Aphasiology

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/paph20

Development of a tailored intervention to

implement an Intensive and Comprehensive
Aphasia Program (ICAP) into Australian health
services

Kirstine Shrubsole, David Copland, Annie Hill, Asaduzzaman Khan, Melissa

Lawrie, Denise A. O’Connor, Moya Pattie, Amy Rodriguez, Elizabeth C. Ward,
Linda Worrall & Marie-Pier McSween

To cite this article: Kirstine Shrubsole, David Copland, Annie Hill, Asaduzzaman Khan, Melissa
Lawrie, Denise A. O’Connor, Moya Pattie, Amy Rodriguez, Elizabeth C. Ward, Linda Worrall &
Marie-Pier McSween (2022): Development of a tailored intervention to implement an Intensive
and Comprehensive Aphasia Program (ICAP) into Australian health services, Aphasiology, DOI:
10.1080/02687038.2022.2095608

To link to this article: https://doi.org/10.1080/02687038.2022.2095608

Published online: 29 Jun 2022.

Submit your article to this journal

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=paph20
APHASIOLOGY
https://doi.org/10.1080/02687038.2022.2095608

Development of a tailored intervention to implement an

Intensive and Comprehensive Aphasia Program (ICAP) into
Australian health services
Kirstine Shrubsole a,b,c, David Copland a,b,d, Annie Hill a,b,e,f,
Asaduzzaman Khan b, Melissa Lawrie g,h, Denise A. O’Connor i, Moya Pattiej,
Amy Rodriguezk,l, Elizabeth C. Ward b,m, Linda Worrall a,b,d and Marie-
Pier McSween a,b
a
Queensland Aphasia Research Centre, The University of Queensland, Herston, Brisbane, Australia; bSchool
of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Australia; cFaculty of Health,
Southern Cross University, Gold Coast, Australia; dCentre of Research Excellence in Aphasia Recovery and
Rehabilitation, Australia; eSurgical Treatment and Rehabilitation Service, Metro North Hospital and Health
Service, Queensland, Australia; fCentre for Research in Telerehabilitation, School of Health and Rehabilitation
Sciences, The University of Queensland, Brisbane, Australia; gGold Coast University Hospital, Gold Coast
Hospital and Health Service, Australia; hFaculty of Health, Griffith University, Gold Coast, Australia; iSchool of
Public Health and Preventive Medicine, Monash University, Melbourne, Australia; jSpeech Pathology
Department, The Wesley and St Andrew’s War Memorial Hospitals, Uniting Care Health, Brisbane, Australia;
k
Atlanta VA Medical Center, Center for Visual and Neurocognitive Rehabilitation, 1670 Clairmont Rd,
Decatur, GA, USA; lEmory University School of Medicine, Department of Neurology, Atlanta, GA, USA
Princess Alexandra Hospital, Brisbane, Australia; mDirector, Centre for Functioning and Health Research,
Queensland Health

ABSTRACT KEYWORDS
Background: The Aphasia Language Impairment and Functioning Intensive and
Therapy (LIFT) program is one example of an Intensive and Comprehensive Aphasia
Comprehensive Aphasia Program (ICAP) developed in a research Program; implementation
setting. This ICAP has shown promising improvements in naming, science; aphasia; behaviour
change
communication participation and communication-related quality of
life, and is ready for translation into health services. However, there
are challenges to implementing ICAPs into clinical services, includ­
ing delivering high treatment doses with existing staffing, and
providing a cohort model where patients start and finish concur­
rently. No Australian studies have investigated local clinicians’ or
clinical stakeholders’ perspectives on translating the Aphasia LIFT
program into existing health services. It is vital to understand the
clinical context in which implementation is intended so that
a theory-informed implementation intervention can be tailored to
address identified barriers.
Aims: This study aimed to identify potential barriers and facilita­
tors to implementing Aphasia LIFT into existing healthcare ser­
vices from the perspectives of clinical stakeholders and
experienced LIFT clinicians, and develop a theory-informed imple­
mentation intervention for Aphasia LIFT, tailored to the intended
implementation context.

CONTACT Kirstine Shrubsole kirstine.shrubsole@scu.edu.au Faculty of Health, Southern Cross University, Gold
Coast, Australia
© 2022 Informa UK Limited, trading as Taylor & Francis Group
2 K. SHRUBSOLE ET AL.

