Harnessing insights from a community of practice to progress aphasia psychological care in Ireland: A mixed methods integration study informed by normalisation process theory

ABSTRACT

Background

A range of individual and systemic barriers to delivering psychological care to people living with aphasia are widely reported. An integrated model of care, stepped care, has been proposed. Integrated aphasia care constitutes a complex intervention that necessitates local adaptation and implementation. Whilst a need for better access to aphasia psychological care has been documented in Ireland; no coordinated approach has been developed or actioned.

Aims

To discern overarching principles for advancing the implementation of coordinated aphasia psychological care in Ireland by drawing on the perspectives of Speech and Language Therapists (SLTs), Occupational Therapists, and Clinical Psychologists.

Methods & Procedures

A convergent parallel mixed methods study comprising qualitative interviews with SLTs; a survey of interdisciplinary stroke professionals; and an integration by triangulation of the interview and survey findings. The implementation science framework Normalisation Process Theory was used as a lens to discern how clinicians make sense of, are enrolled in, and enact aphasia psychological care.

Outcomes & Results

Four SLTs were interviewed and there were 40 survey respondents. Empowering clinicians to deliver aphasia psychological care requires training, professional and emotional support, and clarity around the way that care is integrated across settings and disciplines. It is necessary to develop a shared interdisciplinary conceptualisation of such a pathway, and to leverage the apparent desire for change.

Conclusions

The findings address a lack of empirical knowledge about the ways in which clinicians might be supported to delivering integrated aphasia psychological care in Ireland. The study will inform ongoing research and has relevance for other jurisdictions.

KEYWORDS:

• aphasia
• stroke
• psychological care
• health services research
• implementation science

Introduction

Internationally, there is evidence from audits of stroke services and research with people with aphasia, Speech and Language Therapists (SLTs), and other stroke professionals, that people with aphasia experience barriers in accessing appropriate psychological care (Baker et al., 2021; Baker et al., 2017; Baker et al., 2019, 2020; Horgan et al., 2014; Manning et al., 2020; Manning et al., 2022; McElwaine et al., 2015; McElwaine et al., 2016; Northcott et al., 2017; Parr et al., 2006). This is highly salient given that people with stroke and aphasia are at greater risk of depression than people with stroke and no aphasia (Mitchell et al., 2017; Zanella et al., 2023).

SLTs have identified a need for clarity on their role in delivering psychological care, as well as for professional support, mentorship, and training opportunities (Baker et al., 2021; Manning et al., 2023; Northcott et al., 2017; Sekhon et al., 2015). Across countries with quite different health and social service configurations like Ireland, United Kingdom (UK), and Australia, SLTs perceive similar service-level shortcomings with resourcing; leadership and management support; coordinated care across disciplines and settings; and access to mental health professionals, including those with specific aphasia knowledge and skills (Baker et al., 2021; Manning et al., 2023; Northcott et al., 2017; Sekhon et al., 2015). This recurring pattern of similar individual and service level barriers suggests a need for an integrated approach to delivering aphasia psychological care.

Integrated care consists of coordinated pathways of health and social care, ideally community-based, that target improved health-related quality of life and personally meaningful outcomes for people with chronic conditions like stroke (Health Service Executive, 2017; World Health Organisation, 2016; World Health Organisation (WHO), 2002). In mental healthcare, the stepped psychological care framework, specifies how interdisciplinary care should be coordinated or integrated to match the right level of care to a person’s needs in a timely manner. For example, different levels of care might be appropriate including low intensity primary care and high intensity, specialised psychology input (National Institute for Health and Care Excellence (NICE), 2018). Originally developed in the UK, stepped psychological care has been adapted and implemented to suit local contexts in diverse settings like Ireland, France, The Netherlands, Nigeria, and Vietnam (Do et al., 2022; Gandré et al., 2019; Gureje et al., 2019; National Institute for Health and Care Excellence, 2016; National Institute for Health and Care Excellence (NICE), 2018; Oosterbaan et al., 2013; Richards et al., 2012; Twomey & Byrne, 2012). Whilst equivocal, there is some evidence for the cost and clinical effectiveness of reconfiguring mental healthcare, a finite resource, so that the intensity of input may be stepped up or down according to patient need (Ho et al., 2016; Oosterbaan et al., 2013).

