. Crotty server, and is therefore only accessible by the end users.
(1998) noted, “In subjectivism meaning does not come out VSee requires that participants have access to Windows XP
of an interplay between subject and object but is imposed on SP3, Windows Vista or later versions, Mac OSX 10.6 and
the object by the subject” (p. 9). This foundation above, or iPad iOS 5.0 or later.
encouraged an examination of home safety as clients
interpret the issues through their own experiences. Drawing
on strengths from both qualitative and quantitative research,
a “multicase study” (Stake, 2006, p. vi) design with a PROCEDURES
primarily qualitative focus was used. Narrative learning data Following recruitment, an initial in-person session was
was supplemented by the use of a pre and post measure of scheduled in the participant’s home. During the initial
home safety, the Safety Assessment for Function and the session, informed consent was obtained and the researcher
Environment for Rehabilitation – Health Outcome performed baseline assessment using the SAFER-HOME v.
Measurement and Evaluation (SAFER HOME) v. 3, (Chiu et 3. Participants were then instructed to create photographs of
al., 2006). home safety concerns that would be used to guide future
web-based sessions. These were sent to the researcher
prior to each telehealth session through email or via text
messaging, which allowed for session preparation focused
PARTICIPANTS (when possible) on specific issues within the photo.
Participants were six “purposefully selected” (Creswell, Member checking was used to establish trustworthiness
2013, pp. 299-300), older adults over the age of 65 who (Creswell, 2013) along with a researcher reflexivity journal,
were recruited via email or a recruiting flyer distributed which was used to expose bias and analyze the learning
through personal and professional contacts. Inclusion experience from the perspective of the researcher (Lincoln &
criteria included a fundamental knowledge of digital or cell Guba, 1985).
phone photography, computing, and email use. It was Following baseline assessment, three sessions were
important that participants were comfortable with scheduled based on participant availability and administered
technology, to be able to improve their understanding of remotely via web-based video-conference, with the
home safety while at the same time managing the participants communicating from the computer in their
technology. Individuals who had experienced recent health homes. During these web-based video sessions, the
problems were excluded if they had previous exposure to participants engaged in telehealth sessions based on open
occupational therapy services focused on home safety. ended questions designed from James Spradley’s
After emailing their interest in participating in the study, six developmental research sequence (Spradley, 1979), moving