Methods and Procedure: This study comprised two distinct

phases. In phase 1, qualitative semi-structured interviews were
conducted with clinical stakeholders (n = 13) and Aphasia LIFT
clinicians (n = 5) to identify key barriers and facilitators to Aphasia
LIFT implementation. Interviews were informed by the Theoretical
Domain Framework and data analysed using content analysis. In
phase 2, barriers were mapped to behaviour change techniques
and implementation strategies using two mapping approaches,
leading to the development of the implementation intervention.
Outcome and Results: Combined clinical stakeholder and Aphasia
LIFT clinician perspectives revealed six main barriers: ‘patient-level
factors’, ‘environmental context and resources’, ‘beliefs about cap­
abilities’, ‘the Aphasia LIFT innovation’, ‘knowledge’, and ‘skills’. Key
implementation barriers included a perceived lack of flexibility of the
Aphasia LIFT program’s structure, and an overall lack of confidence
that the program could be feasibly delivered within a constrained
healthcare environment. An implementation intervention was sub­
sequently designed that incorporated six components: (i) Executive,
leadership and stakeholder support, (ii) Allocation of clinical staff, (iii)
Interactive education and training program, (iv) Resource procure­
ment and provision, (v) Ongoing implementation support, and (vi)
Consumer engagement and promotion.
Conclusion: The context-specific barriers and facilitators identified
in this study informed the development of a tailored implementa­
tion intervention to facilitate translation of the Aphasia LIFT ICAP
into clinical services. This implementation intervention will be eval­
uated in a future study.

Introduction
Despite robust evidence that aphasia treatment can be effective in improving language
and communication outcomes (Brady et al., 2016), current speech language pathology
(SLP) services are insufficient and are often characterised by inadequate dose of aphasia
intervention, insufficient attention to participation across the continuum of care, and
a failure to address family/caregiver needs (Aphasia in North America; Simmons-Mackie,
2018). Intensive Comprehensive Aphasia Programs (ICAPS) were developed to close the
evidence-practice gap by implementing best practices in intensity and comprehensive­
ness of aphasia intervention. While best practice in treatment intensity or dose is yet to be
determined (Cherney, 2012; Pierce et al., 2021), there is evidence that high-dose aphasia
treatments can improve outcomes (Brady et al., 2021). Best practices in comprehensive­
ness of intervention should not only include goal-directed therapy (Brown et al., 2021;
Hersh et al., 2012; Rosewilliam et al., 2011), in which language impairment can be targeted
in addition to communication activity and participation (Rose et al., 2013), but also include
family and caregiver support (Simmons-Mackie, 2018) and evidence-based treatment
approaches such as computer (Zheng et al., 2016) and group therapy (Lanyon et al.,
2013) to achieve the best outcomes.
Intensive and Comprehensive Aphasia Programs (ICAPs) are a relatively new approach
to aphasia treatment that incorporate these key elements of high-dose and comprehen­
sive aphasia treatment (Monnelly et al., 2021; Rose et al., 2013; Rose et al., 2021). ICAPs are
delivered to cohorts of people with aphasia that start and end therapy at the same time,
 APHASIOLOGY 3

