Developing consensus-based clinical competencies to guide stroke clinicians in the implementation of psychological care in aphasia rehabilitation

Introduction

People with aphasia after stroke experience depression and anxiety and a range of associated negative outcomes that persist over time (Zanella et al. 2023; Morris et al. 2017). On this basis, it is vital for clinicians to be competent and confident to deliver low-intensity psychotherapeutic interventions, such as mood screening, counselling, behavioural activation, problem solving and relaxation therapy (Thomas et al. 2013; Kneebone 2016; Visser et al. 2016; Golding et al. 2017; Wong et al. 2018; Thomas et al. 2019; Sekhon et al. 2022). There is, however, an evidence–practice gap in the consistent and sustained provision of low-intensity psychological care after stroke and aphasia. Further research into how to address this gap is a priority (Kristo and Mowll 2022).

There are many factors which contribute to the evidence–practice gap in psychological care after stroke and aphasia. The Theoretical Domains Framework (TDF) provides a lens through which to view and understand the influences on health-professional behaviour (Atkins et al. 2017). The TDF comprises 14 domains spanning: (1) knowledge; (2) skills; (3) social/professional role and identity; (4) beliefs about capabilities; (5) optimism; (6) beliefs about consequences; (7) reinforcement; (8) intentions; (9) goals; (10) memory, attention and decision processes; (11) environmental context and resources; (12) social influences; (13) emotion; and (14) behavioural regulation (Cane et al. 2012). Seminal work exploring barriers and facilitators to multi-disciplinary and psychological care for people with aphasia highlights that knowledge and skills domains are key influences in the successful delivery of psychological care after stroke and aphasia (Rose et al. 2014; Sekhon et al. 2015; Carragher et al. 2019; Baker et al. 2020; Sekhon et al. 2022). As such, the development of clinical competencies in ‘knowledge’ and ‘skill’ domains is critical to enhancing the translation of best evidence to practice.

Stroke clinicians require knowledge and skills to identify mood problems; provide psychological support and therapies; and triage to mental health specialists as required (Kneebone 2016; Baker et al. 2020). They also need the knowledge and skills to optimise communication support for people with aphasia (Foster et al. 2016; Carragher et al. 2020). Implementation of stepped psychological care, adapted for people with aphasia after stroke, offers a potential solution to address these requirements (Kneebone 2016). Stepped psychological care is an evidence-based framework to guide stroke clinicians in triaging the person with aphasia to one of four levels of increasing psychological treatment intensity, depending on symptom severity and level of care required (Kneebone 2016) (Fig. 1).

Fig. 1.

Stepped psychological care framework after stroke and aphasia (Kneebone 2016).

At level 1, mood screening can support the identification of depression and anxiety symptoms. Following mood screening, the person is matched to one of four intervention levels. Those with significant depression/anxiety require further assessment and can be matched to higher-intensity psychotherapeutic interventions at levels 2, 3 or 4 (e.g. specialist mental health care facilitated by clinical psychologist and/or medical practitioner). Those without significant depression/anxiety remain at level 1 for low-intensity psychotherapeutic interventions to prevent mood difficulties. Stroke clinicians (e.g. nurses, speech pathologists, psychologists, occupational therapists, social workers and medical practitioners) are well-positioned to deliver low-intensity psychotherapeutic interventions after stroke. Guidance to support the implementation of stepped psychological care in stroke and aphasia rehabilitation has been developed as part of clinical service improvement and guidelines (National Health Service Improvement 2011; Stroke Foundation 2023). However targets for competency development to facilitate low-intensity, level-1 psychotherapeutic interventions are needed to guide behaviour change in stroke clinicians.

Clinical competence refers to the judicious use and integration of knowledge, skills, values and attitudes for the delivery of a professional service (Fernandez et al. 2012; Fisher 2016). The development of a competency rating scale aims to influence behaviour change in domains 1 and 2 of the TDF – knowledge and skill acquisition. Competency rating scales, such as observer-rated and self-rated measures, can assist clinicians to develop proficiency in facilitating interventions in a consistent manner, gauge competency development and identify areas for professional growth. Observer-rated measures are commonly used when a highly experienced clinician observes a novice or less experienced clinician (McAllister et al. 2011). Self-rated measures prompt the clinician to reflect on their practice and can be used as a framework to facilitate discussions between them as the learner and their clinical supervisor (e.g. measuring self-efficacy in counselling, see Victorino and Hinkle 2019).

A clinical tool including both observer and self-rated items may benefit competency development and promote reflective practice in the delivery of psychotherapeutic interventions in post-stroke aphasia (Mann et al. 2009; McAllister et al. 2011; Caty et al. 2015). The initial development of competency items for a clinical tool requires contributions from key stakeholders, such as clinicians who will use the tool and people with aphasia. Consensus-based methodologies are appropriate to gain preliminary directions in competency item development and have been successfully used in areas of compassion-based therapy (Liddell et al. 2017), brief psychodynamic investigation therapy (Tadic et al. 2013), group-based rehabilitation interventions (Wong et al. 2019) and neuropsychological assessment feedback (Wong et al. 2024).