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from broad descriptive questions through structural
questions, and finally into contrasting questions. Sessions
RESULTS
included a discussion of how the images in the photographs Procedural findings reported here are related to the
related to past accidents, near misses or home safety process of providing this very specific home safety program
issues. A near miss was defined as “an unplanned event via telehealth, to allow others who attempt client education
that did not result in injury, illness, or damage – but had the via telehealth to better prepare for the unique challenges.
potential to do so” (National Safety Council, 2013). After Examples of participant narratives are offered as examples
each telehealth session, a new photo assignment was related to the previously detailed research questions.
given, based on the discussion(s) as they evolved in the
prior session.
Sessions were audio/video recorded using VSee and
transcribed using Microsoft Word® within 48 hours.
PROCEDURAL FINDINGS
Participants were assigned an alias during transcription and The participant-created photographs, which arrived via
the session recording was deleted. Following the three email or text prior to the telehealth sessions, were
telehealth sessions, a final in-person session was scheduled sometimes intentionally staged and very creative, while
during which the SAFER-HOME, v. 3 was re-administered to others were more concrete and focused on current
quantify any functional or environmental changes that had environmental conditions. Likewise, the descriptions
been made. This process took place over a seven-week provided by the participants about the photos varied based
period. on many factors. These factors included participants’ level
of trust and confidence in the researcher, their expectations
of the role of the occupational therapist in the process, and
their willingness to share stories that exposed past failings.
DATA ANALYSIS Participants who were comfortable with abstract concepts
seemed more willing to engage in reflection; those who
Telehealth session analysis included ‘within case
seemed more concrete focused on finding a right or wrong
analysis’ (Creswell, 2013, p. 101), as well as a ‘cross case
answer to their experiences. In this telehealth educational
synthesis’ (Yin, 2009, p. 156). During an initial round of
experience, technology was ever present in the learning
open-coding, the researcher read transcripts, examining
process, and offered both barriers and supports to learning.
patterns that participants discussed in their photo-supported
Change in the SAFER-HOME, v. 3 scores, and the richness
narratives (Creswell, 2013). This ‘within case analysis’
of the participant narratives (discussed below) indicate a
(Creswell, 2013) was performed immediately following
benefit from this learning experience.
telehealth sessions, and contributed to successive session
topic assignments while also informing thematic categories.
Content analysis was performed, across cases, on all TECHNOLOGY
session transcripts; data were organized categorically,
coded and combined with concepts emerging from Technology can create a challenge for intermittent
photographs and researcher reflections. Memos were users due to constant evolution and inconsistencies in
assigned to provide context to codes. Themes that software, which can slow the work process. The older
emerged from the data related to narrative learning and the adults in this study were confident and quite comfortable
use of photography were technology use, concrete versus with the use of technology. Yet one challenge technology
abstract learners, and developing rapport. posed was that occasionally, web-connections were lost,
temporarily interrupting a telehealth session, as in the
The qualitative analysis was corroborated by
following example. In a telehealth session focused on a
quantitative data from the SAFER-HOME v.3. This measure
stumbling fall, augmented with the photo in Figure 1,
was non-experimental and used descriptive statistics to
Participant 2 explained:
measure pre/post scores related to home safety. Data
reflected the participants’ environment(s) and ability to It was just like I was diving forward and I kept flailing
function safely during activities of daily living. The SAFER- with my arms and kept going and kept going and I
HOME v. 3 was administered to obtain information about thought oh my God I’m going to go straight through the
their individual change over time. These assessment scores window. But I managed to get stopped because there is
were not generalizable but offered an indication that the a chair there and a good heavy table and I managed to
home safety education program led to individual get stopped without going down on even one knee and
improvement. Paper copies of de-identified data were uh—I was just trying to get my balance and
scanned and saved electronically, along with photos, (disconnect). (Session one)
transcriptions, and reflexivity journals on a password
protected, encrypted file as an audit trail of the analysis. Once we reconnected, I prompted Participant 2 to finish
and she offered, “well yeah, well I don’t know what else—
that is really all there is about that.

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 wanted it good and hot and I was putting my coat on
and I thought, what is burning, the stove isn’t even on
and a couple minutes later I thought, something is
burning? And then I remembered the microwave! And
the rice bag was burned, the cloth actually burned. See
there was some time left on the microwave when I put it
in, so it could have gone for 30 minutes—I don’t know—
I could have burned the house down! (Session three)

Figure 1. The path of Participant 2’s near fall.

In a study focused on learning through the narration of
a story, losing connection mid-story was disruptive and
participants were less detailed once the connection
resumed. Overall, the older adult participants did not seem
to allow technology challenges to interfere with the session Figure 2. Participant 1 photo represented numerous times
and often managed to laugh at themselves without that she forgot items cooking. In the third telehealth session
internalizing any of the challenges. (session four overall), this participant newly disclosed the
details of a cooking accident, insisting those events were
rare or even one-time occurrences.
SELF-DISCLOSURE
Building a trusting and comfortable relationship to put
Participant 1 also related another accident scenario in
clients at ease and foster self-disclosure occurred in an
the third telehealth session. As a workman entered the
intentional manner in the online format. It was important for
home, he slipped off the front landing and fell into the dining
participants to feel confident that the role of the researcher
room table, hitting his head. These events further
was not to impose change, nor report safety challenges to a
encouraged her interest during the final in-person visit.
participant’s family. The degree of self-disclosure differed
Participant 1 engaged in nearly three hours of home safety
across clients.
discussion, primed by recent events. A level of trust with
Participant 1 was politely participatory during sessions. this participant had taken some time to establish, yet she
However, it was not until the third telehealth session that this ultimately experienced transformative learning because of
participant seemed to embrace the process of selecting and the telehealth presence of a clinician in her home.
staging a photo containing several salient elements. During
A positive example of building a relationship that
the concluding session, Participant 1 finally seemed
fostered self-disclosure was found with married Participants
comfortable sharing her mistakes and offered the following
3 and 4. This couple participated together and seemed to
narrative, prompted by the Figure 2 photo:
share the learning, planning, and the decision-making
You know what I did this weekend—just three days related to home safety. Their rich narratives were therefore
ago? I was taking hot food over to my daughter’s, we therapeutically productive.
were serving a Chinese meal and we wanted everything
While Participant 5 was friendly, she was more reticent
good fresh and hot, so I was putting everything in my
to self-disclose content. She discussed topics she was
cooler, and I had my hot food in there and I put a rice
familiar with–but admittedly would likely do nothing about.
bag in the microwave for three minutes because I
She photographed throw rugs, and indicated that she knew