More recently, adapted stepped psychological care principles have been proposed and examined for stroke and post-stroke aphasia (Baker, 2018; Kneebone, 2016). The intensity and specialism of input range from universal and low level care, including from SLTs, for example through communication therapy, psychosocial support, specific interventions and mental health screening (Baker, 2018). For those who need it, onward referral to mental health professionals like psychologists and psychiatrists ensures more specialised and intensive input in appropriate care settings (Baker, 2018).

Rather than being a linear pathway of increasing therapeutic input, stepped psychological care entails joint working arrangements and connected pathways of care across SLTs and other disciplines, like Clinical Psychology. Such interdisciplinary coordination may facilitate SLTs to deliver psychosocial support with clarity around their professional scope of practice, with access to more specialised advice and opportunities for onward referral, as needed. Conversely, it provides opportunities for other mental health professionals to avail of aphasia communication training and other support from SLTs. A lack of aphasia knowledge and communication skills among health professionals is perceived by SLTs and people with aphasia as a barrier to accessing aphasia psychological care (Manning et al., 2020; Northcott & Hilari, 2018). It is also experienced as disempowering by people with aphasia (Manning et al., 2019).

Spanning multiple disciplines and care settings, integrated and coordinated aphasia psychological care constitutes a complex intervention: one which ideally is adapted, refined and implemented locally in partnership with stakeholders affected by, and/or delivering, that intervention (Skivington et al., 2021). This requires a deep understanding of the local context, and the barriers and levers to implementing the intervention. Such considerations are at the heart of implementation science frameworks like Normalisation Process Theory (NPT). NPT has been extensively applied across multiple research designs to understand the context, mechanisms and outcomes of translating an intervention into routine ‘work’ or practice (May et al., 2022). It draws on robust implementation theory to generate a deep understanding of the mechanisms and processes necessary for an intervention to be successfully embraced, enacted, and embedded.

The four core NPT constructs are Coherence, Cognitive Participation, Collective Action, and Reflexive Monitoring. Coherence is how people make sense of the ‘work’ of carrying out an intervention. This entails being able to differentiate an intervention from the default ways of working; having an individual or shared, communal specification or understanding about the purpose of an intervention; and internalising understanding its relevance. Cognitive Participation is how people join in with and support the work of the intervention. It entails initiating and being enrolled in the work of the intervention; legitimating it as part of routine work and roles; and activating people to have continued support for it. Collective Action is how people collectively enact, and are supported to enact, the routine work of the intervention. It captures the way people do the work required (interactional workability); and the extent they have confidence in both each other (relational integration) and in the appropriate allocation of tasks (skill-set workability). It also entails contextual integration or organisational and system-level support for an intervention. Finally, Reflexive Monitoring is how people collectively appraise interventions (May et al., 2022). These are summarised in table 1.

Table 1. Normalisation Process Theory constructs and Aphasia Psychological Care (APC)

Construct	Explanation and sub-constructs	Operationalisation in this study
Coherence	Differentiating the intervention from usual ways of working. Individual and/or shared understanding about the purpose of an intervention (individual specification and communal specification, respectively. Perceiving the intervention to have value for their work (internalising).	How do clinicians make sense of APC?
Cognitive participation	Initiating; being enrolled or joining in with an intervention. Legitimating, activating, or having continued support for, an intervention	How do clinicians value and legitimise APC?
Collective action	How people do the work required (interactional workability). People’s confidence in one another (relational integration) and confidence that tasks are being allocated appropriately (skill-set workability). Contextual integration or organisational and system-level support for an intervention.	How do clinicians enact, or are enabled to enact APC into their routine work?