The aim of this study was to develop a consensus-based rating scale for clinical competencies in facilitating individual-based, low-intensity psychotherapeutic interventions for people with post-stroke aphasia.

Methods

Results

Discussion

This study reports the preliminary list of items in development of a clinical competency rating scale that can be used as a self-reflection and observer-rated tool for facilitating low-intensity, level-1 psychotherapeutic interventions for people with post-stroke aphasia. In accordance with the ‘knowledge’ and ‘skills’ domains of the TDF, this provisional competency rating scale has the potential to guide clinicians’ behaviour in practice and assist in the evaluation of training programs (‘Psychological Care in Aphasia Rehabilitation Competency Scale’, Supplemental file S9). It may also assist to identify and target the behaviours required to implement psychotherapeutic interventions in stroke and aphasia rehabilitation.

The development of knowledge, skills and confidence through training can address the barriers that clinicians face in supporting the psychological wellbeing of people with aphasia (Baker et al. 2010; Sekhonet al. 2015; Carragher et al. 2019; Bakeret al. 2020). A combined self-rated and observer-rated competency checklist aligns with concepts of assessment for learning and promotes collaboration between the clinician and observer (McAllister et al. 2011; Miles et al. 2016; Oyinloye and Imenda 2019). Winkelbauer (2020) also suggests that mutually engaging both the observer and the person being observed enhances the authenticity of competency-based assessments in the healthcare context.

Interestingly, this study highlights a contrast in perspectives of people with aphasia and stroke clinicians regarding ‘therapy structure’ versus flexibility in psychological care. Participants with aphasia highlighted the importance of providing structure to therapy sessions, whereas clinicians placed a larger emphasis on flexibility and adaptability in sessions. Competencies detailing a focus on maintaining structure within the round 1 survey did not reach consensus and were removed from the rating scale. This finding may reflect differences in understanding of therapy session ‘structure’. The clinicians may have perceived this as a rigid and manualised approach rather than the concept of having a therapy plan, adhering to the plan, tailoring level of difficulty/complexity of tasks, summarising the session and, if appropriate, setting in between session tasks. A value for structure by people with aphasia may reflect the need for consistency, clarity and routine due to the frequency of changes between settings and new speech pathologists (e.g. acute, inpatient, outpatient, rehabilitation, community setting). Previous research reflects the need for both structure and flexibility in stroke recovery for people with aphasia in the first 12 months (Grohn et al. 2014). Participants, in this current study, may have therefore seen a structured therapy approach with defined goals as conducive to progress.

Flexibility in rehabilitation aligns with a social model of care, which considers the interaction between a person’s personal, environmental, physical and societal factors (Elman 2016; World Health Organization 2001). To ensure some degree of structure, however, clear person-centred goals need to be set and inclusion of the person with aphasia in creating meaningful goals is needed (Worrall et al. 2011b; Worrall 2019). In this current study, goal setting and flexibility is addressed in both competency 6: ‘I can adapt therapy sessions based on personal factors of the person with aphasia’ and competency 14: ‘The clinician takes a person-centred approach to goal setting, encouraging the person to participate in identifying goals for intervention’.

Several notable findings were also derived from the e-Delphi survey process. The competencies within the subcategory ‘significant others’ (friend or family member) considerations’ were all deemed important but only one out of four were retained in the final rating scale following round 2. This was a surprising finding given the emphasis on the importance of addressing the needs of significant others highlighted across focus groups and in previous research evidence (Grawburg et al. 2013; Sekhon et al. 2019). This study concurs that including significant others’ psychological care is an important focus in stroke rehabilitation but the majority of relevant competency items did not gain adequate consensus. This could be due to a number of implementation barriers for clinicians such as time, caseload pressures and the fact that family members aren’t the primary patient or client receiving the stroke service. It could also be due to the lack of routine family-focused care. Regardless of the barriers, stroke clinicians can access clinical resources to support families, for example they can identify and measure life impacts for family members (Grawburg et al. 2019). It is also necessary for stroke clinicians to inform and advise family members of psychological care supports (e.g. review by general practitioner and/or psychologist, community or peer supports). Hence, competency 22 detailed advising significant others to consult their general practitioner to discuss their own mental health.