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they were a trip hazard, but she was keeping them. This Table 1. SAFER-HOME, v. 3 Results
resistance to change included her beer drinking, which she
indicated she had no intention of changing. Participant 5 Initial Final Change
was very adept in steering the direction of a conversation, Visit Visit
and deflected questions that asked her to reason about her Participant 1 14 6 -8
drinking. She used humor to frame a discussion on driving Participant 2 4 3 -1
in Atlanta traffic to visit family. However, as the story
Participants 3 and 4 11 8 -3
unfolded it became clear that when and where she would be
able to get off the road and enjoy “some suds” was an Participant 5 9 6 -3
underlying part of the travel plan:
Participant 6 4 4 0
We had discussed going a ways and stopping and
spending the night, but it’s like I said, who wants to stop Note. Negative scores indicate fewer home safety issues.
at two o’clock in the afternoon. Unless we could just
leave home later in the day and get in there about five
PHOTOGRAPH USE
o’clock, the traffic through Chattanooga is not bad.
Even Nashville doesn’t bother me so we could get in The process of photo elicited narrative learning made
there kind of late, five or six o’clock in the afternoon and an impact on these participants in that it focused their
then walk around. ‘Cause when I get out of the car I reflection on past safety experiences. The use of the photos
like to walk around anyway, stretch my legs and then, and the stories that the participants shared seem to
have myself go back, and have a couple of beers, and personalize the topic and provide a foundation for future
then go eat supper. Well by then it’s eight or nine planning. Rather than looking at a pamphlet with
o’clock and I’m ready to relax. (Session three) instructions on how to make a home safer, photos created
While it is possible that Participant 5’s effort to control by the participant made the experience more applicable to
the flow of discussion was related to the quality of the them and, therefore, a more “authentic learning” experience
rapport, it is possible that she was trying to avoid the (Ravitch, 2010, p. 23). Past experiences captured in the
transformative experience that narrative learning, through photo meant that all of the items addressed were issues that
reflection, could achieve. were relevant because they were events from the
participants’ lives. However, the concept of digital
photography in support of narrative learning as a way to
focus reflection was a different experience for each
OUTCOME MEASURE participant. A greater depth of discussion seemed to
accompany a more abstract or sometimes staged photo,
Improvements in SAFER-HOME v. 3 scores, although and a more concrete photo seemed to be associated with
slight, occurred for five of six participants in this study. participants who simply wanted recommendations on a topic
Because of the small sample, it is not possible to draw that had challenged them in the past.
specific cause and effect relationships between the photo-
elicited narratives and changes in the overall SAFER-
HOME, v. 3 Assessment. While the SAFER-HOME, v. 3 ABSTRACT VERSUS CONCRETE PHOTOS
remains a good choice for this type of comparison, this
Participants needed an example to focus their photos
research project is exploratory in nature and the data
on a specific topic or area, such as kitchen safety. For
indicating that this process contributes to a safer
some participants this additional prompting was not
environment is found only in descriptive subsections of this
adequate, and they needed specific examples. For
assessment tool. In some cases, SAFER scores on specific
example, if a participant wanted to discuss a time when they
line items did not improve after greater understanding of
fell, the researcher suggested they should try to take a
how an individual participant functioned within their space.
picture of the area, or set up something in the photo that
This occurred with Participant 1 during the initial session
would remind them about the experience.
when it was noted that the bathtub had a non-skid surface
and grab bar. A discussion on her bathing preferences and Examples of abstract and concrete photographs are
a past fall, combined with her resistance to consider found in Figure 3. Participants 3 and 4 were the most
changes, indicated she was less safe in that category, enthusiastic and seemed to embrace the abstract use of a
resulting in a poorer score. photograph. Other participants, at some point, were
challenged to know what to include and sought out the
This assessment tool determined whether individuals
researcher’s ideas. Participant 6, stated during the second
were making use of their learning in a functional way. Most
session: “I don’t know what we will talk about—I’m really just
participants, as indicated in Table 1 below, showed slight
a couch potato” and “Well I looked over the house and I
improvements often attributed to reducing clutter that
couldn’t find anything I thought that was a real problem,
allowed for a wider pathway or reducing trip hazards.
except what I call, those little choke points that you might
have a problem getting through.”