In this study, we used NPT as a lens to understand how interdisciplinary clinicians signed up to an Irish-based online community of practice, Supporting Emotions with Aphasia (SEA), make sense of and enact, or are enabled to enact, aphasia psychological care. However, given that coordinated aphasia psychological care is not routinely embedded in Ireland, we focused only on the first three of the NPT constructs, which are summarised in table 1. SEA was established in 2021 by Irish Association of Speech and Language Therapists (IASLT). The first and third author established and lead SEA. Its purpose was to address a need for training, interdisciplinary dialogue, and learning as part of working towards a model of coordinated interdisciplinary aphasia psychological care. The initiative had been influenced by literature highlighting the potential benefits of such interdisciplinary communities enhancing knowledge, collaboration, implementation, and complex problem solving (Greville et al., 2023; Shaw et al., 2022). The initial membership included mainly SLTs, occupational therapists (OTs), and clinical psychologists and neuropsychologists (PSYs). A series of webinars and training opportunities were funded by the Health and Social Care Professionals Office of the Health Service Executive or HSE (Irish health service).

The objectives of this study were to (1) understand the perspectives of SLTs that had undertaken aphasia counselling training towards aphasia emotional support delivery; (2) examine the views of interdisciplinary clinicians towards SEA and aphasia psychological care implementation; and (3) to discern overarching principles for advancing the implementation of coordinated aphasia psychological care in Ireland.

Materials and Methods

The design was convergent parallel mixed methods incorporating qualitative interviews (study 1); a cross-sectional survey (study 2); and integration by triangulation of the interview and survey findings (study 3 (O’Cathain et al., 2010). Survey and interview data were collected concurrently in April and May 2022; all participants were members of SEA. Study 1 examined the perspectives of SLTs on delivering emotional support to people with aphasia having attended a short counselling training course. Study 2 probed perspectives of interdisciplinary SEA members towards aphasia psychological care and the SEA community of practice. Study 3 aimed to integrate the findings of studies 1 and 2 to obtain overarching principles for advancing aphasia psychological care implementation in Ireland. The Research Ethics Committee of the Faculty of Education and Health Sciences University of Limerick approved the study (2021_12_19_EHS).

Study 1: Interviews

All SLTs that attended had a two-day creative counselling course delivered through IASLT and SEA were invited to participate. Study information was circulated via an IASLT email and interested parties contacted the researchers directly. Informed consent was confirmed by email in advance. Participants were four female SLTs working with people with aphasia in acute, rehabilitation and/or primary care settings in Ireland. A topic guide was developed and piloted to probe perspectives on delivering aphasia psychological support. It included questions relating to delivering emotional support to people with aphasia including current work practices, the impact of attending training, further support required, team structures, and perspectives on aphasia services. See Supplementary Materials.

The second author led data collection and analysis processes in consultation with other authors. Interviews were conducted on Zoom in April and May 2022 and averaged 30 minutes (range 25-35). Recordings were pseudo-anonymised, transcribed and deleted. As a starting point, we applied a flexible deductive coding approach (Fletcher, 2017) using a detailed NPT codebook underpinning the three constructs in table 1 (May et al., 2022). This framework involved several ‘rounds’ of coding and critical discussion between authors to ensure that data were comprehensively matched with NPT constructs in such a way that did not diminish the original meaning.

Study 2: Survey

We used the Normalisation Measure Development questionnaire (NoMAD) as a starting point (Finch et al., 2015). This is a set of validated questions aligned with the NPT constructs that can be used to measure the perspectives of health professionals involved in carrying out or implementing health interventions. We specified the name of the intervention as “aphasia psychological support” in the initial orientating questions, and as “SEA community of practice” in later sections. The purpose was to understand how interdisciplinary SEA members perceived the value of the community of practice for progressing aphasia psychological support and for providing opportunities for new ways of working, and their beliefs around the status of aphasia psychological care implementation in Ireland. We excluded some questions aligned with the construct Reflexive Monitoring as well as those less salient to SEA membership (e.g., management support). We additionally included some extension questions that probed the types of informational, training, support, research and/or networking opportunities that they would like SEA to deliver in future. We refined the instrument after piloting with an SLT colleague. The final questionnaire was administered on Qualtrics and contained 19 questions, including multiple choice, open response, and sliding scales. These were presented over four screens. See Supplementary Materials for questions aligned with each NPT construct (Finch et al., 2018).