and treatment includes a combination of individual and group sessions that target both
impairment and activity/participation according to an intensive delivery schedule (Rose
et al., 2013). The original definition described ICAPs as providing the above elements over
at least 3 hours of treatment per day for at least 2 weeks, utilising a range of treatment
approaches including patient and family education (Rose et al., 2013). Modified ICAPs
(mICAPS) refer to programs that meet all ICAP criteria with the exception of a change to
either intensity or programming (Rose et al., 2021). ICAPs have been shown to lead to
significant improvements in naming skills (Babbitt et al., 2015; Dignam et al., 2015), overall
language impairment (Babbitt et al., 2015; Leff et al., 2021; Winans-Mitrik et al., 2014),
communication participation (Babbitt et al., 2015; Dignam et al., 2015), communication
confidence (Babbitt et al., 2015), communication-related quality of life (Dignam et al.,
2015; Hoover et al., 2017) and psychosocial well-being (Griffin-Musick et al., 2021). ICAPs
are unique in that they simultaneously provide evidence-based comprehensive treatment
(Rose et al., 2013) with sufficient dose across several domains of the International
Classification of Functioning, Disability and Health (ICF; World Health Organization,
2001) to effect meaningful change for people with aphasia and their family members
(Babbitt et al., 2021).
In addition to the improved clinical outcomes following ICAPs/mICAPs, different
stakeholder groups have reported benefits in their use over usual care. For example,
people with aphasia and their family members perceived treatment to be more indivi­
dualised and ‘in-depth’ than previously received therapy (Babbitt et al., 2021), likely
reflecting the implementation of high-dose treatments and goal-directed nature of the
ICAP model. Importantly, the cohort model was seen to offer psychosocial benefits as it
promoted interaction between people with aphasia and their families in the cohort who
could offer each other support (Babbitt et al., 2021), something that is not standard
practice in SLP services. Additionally, clinicians felt rewarded by the therapeutic relation­
ships they developed with ICAP participants (Babbitt et al., 2013). Clinicians perceived that
“the intensive setting was superior to typical settings” (Babbitt et al., 2013, p. 403) to
maximise therapeutic gains, and noted that ICAPs should be available to all people with
aphasia.
Given that ICAPs/mICAPs lead to positive and significant changes to impairment and
participation measures and are highly valued by people with aphasia, family members,
and clinicians, it is important to determine whether these programs can be offered within
existing healthcare services as an evidence-based service delivery option. While some
adoption of ICAPs has been reported (Rose et al., 2021), there are relatively few ICAPS and
mICAPS offered globally. The most recent survey by Rose et al (2021) found that only 14
ICAPs and 7 mICAPS (a total of 21 ICAP/mICAPs) were available internationally, which had
increased from 12 ICAPS in 2013 (Rose et al., 2013). The identified programs were
generally well-established, running for an average of 8.9 years for ICAPs and 7 years for
mICAPs at the time of the survey. However, a number of ICAPS had ceased to operate
since the 2013 survey, highlighting issues of sustainability and financial stability (Rose
et al., 2021). While student placements have supplemented ICAP costs in some cases
(Griffin-Musick et al., 2021), funding poses a barrier to implementing and sustaining ICAPs
(Boyer et al., 2020).
4 K. SHRUBSOLE ET AL.

Challenges to implementing the ICAP/mICAP model into existing clinical services have
also been identified from clinicians’ perspectives. A recent international study of SLPs
(n=34) informed by the Theoretical Domains Framework (TDF; Cane et al., 2012) identified
a number of factors influencing ICAP implementation (Trebilcock et al., 2019). The
prominent influencing factors were: ‘environmental context and resources’ such as time-
limited services, ‘beliefs about consequences’ that ICAPs would not be beneficial for all
patients (e.g., those with low motivation), ‘social/professional role and identity’ where
workplace culture dictated the SLP role was to provide short-term treatment for aphasia,
‘skills’ including a lack of experience in providing holistic aphasia services, and lack of
‘knowledge’ about current research evidence on ICAP/mICAP models. Following the
identification of these factors, Trebilcock et al. (2021) designed an online implementation
intervention, Aphasia Nexus, to increase delivery of intensive and comprehensive aphasia
services. That implementation intervention is currently being piloted, and so the impact of
this is not yet known. However, it should be noted that many clinicians did not perceive it
as feasible to deliver a complete ICAP from the start, rather regarded it as an “ICAP
journey” where a “step by step approach building up to a full ICAP” was needed
(Trebilcock et al., 2021, p. 6), such as increasing the intensity of therapy or commencing
a therapy group. In other words, the Aphasia Nexus implementation intervention did not
relate to implementation of a specific program in its entirety. Therefore, effective strate­
gies required to implement a complete ICAP/mICAP into existing clinical services is
unknown.
In summary, ICAPs have been found to be efficacious in improving language and com­
munication outcomes for people with aphasia and are also valued by people with aphasia,
family members, and clinicians. However, implementation to date has faced numerous
challenges. As noted by Rose and colleagues (2021), further research is needed to address
the evident lack of ICAP implementation internationally. To date though, there has been no
published implementation intervention designed specifically to achieve this aim.

The Aphasia LIFT program

In Australia, there is currently one ICAP/mICAP in operation (Rose et al., 2021), the Aphasia
Language Impairment and Functioning Therapy (LIFT) program. Aphasia LIFT was initially
delivered in the traditional ICAP format with 48 hours of treatment provided over 3 weeks
(Rodriguez et al., 2013), and was then modified to reflect a more distributed model
(mICAP), whereby the 48 treatment hours were delivered over an 8-week period due to
improved naming outcomes shown by Dignam et al. (2015). In the distributed model,
people with aphasia received 2-3 hours of therapy 3 times a week. Overall, Aphasia LIFT
has been shown to be feasible, efficacious in a research setting, and to benefit partici­
pants’ language impairment and functional communication (Dignam et al., 2015;
Rodriguez et al., 2013).
However, Aphasia LIFT (in either its original or modified format) has not yet been
translated into clinical services. Considering the majority of aphasia services are based in
hospitals and health services in the Australian context, it is important to determine
whether this model is feasible and potentially effective in such an environment.
Moreover, it is necessary to understand what elements of an implementation intervention
may effectively facilitate the success of this program. It has been argued that there needs
 APHASIOLOGY 5