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Figure 3. The more abstract photo on the left was staged recalling a time when stepping on a fallen walnut led to a twisted
ankle. On the right is a more concrete photo, showing an uneven concrete surface as a trip hazard.

Participant 5 struggled with the abstract nature of the Participant 5 seemed to maintain a focus throughout
photo assignment: that she was part of the study to help out the researcher,
and would do whatever was needed. This helpful
Participant 5: A picture of something—well, that’s going
perspective seemed to limit her ability to reflect and learn
to be—I’ve had a driving challenge before and, in
from her experiences.
several ways.
Participant 6 seemed to see his role as the family’s
Researcher: Okay.
problem solver. Each time he and his wife experienced a
Participant 5: I’m not sure, I’m not sure I can send you safety problem, he sought out advice and implemented a
a picture of like ice on the road. change. This process worked well for Participant 6 and his
wife, so he was less inclined to dive deeper into a reflective
Researcher: Okay. experience and tie the past safety issues to potential future
Participant 5: I don’t know how I’m going to send you a issues. He perceived the problem to be fixed after changes
picture of that. were made.

Researcher: Well, you don’t have to, just something

that reminds us, something to get us talking.
Participant 5: I could send you a picture of my car and
that would get us talking.
DISCUSSION
Current findings were examined in light of existing
Researcher: Okay. Whatever inspires you.
literature on older adults and the use of technology, and
Participant 5: Would that be okay? building rapport; using photography as part of narrative
learning with abstract versus concrete learners; and
Researcher: That would be fine. It’s up to you.
collaborative cognition. Study limitations as well as
(Session two)
recommendations for occupational therapy practice via
This exchange led to a very concrete photo of Participant 5’s telehealth follow.
car parked in her garage seen below in Figure 4.

TECHNOLOGY
Findings in this study indicate that older adults were
quite comfortable with the use of technology. Broady, Chan,
and Caputi (2010) examined existing literature related to
attitudes and abilities with computers and essentially found
that the attitude and experiences of young and old are
similar, countering the popular myths about older adults and
computer use. The authors identified several factors that
are likely to enhance an older person’s experience with
computers. These include allowing ample time for skill
mastery, treating the older adult user/learner in a positive
manner that makes them feel valued, and the teacher’s
expectation of success.
Figure 4. Participant 5’s car parked in the garage.