Convenience sampling informed recruitment. All qualified professionals that had opted in for further contact relating to SEA were invited to participate. Prior attendance at SEA training or webinars was not a requirement. An email was circulated via the SEA mailing list attaching study information and an anonymised weblink. Data were collected over a 7-week period between April and May 2022; two email reminders were circulated. Data were downloaded from Qualtrics and transferred to Excel for descriptive statistical analysis. Open-ended responses were analysed numerically where possible, for example, if the response matched with a pre-existing multiple-choice option that had not been selected. Otherwise, open-ended responses were grouped according to similar content and described narratively alongside quantitative data.

Study 3: Integration

The findings of the interview and survey studies were integrated to generate preliminary recommendations for implementing coordinated aphasia psychological care in Ireland using the Triangulation protocol (O’Cathain et al., 2010). This process was led by the first author in consultation with the other authors. Findings were extracted and summarised according to the NPT headings and operationalisation in table 1 (How do clinicians make sense of aphasia psychological care (APC)? How do clinicians value and legitimise APC? How do clinicians enact or are enabled to enact APC into their routine work?). Per protocol, the data were examined for completeness (i.e., that all elements of both data sources had been accounted for and considered). The extent to which data sources were aligned (convergence) and/or conflicted (divergence) was coded to indicate full or partial agreement (and/or dissonance) both in terms of meaning and prominence. Methodological silence was recorded when one data source only contributed to a finding (e.g., the finding relating to SLTs experiencing burn-out was not captured for methodological reasons with the interdisciplinary clinician group). At this point, it was possible to appraise synergies across both sets of findings in terms of scope, nature, and coverage. Then the implications for progressing coordinated aphasia psychological care were generated inductively, informed by the overall summary of triangulated data.

Results

Study 1: Interviews

We generated three overarching themes. (1) Legitimation highlighted how participants believed supporting emotions to be a legitimate part of SLT practice for several reasons including a perceived prevalence of mood disorders among people with aphasia and the potential impact of low mood on engaging in SLT.

[P02] “I feel like obviously a massive part of our role is to support emotions in aphasia”.

[P01] “All my patients were crying when they were coming to sessions and it still happens you know I have an awful lot of tears … ”

[P01] “ … everybody was in .. very low mood, it was very hard to engage people in therapy and people were going home without having made any gains because the mood was such a problematic thing”.

They acknowledged their role in supporting conversations about wellbeing and mood; but all perceived a need for further clarity around the professional scope of practice.

[P04] “We have a really good opportunity to help people mind their wellbeing … so I do think it’s part of our role … language supports so much discussion about wellbeing”.

[P02] “I’m very aware of boundaries and what’s my role as well … we do have a lot of skills … that overlaps with counselling, but you have to be really careful of your role … and if you’re allowed to counsel”.

(2) Skill-set workability reflected how participants felt insufficiently equipped and skilled to delivering counselling support. When available, caseload demands often prevented participants from attending training.

[P02] “We get loads of opportunities through the HSE that we don’t have avail of or we cancel out of our diaries around, stress management and all of that because like the clients come first”.

In absence of upskilling opportunities, some drew on personal counselling experiences and/or sought training in their own time.

[P03] “I felt was I relying on personal skills more than my professional training background … I’ve been seeking out professional training in this area of emotional support … I had to do some extra training to safeguard myself.”

All reported increased confidence after attending an aphasia counselling course. For some, it had validated their role in delivering a ‘low level’ of psychological care and was practical.

[P04] “It’s definitely one of the courses that I’ve done that I feel like I have used the most from”.

[P02] “It’s ok if you don’t know why the person is stressed but just acknowledging and I see your stressed like that’s essentially all they need”.

(3) Contextual integration illustrated how all participants identified a need for professional clinical support and for acknowledgement that SLTs need to maintain their own wellbeing when delivering emotional support.

[P03] “I definitely see a huge gaping hole in terms of the emotions supports professionally … we’re not trained to provide those to one another … supervision is all very … clinical governance … It has never been acknowledged … that you might need to look after yourself emotionally … to do your job … you will burnout if you’re not in a good mental headspace yourself”.

All felt strongly that aphasia psychological support is necessarily interdisciplinary. Burn-out was exacerbated by their experiences of being unable to refer onto or collaborate with appropriate interdisciplinary professionals.

[P04] “There’s no … OT, there’s no psychologist so it’s really poor in terms of professionals”.