to be a move away from the dominant step-wise approach to clinical effectiveness

research (Glasgow et al., 2003; Proctor et al., 2008), as this contributes to a delay in clinical
uptake and often fails to consider the external validity of such interventions (i.e., the
clinical context). As such, studies that concurrently evaluate both effectiveness and
implementation (i.e., hybrid implementation-effectiveness trials) are recommended to
improve the speed of translation (Curran et al., 2012).
Prior to evaluating implementation, a tailored (Baker et al., 2015) and theoretically-
informed (Eccles et al., 2005) implementation intervention must be developed to address
known barriers. However, perceived barriers to translating the Aphasia LIFT mICAP into
the specific implementation context of interest are unknown. The current work builds on
previous research identifying barriers in implementing ICAPs (Trebilcock et al., 2019) and
the experience of ICAP delivery (Babbitt et al., 2013). We focus here on the implementa­
tion of the Aphasia LIFT mICAP and the perspectives of both clinicians who have delivered
it and relevant clinical stakeholders who may potentially adopt the program, in order to
design a comprehensive intervention with the greatest chance of success. Understanding
the implementation context is likely to be particularly important to facilitate implementa­
tion, considering the cost implications and service-delivery constraints previously identi­
fied (Rose et al., 2021; Trebilcock et al., 2019). Therefore, this study aimed to: (1) identify
potential barriers and facilitators to implementing Aphasia LIFT into existing healthcare
services from the perspectives of local clinical stakeholders and experienced Aphasia LIFT
clinicians, and (2) develop a theory-informed implementation intervention for Aphasia
LIFT, tailored to the intended implementation context.

Methods
This study involved two distinct sequential phases. In Phase 1, qualitative semi-structured
interviews were conducted with a) clinical stakeholders, i.e., clinicians and managers
working in health services, and b) Aphasia LIFT clinicians, i.e., clinicians with experience
delivering the Aphasia LIFT mICAP. Interview questions were designed to identify key
barriers and facilitators to implementing and delivering Aphasia LIFT. Phase 1 results,
reported in accordance to the consolidated criteria for reporting qualitative research
(COREQ, Tong et al., 2007), then informed Phase 2, where an implementation intervention
was developed to overcome the identified barriers.

Phase 1: Semi-structured interviews

Participants and sampling
Purposive sampling was undertaken from two participant groups whose input was
relevant for future Aphasia LIFT implementation. We sought the perspectives of clin­
icians working in the intended implementation context, which would likely be
a metropolitan health service in order to achieve sufficient numbers to run a cohort
model. In addition, we wanted to gain the perspectives of clinicians who had experience
delivering Aphasia LIFT in order to identify whether there were differences between
reported barriers and facilitators of the two groups. Participant group 1 included
speech-language pathologists (SLPs) working in a variety of roles (both management
and clinical) in relevant clinical contexts (i.e., rehabilitation, outpatient and community
6 K. SHRUBSOLE ET AL.

settings) in metropolitan health services. Participant group 2 included SLP clinicians

with direct previous experience implementing Aphasia LIFT in a research setting.
Twenty-three potential participants were invited to participate by a project officer. Of
these, 18 participants were available and consented to take part. The project had
Human Research Ethics Committee approval (HREC/13/QPAH/531), and participants
provided written, informed consent.

Materials and Procedure

A topic guide was developed by the first author (KS) and other Aphasia LIFT investigators
and then piloted (See supplementary material: Appendix A). Interview questions were
informed by the Theoretical Domain Framework (TDF; Cane et al, 2012) to explore
potential barriers and facilitators to implementing Aphasia LIFT within clinical services.
The TDF integrates 33 behaviour change theories (Michie et al., 2005) and includes 14
domains: (1) knowledge; (2) skills; (3) social 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). The
interview guide differed for clinical stakeholders and Aphasia LIFT clinicians; the former
focussed primarily on perceived barriers and facilitators to implementing Aphasia LIFT
into their current clinical service (e.g., What would it take to implement the program into
your service?), whereas the latter focused on the experience of directly delivering the
program and if adaptations may be required for implementation.
Interviews were conducted by the author (KS) who is an experienced qualitative
researcher and speech language pathologist with over 15 years experience working in
a variety of Australian healthcare settings. The interviewer knew two of the Aphasia LIFT
clinicians prior to this study, but did not have relationships with any other participants.
Interviews were conducted either face-to-face at the participants’ workplace (n=13) or via
video conferencing (n=5) between October 2019 and June 2020. Interviews had a mean
duration of 63 minutes ± 11 minutes, with approximately half of this time dedicated to the
topics described here; the remainder focussed on a related topic that will be reported
elsewhere. Interviews were audio recorded and transcribed verbatim, and the interviewer
took detailed field notes.