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 Werner, Carlson, Jordan-Marsh, and Clark (2011) PHOTOGRAPHS
examined some of the psychosocial characteristics and
coping skills of older adults who were and were not active No evidence was found in the literature of photo-elicited
computer users. These researchers stated: narrative learning directly influencing home safety.
However, Gidman (2013) wrote about the use of patient
Older adults who tend to be actively involved, rather storytelling to help student nurses understand their patients’
than withdrawn, were more likely to use computers. experiences. The author recommended that while student
Correspondingly, active coping approached significance nurses learn from the storytelling experience, it is up to
as an independent predictor of greater general educators to understand this educational process and build
computer use. These results may be indicative of a upon its value by facilitating student reflection. The findings,
dispositional proactive approach to challenges, such as as well as the improved SAFER-HOME, v. 3 scores, support
learning to use technology later in life. (pp. 442-443) the value of combining photographs and narrative. The
Werner et al.’s work (2011) is relevant to this study as reflection experienced while taking photos and then
the older adults who reported they were comfortable with discussing the stories behind the images was powerful. This
technology were also active and engaged with their families reflection supported changes in insight as well as
and other social circles, and participated in some form of environment.
work or study on a regular basis.
CONCRETE VS ABSTRACT
The example of a concrete photographs (Figures 3 and
RAPPORT 4) were considered through the lens of a study by Janzen,
The experience of this study suggests that the building Perry, and Edwards (2011) who stated, “Photovoice as an
of rapport in a telehealth setting to facilitate participant self- artistic pedagogical technology supports the existence of
disclosure, requires intentional effort and skill. Rogers authentic voice, fulfills the criteria of being an authentic
defines rapport as “positive, synchronous interactions that medium, and provides a channel for authentic statements”
reflect closeness or connectedness in a relationship” (2015, (p. 12). These researchers question the possibility of
p. 20). Tickle-Dengan and Rosenthal (1990) identified creating a “social presence” by projecting oneself in an
nonverbal behaviors as a key element in creating rapport. online educational experience. This social presence is
For instance, they identified “bodily postures” (p. 290) that important in developing cohesive collaborative communities
indicated attentiveness and positivity such as smiling and that facilitate unguarded communication (Garrison, 2007).
head nodding to be nonverbal behaviors that support Participants 5 and 6’s photographs, quite concrete in nature,
rapport. In this study, these mannerisms, required the did not open a door to relationship building and therefore did
therapist/researcher to focus their gaze on the web cam, not add a social presence to this educational experience—
rather than the image on the computer monitor. It was easy nor did they help facilitate an unguarded conversation.
to drift away from this view and look at the face of the Participant 6 took a photo because he was asked to, and
participant. This action, although repeatedly corrected, simply offered a “show and tell” type story with no
perhaps gave the participants the feeling that the therapist/ anticipation that he may derive future benefit from the
researcher was gazing down and not looking directly at experience.
them. Naufel and Beike (2009) examined abstract and
While rehabilitation therapists use therapeutic touch to concrete thought in terms of goal performance. They found
build rapport, a study by Morris Henegar, Khanin, Oberle that when individuals created concrete goals they focused
and Thacker (2014) indicates that touch is not always on how the goals were implemented; individuals who
perceived as intentional. These researchers examined the created abstract goals were focused on the reasons why the
use of touch by occupational therapy practitioners and found goals were implemented. Certainly the environmental nature
that 80% of all therapeutic touches given were “instrumental of home safety can be a concrete issue, and some
in nature,” and used with handling techniques rather than participants struggled to find an abstract way to explore this
the “expressive touch” which is more likely to build rapport topic. Creativity seemed to emerge when there was
and client self-esteem (2014, p. 140). Understanding that genuine curiosity about the subject.
human touch is a method of developing rapport, one must
recognize that it is often not intentionally developed within COLLABORATIVE COGNITION
in-person sessions in a therapeutic manner. It is important
to build rapport in both telehealth and in-person service Participants 3 and 4 had been married for many years
delivery. The use of video recording and post session and shared the telehealth experience. They provided a
reflection offers the practitioner an opportunity to improve unique view into what previous researchers described as
rapport-building skills in telehealth practice. collaborative cognition (Berg, Johnson, Meegan, & Strough,
2003; Dixon, 1996; Dixon & Gould, 1996). Strough, Cheng,
and Swenson (2002), regarding collaborative cognition,
stated, “solving problems with other people may allow older
adults to compensate for age-related declines in their
problem-solving ability and age successfully” (p. 26).