[P01] “There’s very little support, I can’t tell you the last person or time someone got psychology”.

[P03] “There is no service that I’m aware of nationally or locally here that would be able to provide counselling or formal structured, psychological support for people with moderate to severe an acquired communication difficulties”.

[P02] “I’m … particularly aware of what I mentally take on or what I offer”.

This was linked with under diagnosis and mental health treatment for their clients, additionally compounded for those with aphasia. Some perceived an over-prioritisation of physical over psychological impairment.

[P01] “I have a patient; I think she is very depressed … it can be very hard to get a doctor to even say that to and then to get follow on is almost impossible”.

[P03] “I know we pretend that mental health is just as important as physical but in a very stretched HSE service it just isn’t”.

A lack of recognition of the wider role of OTs in mental healthcare was also identified.

[P02] “OT have a longstanding role in mental health, more than we do.

Study 2: Survey

Forty datasets were included. This corresponded to a response rate of 20% based on SEA membership of 196 at time of survey. Completion rate was 88%. Most were SLTs (65%), PSYs (15%), OTs (10%). Other respondents included two cognitive rehabilitation instructors, one Social Worker, and one stroke group coordinator. Most worked in primary care/community (40%), inpatient rehabilitation (28%) and acute/sub-acute hospitals (20%). One quarter worked across multiple settings. See Table 2.

Table 2. Survey participant characteristics

Summary of responses
Total consented	44
Total eligible	40
Total datasets ab	40
Completion rate	88%
Professional role: n (%)
SLT	26 (65)
PSY	6 (15)
OT	4 (10)
Other	4 (10)
Work setting(s): n (%)
Primary Care/Community	16 (40)
Inpatient rehabilitation	11 (28)
Acute/sub-acute hospital	8 (20)
Inpatient stroke unit	7 (18)
Early Supported Discharge	5 (13)
3^rd sector support organisation	4 (10)
University	4 (10)
Outpatient rehabilitation	2 (5)
Residential care	1 (3)
Works in multiple settings	10 (25)

Coherence on coordinated aphasia psychological care

Respondents varied in their familiarity with the concept of coordinated aphasia psychological care. For just over one third, it was very familiar (n=14, 37%); and for just under a third, it felt very new (n=12, 31.5%). Less than half believed that coordinated aphasia psychological care was not at all part of their current work; however, 87% believed it would become part of routine work to some extent.

Cognitive Participation

All respondents strongly agreed that they were open to working with colleagues in new ways as part of SEA. All respondents saw the potential value of its activities for their work. Most strongly agreed that participating in SEA was a legitimate part of their role (n=32, 89%), and that they would continue to support it (n=34; 94%). Most believed that key people would drive the community forward and get others involved (n=34; 92%).

Collective Action

Most agreed that they could easily integrate being part of the community into their existing work schedules. Most were interested in online training (86%), self-directed learning opportunities (e.g., access to recorded events, talks and training materials) (84%), seminars/webinars (84%), and workshops/practical hands-on sessions (73%). Most wanted to hear from people living with aphasia (84%) and case presentations (81%). Over half wanted mentoring and peer support within their discipline (51%). Most participants wanted to hear from other disciplines (70%) and over half wanted interdisciplinary mentoring opportunities (59%).

However, most identified other work and time commitments (n=31, 84%) as barriers to taking up SEA opportunities. Over half reported travel or geographical barriers (n=22, 59%). Just over 10% identified a range of additional barriers, including resourcing and staffing, and reduced technology/internet access.

Study 3: Integration

A summary of the data extraction and convergence and completeness assessment is in table 3. Through the triangulation process, we generated several overarching implications for aphasia psychological care implementation in Ireland that are underpinned by NPT. First, although they do not believe it to be currently practiced, interdisciplinary clinicians are positive about the potential for future aphasia psychological care implementation and agree that it is a legitimate part of their role. Second, we need to ensure clear, consistent, and coherent conceptualisation of integrated aphasia psychological care within, and across health disciplines. Third, interdisciplinary clinicians want and need aphasia psychological care-relevant training and to hear other perspectives. However, geographical, financial and time/caseload barriers to attending training must be addressed. Many clinicians prefer online formats, however not all have sufficient access to technology. Fourth, interdisciplinary clinicians may value opportunities for interdisciplinary support and mentorship as part of aphasia psychological care delivery. Finally, SLTs have specific needs including for clarity on their professional scope of practice in relation to aphasia psychological care; and for professional emotional support to enable them to deliver aphasia psychological care whilst safeguarding their own wellbeing.