Data Analysis
De-identified transcripts were uploaded to QSR International’s NVivo 12 software (2018)
and analysed using qualitative content analysis (Graneheim & Lundman, 2004).
A combined deductive and inductive approach was used. Factors influencing implemen­
tation were deductively coded to the 14 domains of the TDF plus two additional domains
validated by Huijg et al (2014); ‘patient characteristics’ and ‘innovation characteristics’. For
each domain, specific underlying constructs and subconstructs were inductively identi­
fied. Related codes were grouped into subcategories, which were further clustered into
categories. Each code was classified as either a barrier or facilitator. Coding was con­
ducted by four members of the research team (KS, AD, AH, and GH), with peer checking
completed for all transcripts. Team consultations occurred regularly for agreement and
 APHASIOLOGY 7

consistency of coding with differences resolved through discussion. The findings of each
participant group were analysed separately then integrated using a narrative approach to
offer intergroup comparisons (Fetters et al., 2013).

Phase 2: Design of implementation intervention

This phase aimed to design a theory-informed implementation intervention to address
previously identified barriers using intervention mapping.

Procedure
The implementation intervention was designed by two members of the research team (KS
and MM) with expertise in implementation science and knowledge of the implementation
context. Intervention design was informed by evidence-based approaches and integrated
with qualitative findings from Phase 1 to promote internal validity and contextual
relevance. Two mapping approaches were applied to ensure coverage of all identified
implementation barriers and provide guidance for future tailoring to localised barriers.
The process for designing the implementation intervention is shown in Figure 1.
Firstly, the researchers reviewed the key TDF barriers identified in Phase 1 and con­
sidered appropriate evidence-based Behaviour Change Techniques (BCTs) listed in the
Behaviour Change Taxonomy v1 (Michie et al., 2013). This mapping was facilitated by the
process outlined in the Behaviour Change Wheel workbook (Michie et al., 2014), where
broad intervention functions (or categories) likely to be effective in bringing about
change according to expert consensus (Michie, Atkins & West, 2014, page 113) were
populated into a matrix. The research team considered these intervention functions
according to a number of criteria including affordability, practicability and acceptability,
and selected potential intervention functions and associated BCTs for further deliberation.
In order to ensure that all key barriers were addressed, additional consideration of
patient- and innovation-related barriers was facilitated by the CFIR-ERIC Mapping Tool
(Waltz et al., 2019). This tool supports selection of implementation strategies compiled by
the Expert Recommendations for Implementing Change (ERIC) group according to spe­
cific Consolidated Framework for Implementation Research (CFIR) barriers, as endorsed by
implementation experts (Waltz et al, 2019). The mapping tool was used to generate a list

Figure 1. Study design and procedures Key: TDF = Theoretical Domains Framework; BCT = Behaviour
Change Technique; ERIC = Expert Recommendations for Implementing Change
8 K. SHRUBSOLE ET AL.

of additional implementation strategies to consider, with high-scoring strategies

(endorsed by >50% of expert panellists in Waltz et al, 2019) selected for further con­
sideration. The use of two implementation frameworks has been employed previously to
select and develop multi-level implementation strategies (i.e., clinician, patient and
organisation; Ahmed et al., 2020), with two frameworks found to complement each
other and allow comprehensive coverage of clinician-level and organisation-level factors.
Subsequently, after all potentially appropriate BCTs and ERIC strategies were identified,
the research team brainstormed to identify the most suitable components of an imple­
mentation intervention to address each of the key barriers in terms of the feasibility to be
implemented in the clinical setting. This process involved the research team considering
the Phase 1 results and specific participant quotes to support strategy selection. Finally,
the research team made pragmatic decisions about how the selected intervention cate­
gories and specific BCTs and ERIC strategies could be feasibly combined and delivered as
distinct intervention components.

Results
Phase 1: Semi-structured interviews
Demographic information
The mean age of participants was 43 (+/- 9) years, all identified as female, and they had an
average of 21 (+/-8) years of clinical experience.