Interestingly, the expert panel of clinicians reported differences in terminology and concepts likely due to their differing professional backgrounds (i.e. speech pathologists and psychologists). For example, terms such as communication competence and person-centred care required clarification across e-Delphi rounds. This may have led to competency 10 almost not reaching consensus: ‘The clinician acknowledges the communication competence of people with aphasia’. It could be posited that communication competence may be one strategy to facilitate person-centred care for people with aphasia. Bright et al. (2018) describe how relationship-centred practice is established through client responsiveness. For people with a communication disability, supported communication, including acknowledgment of competence, demonstrates this responsiveness (Worrall 2011a; Brown et al. 2012), thus fostering therapeutic alliance. Hence, the competency rating scale includes both concepts (C.10–12, 14). The competency rating scale developed in this study offers a unique combination of competencies that are required to adapt psychotherapeutic interventions for people with aphasia.

In contrast, competencies relevant to psychotherapeutic interventions (e.g. cognitive behavioural therapy; compassion-focused therapy) for a neurotypical clinical population tend to primarily focus on skill development in the specific therapy approach, and general therapeutic alliance competencies such as creating trust and collaboration (Roth and Pilling 2008; Liddell et al. 2017). Such competency frameworks provide detail about the different types and levels of skill but assume adequate communication between therapist and client in largely ‘talk-based’ processes. This study has developed a competency rating scale that explicitly states items to guide clinician behaviour in using communication supports in post-stroke aphasia. This finding is also influenced by the representation of speech pathology participants with expertise in aphasia and communication support and access. The sample of people with aphasia lacked variability in aphasia severity. People with severe aphasia should be included in future research to explore their specific communication and psychological needs. The competency items (Supplemental file S9) reflect a person-centred care approach, where care can be adapted for a person with any type or severity of aphasia, social or cultural background. For example, items include consideration of: ‘person needs’ (item 5) ‘personalised communication support’ (items 7, 8, 11 and 12); and ‘personally tailored psychoeducation’ (item 13).

The clinician requires knowledge and skills to actively support the client’s communication in psychotherapeutic intervention sessions. For example, to ensure counselling is accessible, the clinician needs to support the person with aphasia to understand and talk using appropriate strategies (e.g. using key words, offering choices or using gestures to get the ‘message in’ and/or ‘message out’). Examples of studies that have adapted psychotherapeutic therapies for aphasia using communication supports and study-specific training and competency development for therapists are emerging in the research evidence. For example, these studies have developed training programs and competency development for therapists to implement: motivational interviewing for people with a range of communication problems in a stroke trial (Patel et al. 2018); and a brief solution-focused therapy for people with mild to severe aphasia (Northcott et al. 2021).

The preliminary list of items in the ‘Psychological Care in Aphasia Rehabilitation Competency scale’ (Supplemental file S9) has the potential to guide training in the foundations of psychological care in post-stroke aphasia. The self-rated items and observer-rated items promote reflective practice and highlight important aspects of care (e.g. mood screening, communication support) and clinician behaviours (e.g. interpersonal skills). In practice, clinicians may be guided in a supportive approach to achieve competence by a trusted and experienced supervisor (McAllister et al. 2011). Specific clinical simulations, role play or training opportunities may be explored for clinicians not deemed competent in particular items. Clinicians can improve knowledge and skills through training as evidenced in counselling education (Sekhon et al. 2022) and communication partner training (Simmons-Mackie et al. 2016). Online and in person training and resources are available to clinicians via various professional organisations (e.g. the Aphasia Institute, Canada: https://www.aphasia.ca/health-care-providers/education-training/training-programs-workshops/; and Better Conversations, UK: https://www.ucl.ac.uk/short-courses/search-courses/better-conversations-aphasia-e-learning-resource).

In this study, one new and essential competency was proposed by a clinician in round 2 of the e-Delphi survey process but it was not adopted due to a number of reasons. The suggested item was: ‘identifies concerns about the mental capacity of the person with aphasia to make specific decisions and provides or arranges for a capacity assessment as appropriate’. While evaluating a person with aphasia’s decision-making capacity is important, numerous complexities and issues regarding such assessments have been well-documented (Helm-Estabrooks 2002; Aldous et al. 2014). The assessment and impact of reduced mental capacity in the context of psychological care requires further research and possibly further consensus agreement.

Conclusion

A 19-item competency rating scale comprising self and observer-rated scales was developed as a preliminary list through consensus with key stakeholders, with representation from speech pathologists and psychologists. The resulting tool can be used to supplement clinician training in facilitating low-intensity psychological interventions for people with aphasia within the stepped psychological care framework.

Supplementary material

Supplementary material is available online.

Data availability

The data that support this study are available in the article and accompanying online supplementary material.

Conflicts of interest

The authors declare no conflicts of interest.

Declaration of funding

The study was funded by La Trobe University School of Allied Health Strategic Research Grant Scheme (2020). Sarah Wallace is supported by a National Health and Medical Research Council (NHMRC) Emerging Leadership Investigator Grant (1175821). Miranda Rose is supported by a National Health and Medical Research Council (NHMRC) Centre of Research Excellence (1153236).

Ethics standard

The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.