36 International Journal of Telerehabilitation • Vol. 8, No. 1 Spring 2016 • (10.5195/ijt.2016.6183)

 Within the telehealth sessions, Participants 3 and 4 high level of trust is necessary for full communication. This
discussed a variety of experiences, solutions, and even study found that despite expertise in the topic area, greater
friends’ experiences. They addressed more topics with effort was needed to develop a level of trust that may come
greater depth, than other participants. Mezirow (2000) more easily in an in-person setting. Understanding the
stated, “transformative learning is a way of problem solving subtleties of the online environment and how it influences
by defining a problem or redefining or reframing the rapport, client trust, and provider influence is important.
problem” (p. 19). He further stated, “we often become
critically reflective of our assumptions or those of others and
arrive at a transformative insight, but we need to justify our
new perspective through discourse” (Mezirow, 2000, p. 19). LIMITATIONS
The photo, the recollection of a past event, or possibly a A limitation of this study must include the homogeneity
focus on current environmental conditions, helps direct our of the participant group. Attempts were made to recruit from
attention to risk. Turning this attention into a narrative that a three different, more diverse participant pools with no
person owns and shares is supported by a constructivist responses. More intentional recruitment helped to obtain
approach to learning; the creator of the story becomes the participants, but those individuals offered a less diverse
expert. This process is inherently different from the didactic perspective. Possibly because of the focus on the use of
approach to educating patients that is common in health technology, individuals from lower socioeconomic
care, which encourages the patient to be the passive backgrounds may not have had the access to the resources
receiver of information not an expert in creating a safe needed to participate. As a result, the safety issues and
space. In occupational therapy the paradigm expressed in solutions addressed were more narrowly focused and the
Mary Reilly’s statement “Man through the use of his hands, ability to assess the impact of technology on the process
as they are energized by mind and will, can influence the was limited.
state of his own health” (Reilly, 1962, p. 2) continues to hold
meaning in this study. It was not through clinical advice that A second limitation stems from the challenges of
the participants came to understand safety challenges in technology. While technology often offers solutions for
their home, but through knowledge created with their many challenges, when it fails to work consistently in an
photographs and narratives. educational setting, the process of reflecting on
experiences, generating an understanding, and problem
solving can be compromised.
With a focus on narrative learning, guided by the unique
safety needs of very independent older adults, this research
CONCLUSION did not address all areas of the home, as many areas
The purpose of this study was to explore the experience offered no past safety challenge. While the SAFER-HOME,
of a home safety education program for older adults, v. 3 is a valued tool in the field of occupational therapy, the
grounded in narrative learning and delivered electronically focus of this experience was educational in nature, and did
using digital photographs via telehealth. This study also not deliver typical occupational therapy services. It is
contributes to the knowledge of how occupational therapists possible that had the sessions been more prescriptive, the
provide client education through telehealth. participants would have felt a greater obligation to make
changes in their home, resulting in a greater change in
scores. So while the SAFER-HOME, v. 3 is a reliable and
valid home safety measure in occupational therapy, it may
SUGGESTIONS FOR FUTURE not offer statistically significant change when the
intervention provided is solely education based, and
RESEARCH delivered to a well older adult population.
This study has the potential to spur other types of study A final limitation is that understanding narrative learning
on the topic of photo elicited narrative learning. Future was clouded by occupational therapy input. For example, in
research should focus on a more diverse population in terms addition to photos about past accidents, participants took
of race and socioeconomic status. Implementing photos of existing home modifications, and were offered
quantitative studies on the use of the SAFER-HOME, v. 3 concrete advice such as the proper placement of future grab
assessment, in a well, older adult population would be bars and strategies for safe driving. These issues seemed
beneficial. The descriptive qualities of this assessment were to be a natural evolution of the occupational therapist and
beneficial within the individual categories, but overall scores client discussions. Discussions about a photo did not begin
may be limited by a ceiling effect in an independent older with advice from the perspective of an occupational therapist
adult population. The need for a global, yet responsive (e.g., pick up your throw rugs so you don’t trip), yet when the
assessment in the area of home safety is important to narrative did not evolve toward an awareness of a safety
address given the focus on health maintenance in the problem, clients were offered specific, more prescriptive
Affordable Care Act and a growing older adult population. A advice before the session ended. The ethical obligation to
qualitative, grounded theory study focused on rapport in an the safety of the participants was of primary importance.
online, synchronous delivery model could be beneficial
across disciplines. A level of intimacy and privacy is
important for health care providers and their clients, and a

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