Clinical stakeholders’ demographics and usual care and perceived barriers and
facilitators
Clinical stakeholder participants predominantly worked in a combination of roles, with
the majority (9/13) working in hospital-based outpatient settings in addition to other
settings such as acute and inpatient rehabilitation. The roles of the remaining partici­
pants were: acute plus inpatient rehabilitation (1/13), community-based services (1/13,
and management/non-clinical roles (2/13). Four out of 13 included management roles in
their job description. All clinical stakeholders worked in senior positions within metro­
politan tertiary hospitals, metropolitan quaternary hospitals, metropolitan community
health centres or metropolitan private hospitals, and were based in Queensland,
Australia.
Usual care at clinical stakeholder sites: The 13 clinical stakeholder participants worked at
eight distinct locations, with 1-3 clinical stakeholders interviewed per site. Seven of the
eight clinical stakeholder sites provided both inpatient and outpatient aphasia services,
and one site provided community services only. Self-reported usual care at the clinical
stakeholders’ sites is presented in Supplementary Table 1. All participants described their
aphasia services as comprehensive, comprising goal-directed impairment-based and
functional treatment approaches. The majority of services (7/8) provided computer-
based treatments to supplement face-to-face therapy, and approximately half (5/8)
provided group therapy. All inpatient services were time-limited depending on the
patient’s length of admission, whereas most outpatient services could be provided in
an ongoing way provided there were patient goals. The maximum intensity of aphasia
treatment for inpatient services ranged from 5-10 hours per week, in contrast to
 APHASIOLOGY 9