Table 3. Summary of integration by triangulation process

	Interviews	Survey	Convergence and completeness
Coherence How do clinicians make sense of APC?	Interview participants were not asked about their familiarity with APC.	Survey participants did not consistently have a clear understanding of the concept of APC (about 1/3 ‘very familiar’; another 1/3 ‘somewhat so’). Less than half felt that APC was part of their current work. However, most were positive around the possibility of APC being part of their future work.	Methodological silence from interview findings. APC implications were generated from survey data only.
Cognitive participation How do clinicians value and legitimise APC?	All participants believed that delivering emotional support was a legitimate part of the SLT role; but identified a need for further clarity around professional scope of practice.	All participants were open to working with colleagues in new ways. Most believed that their SEA involvement was a legitimate part of their role and confirmed their continued support for it.	Partial agreement. Overall, both sets of findings were complementary despite differences in scope and focus. (Interdisciplinary, though predominantly SLT) survey participants were asked questions about the SEA Community of Practice. Interview participants, all SLTs, were asked about supporting emotions with aphasia as part of APC delivery.
Collective action How do clinicians enact or are enabled to enact APC into their routine work?	Participants discerned a need for professional training opportunities and emotional support. Organisational barriers, including lack of access to interdisciplinary colleagues for themselves and their patients, were identified and perceived to exacerbate risk of burn-out.	Most participants were interested in a range of training, support, and networking activities as part of SEA. In the main, they wanted insights into the lived experience of aphasia; case presentations; and opportunities for within- and inter-disciplinary support and mentorship. Organisational, geographical, and technological barriers to partaking in SEA activities were additionally identified.	Partial agreement. Overall, both sets of findings were complementary despite differences in scope and focus, including differences in participant composition. Both datasets complemented one another in highlighting a need for within-discipline support and mentorship. Methodologically, there was silence from survey participants regarding need for professional emotional support and debriefing structures.

Discussion

In this mixed methods study, we integrated the empirical findings of qualitative interviews with SLTs and a cross-sectional survey of interdisciplinary members of a community of practice interested in supporting the psychological wellbeing of people with aphasia. All elements of research design and analysis were informed by key constructs of NPT, which facilitated a theoretically informed understanding of local contextual factors and implications for progressing an integrated framework for aphasia psychological care in Ireland. First, improved Coherence about integrated aphasia psychological care across interdisciplinary professionals is necessary. This is somewhat unsurprising given that such a model is not currently in operation in Ireland. It complements qualitative research by Baker and colleagues highlighting a need to address a lack of clarity around stepped care among stroke professionals in Australia (Baker et al., 2021). SLTs may need clarity around their role in relation to delivering psychological support. Similar concerns have been explored through qualitative interviews with SLTs in the UK (Northcott et al., 2018); and micro-analysis of therapy sessions in the United States (Simmons-Mackie & Damico, 2014). Second, for Cognitive Participation, we discerned that many SLTs, OTs, and PSYs working with people with aphasia in Ireland were positive about the potential for, and perceived a need for, change in relation to coordinated aphasia psychological care. Furthermore, they viewed their membership of an interdisciplinary community of practice focusing on aphasia psychological care as a legitimate part of their role and are invested in interprofessional collaboration and hearing other perspectives. Although it is important to note that all participants were likely highly interested and invested in improving aphasia psychological care, these are interesting and novel implementation levers that have not been documented previously. This investment and legitimisation suggests a potential window of opportunity for change that mirrors recent recognition of the relatively higher risk of psychological problems for people with post-stroke aphasia in the Irish National Stroke Strategy 2022 – 2027 (Health Service Executive (HSE), 2022). Third, in relation to Collective Action, across all disciplines, aphasia professionals wanted training and learning opportunities in relation to delivering aphasia psychological care. This finding has been documented in previous reports from the UK, Ireland, United States, and Australia (Baker et al., 2019; Manning et al., 2023; Northcott et al., 2017; Northcott et al., 2018; Rose et al., 2014; Sekhon et al., 2015; Sekhon et al., 2019; Simmons-Mackie & Damico, 2014). However, there was a perceived need to overcome service-level access barriers to leveraging such opportunities; and although online, blended formats might help, internet access was not available to everyone. Finally, in keeping with prior research, the SLTs specifically identified a need for maintaining their own wellbeing, particularly in the context of service-level capacity issues and fragmented pathways of mental healthcare. This extends previous research highlighting the burden and pressure experienced by SLTs in supporting the psychological wellbeing of people with aphasia in the absence of appropriate training and in under-resourced healthcare contexts (Rose et al., 2014).