outpatient and community services that were most commonly able to provide between
1.5 and 3 hours of weekly therapy. Some sites used allied health assistant services to
deliver increased therapy intensity. Only two sites (Sites 5 and 6) were able to provide 5 or
more hours of outpatient therapy per week.
Clinical stakeholder perceived barriers and facilitators: For the clinical stakeholders, nine
key factors influencing ICAP implementation were identified. These comprised four key
barriers (‘environmental context and resources’, ‘patient factors’, ‘beliefs about capabil­
ities’, and ‘the Aphasia LIFT innovation’), two domains that acted as both a barrier and
facilitator (‘knowledge’ and ‘skills), and three key facilitators (‘beliefs about consequences’,
‘social influences’ and ‘social professional role and identity’). These factors are briefly
described below with further detail provided in table 1 and the supplementary materials
(Supplementary table 2).
Most clinical stakeholders were of the opinion that the ‘Aphasia LIFT innovation’ itself
was a barrier and was not conducive to straightforward translation into existing services
due to ‘environmental context and resource’ constraints such as a lack of staff and
physical space to conduct the program. The pervading view was that a complete ICAP
could not be implemented without a restructure of their current service or the provision
of additional staff; “I don’t think it’s feasible that we could do it in our current staffing
capacity” (St11). Clinical stakeholders noted that organisational systems and processes
were often detrimental to intensive programs (“I don’t think our booking system could
handle it,” St08), particularly when scheduling needed to be coordinated with other
members of the multidisciplinary team. Access to services and parking costs for patients
were also a barrier, given the program’s intensity.
Many clinical stakeholders compared the required ICAP intensity to their current usual
care and noted that they would ‘have to juggle’ to achieve implementation. Those who
were already providing more intensive services were more optimistic of achieving imple­
mentation but noted that additional resources such as student placements and organisa­
tional support would be needed. This was exemplified by one clinician who stated: “It’s
a service decision and a service redesign almost. So for clinicians, it’s having the support of
their managers and the support of the program drivers to do that. That’s a big shift if,
historically, your service has worked in a different way (St12).”
Within the ‘beliefs about capabilities’ domain, the majority lacked confidence that
implementation was feasible given the structured nature of the ‘Aphasia LIFT innovation’
and the ‘environmental context and resource’ constraints. This was illustrated by quotes
such as, “It’s just impossible,” (St05) and “I couldn’t actually provide half a day therapy three
times a week . . . I don’t think it would work,” (St09). Particular challenges linked to the
‘Aphasia LIFT innovation’ included the cohort model, where clinical stakeholders
explained that having a group of people to start at the same time ‘would be difficult’
(St13), and the perception that the ‘Aphasia LIFT innovation’ needed to be ‘more flexible
(St02)’. Many perceived that the Aphasia LIFT innovation was incompatible with commu­
nity or outpatient settings, so would need to start in the more heavily resourced inpatient
setting; “I think this would be much more achievable from an inpatient point of view.” (St10).
Many potential ‘patient factors’ were identified as potential barriers, including patient
fatigue and readiness for participation. For example, clinical stakeholders expressed
concerns regarding patients’ ability to cope with the program’s intensity and acknowl­
edged that other priorities could limit their participation; “People have lives and sometimes
10 K. SHRUBSOLE ET AL.
Table 1. Summary of domains and constructs/subconstructs identified as key barriers per participant
group (includes domains acting as both barriers and facilitators)
Domain
Environmental context and
resources
(primarily a barrier for
stakeholders; mixed barrier-
facilitator for Aphasia LIFT
clinicians)
Patient factors
(primarily a barrier for both
groups)
Beliefs about capabilities
(primarily a barrier for both
groups)
Aphasia LIFT innovation
(primarily a barrier for
stakeholders; mixed barrier-
facilitator for Aphasia LIFT
clinicians)
Barrier or Constructs/Subconstruct for Constructs/Subconstruct for Aphasia
facilitator clinical stakeholders LIFT clinicians
Barriers ● Lack of sufficient clinical staff­ ● Lack of sufficient clinical staffing,
ing, funding and time to pro­ funding and time to provide
vide Aphasia LIFT Aphasia LIFT
● Poor access to services e.g., ● Poor access to services e.g., park­
parking and transport costs ing and transport costs
● Constrained organisational sys­ ● Lack of sufficient specific and
tems and processes (e.g. book­ packaged resources
ing systems and timetabling)
● Lack of sufficient space/rooms
and facilities to conduct
Aphasia LIFT
● Lack of sufficient specific and
packaged resources
● Organisational culture focussed
on discharge/transfer
Facilitators ● Not a key facilitator for clinical ● Availability of Allied Health
stakeholders Assistants (AHAs) or students
enabled Aphasia LIFT provision
● Sufficient space/rooms and facil­
ities to conduct Aphasia LIFT
● Easily accessible Aphasia LIFT
locations
● Presence or development of spe­
cific and packaged resources
Barriers ● Patient fatigue limits therapy ● Lack of available family/carer
participation particularly in the support
early phases post-stroke ● Patient fatigue impacted
● Patient comorbidities and participation
other therapy commitments ● Patient priorities and goals
limit ability to participate impacted cohesion of group
● Patient readiness - Patients therapy
may have other needs or prio­ ● Patients may have difficulty
rities that limit readiness engaging in goal setting
● Having more severe aphasia
could impact patient’s sense of
achievement
Barriers ● Lack of perceived behavioural ● Lack of perceived behavioural
control in overcoming organi­ control in delivering Aphasia
sational & resource barriers LIFT elements (e.g., goal setting)
● Lack of self-efficacy in imple­ ● Lack of confidence in delivering
menting Aphasia LIFT Aphasia LIFT program initially
● Sense of disempowerment due
to implementation challenges
Barriers ● Flexibility and Structure – lack ● Flexibility and Structure – lack of
of program flexibility program flexibility
● Difficulty achieving enough ● Difficulty achieving enough
patients for the cohort model patients for the cohort model at
at the same time the same time
● Cohort model could impact ● Cohort model could impact
negatively on patients negatively on patients
● Aphasia LIFT incompatible with
community or outpatient set­
tings due to organisational
constraints
Facilitators ● Not a key facilitator for clinical ● Structure of program facilitates
stakeholders a comprehensive approach
● Cohort model could impact posi­
tively on patients
(Continued)
 APHASIOLOGY 11

Table 1. (Continued).
Barrier or Constructs/Subconstruct for Constructs/Subconstruct for Aphasia
Domain facilitator clinical stakeholders LIFT clinicians
Knowledge Barriers ● Lack of familiarity with under­ ● Not a key barrier for Aphasia LIFT
(a barrier and facilitator for lying evidence for Aphasia LIFT clinicians
clinical stakeholders) ● Lack of knowledge of the
Aphasia LIFT elements
Facilitators ● Familiarity with underlying evi­ ● Not a key facilitator for Aphasia
dence for Aphasia LIFT LIFT clinicians
● Familiarity with the Aphasia
LIFT elements
Skills Barriers ● Training - Need for training in ● Training – Need for more train­
(a barrier and facilitator for how program is packaged and ing in how program elements
both groups) delivered and specific therapies should be
● Training - Need for demonstra­ delivered
tion and observation ● Training - Need for demonstra­
tion and observation
● Lack of in-depth experience in
delivering specific aphasia treat­
ment approaches
Facilitators ● Current skill mix is sufficient/ ● Previous skill and experience in
adequate for general elements aphasia treatment sufficient/
of the Aphasia LIFT adequate for delivering Aphasia
LIFT
● Training – adequate training in
how program elements and
specific therapies should be
delivered