Methodological critique

This research incorporated qualitative interviews, and a survey, and a final integration of both sets of findings. The design permitted the examination of issues to do with implementing integrated aphasia care in Ireland using different methods and with different participant sources. Within the research paradigm of Critical Realism (Bhaskar, 2016), this is a methodological strength that helps mitigate both inevitable pitfalls inherent to any research method, and the impossibility of capturing all perspectives on a particular topic. A second strength was the use of NPT to inform the design, analysis, and integration of the studies. This permitted a theoretically informed understanding of the potential levers and barriers that must be considered when designing and implementing integrated aphasia psychological care in Ireland. For example, there is a need to develop a shared understanding of coordinated care that requires input across all relevant stakeholders; there is an apparent desire and appetite for change; and interventions like training, interdisciplinary working, and a defined pathway of care must be implemented to affect change and support clinicians to enact psychological support.

There are several important limitations, however. These were studies with a low number of participants; four for the interview study and 40 for the survey. This had implications for the richness and representativeness of findings. The small sample size, particularly interviews, meant that the final integration by triangulation demonstrated methodological silence on themes like understanding coordinated aphasia care. Therefore, some conclusions are drawn from the survey findings only. Furthermore, this low number of participants were arguably highly interested and invested in improving aphasia psychological care delivery in Ireland. They had been recruited from a small convenience sample of SLTs that completed counselling training, and from a relatively small convenience sample of members of an interdisciplinary community of practice in Ireland, respectively. This reflects an inherent sampling bias, and therefore it is not possible to claim that the findings and conclusions are representative of the wider stroke professional community in Ireland. Another important limitation is that the component studies did not examine identical phenomena. Rather experiences of counselling training and delivering emotional support were used as a proxy for perspectives on integrated aphasia psychological care in the interviews; and survey respondents were mostly asked about their experiences of, and preferences for, the SEA community of practice. Therefore, the findings of the integration were mostly in partial agreement only; with differences in scope, prominence and focus for each conclusion drawn. This reduced the potential for understanding nuanced diverging and converging insights, and therefore decreases the richness and value of the overall analysis (Campbell et al., 2018).

Conclusions

The findings address a lack of empirical knowledge, using an implementation science lens, about the ways in which clinicians might be supported in delivering psychological care in the context of aphasia in Ireland. It is necessary to involve stakeholders in developing a shared understanding and in the design of a coordinated pathway of care, and to harness an apparent consensus around the need for change. Empowering clinicians to deliver aphasia psychological care requires training, professional and emotional support, access to clinical supervision, and clarity around the way that care is integrated across settings and disciplines. The study will inform ongoing participatory implementation work through methodological analysis and stakeholder evaluation of their involvement. Due to the commonalities in access barriers, the findings will have relevance for similar initiatives in other jurisdictions.

Declaration of interest statement

The authors report there are no competing interests to declare.

Acknowledgements

The authors sincerely thank everyone that took part in the interviews, and survey. We are also very grateful to the Irish Association of Speech and Language Therapists for support with circulating the invitation to participate.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/02687038.2023.2224516

Data availability statement

No further data are available in keeping with research ethics requirements.

Additional information

Funding

This work was supported by Seed funding from the Faculty of Education and Health Sciences, University of Limerick, awarded to Dr Molly Manning in 2021. This funding supported the work of Mia Hanrahan as Research Assistant.