they can’t focus on their communication,” (St03). Comorbidities and other therapy commit­
ments were also seen as barriers, with several clinical stakeholders noting that patients
needed an adjustment period to be sufficiently motivated and committed to the program.
Clinical stakeholders also reported that supportive carers or family members would
enable patients’ participation in the program.
Two factors, ‘knowledge’ and ‘skills’ were perceived as both barriers and facilitators.
Most clinical stakeholders believed that they had the necessary skills and experience, and
they were confident in delivering most of the ICAP elements. For example, one clinical
stakeholder stated, “We’re very functionally based anyway (. . .) a bit of impairment, a bit of
computer-based therapy, lots of functional therapy,” (St09). However, the majority agreed
that there was a need for education and training in how to deliver the program, and that
this should include demonstration.
In general, there were positive ‘social influences’ that encouraged clinical stakeholders
to provide patient-centred services, although some noted that patients did not usually
expect to participate in an ICAP. Many reported that their colleagues and the multi­
disciplinary team members were supportive, acknowledging that it was important to get
“everybody on board (St11)”. All clinical stakeholders saw it as their ‘professional role and
identity’ to provide high quality aphasia services “to get the evidence translated into
practice (St03)”, and perceived their organisations were generally committed to the
same cause. Most had positive ‘beliefs about consequences’ that implementing an ICAP
would be beneficial to patients. However, some believed that people with more severe
aphasia may not experience the same benefits and patients may be disadvantaged due to
missing other required therapies. There were mixed beliefs about the benefits to clinicians
12 K. SHRUBSOLE ET AL.

and services; some felt an ICAP was advantageous due to its evidence-base and perceived
cost-effectiveness, while others believed it wasn’t cost effective and could lead to clinician
fatigue. Furthermore, three participants did not see any benefit to the Aphasia LIFT ICAP
in comparison to their usual care, with one clinical stakeholder stating, “We sort of have
a model that we’ve embedded in our health service that we’re quite happy with (St07).”

Aphasia LIFT clinicians’ demographics and perceived barriers and facilitators

Aphasia LIFT clinicians’ experience in implementation ranged from delivering one to
seven Aphasia LIFT programs. Two clinicians had no previous experience working in
aphasia rehabilitation prior to delivering Aphasia LIFT in a research setting. The remaining
three clinicians had previous experience working in acute and community-based rehabi­
litation settings prior to delivering Aphasia LIFT.
For the Aphasia LIFT clinicians, eight key factors influencing implementation were
identified. These comprised two key barriers (‘patient factors’ and ‘beliefs about capabil­
ities’), three domains that acted as both a barrier and facilitator (‘skills’, the ‘Aphasia LIFT
innovation’, and ‘environmental context and resources’), and three key facilitators (‘social
influences’, ‘beliefs about consequences’ and ‘emotion’). The detail relating to these
factors are provided in the supplementary materials (Supplementary table 3) and inte­
grated with the clinical stakeholder perceptions in the section below.

Comparison between participant groups

There were similarities across both groups, with clinical stakeholders and Aphasia LIFT
clinicians identifying ‘patient factors’ and ‘beliefs about capabilities’ as main barriers.
A perceived barrier shared by both clinical stakeholders and Aphasia LIFT clinicians was
factors affecting the patient’s appropriateness for the program, such as their stage of
recovery, their level of fatigue, and possible scheduling challenges as “sometimes they
won’t have the time to do extra therapy” (Cl03). Both groups agreed that Aphasia LIFT
participation was a commitment for patients, who sometimes lacked sufficient motivation
or prioritised other health needs. Individual patient characteristics were also a barrier at
times, with goal-setting particularly difficult for some patients (“lots of people don’t have
goals in life,” Cl01) and some people having a tendency to compare their progress with
others (“this other lady always felt like they were better than her,” Cl03).
In the ‘beliefs about capabilities’ domain, Aphasia LIFT clinicians identified a number of
specific challenges to delivering the program. These barriers contrasted to the clinical
stakeholder group, who focussed primarily on the feasibility of implementing the pro­
gram in the clinical setting. For example, several Aphasia LIFT clinicians discussed diffi­
culties in conducting goal setting with patients, particularly in relation to setting
functional therapy goals. Additionally, three of the five clinicians lacked confidence in
delivering the program initially, although their confidence improved over time; “I know
I was a bit nervous to start with, but it got better towards the end,” (Cl04).
Clinical stakeholders identified ‘Environmental context and resources’ as the main
implementation barrier, whereas Aphasia LIFT clinicians identified this domain as both
a barrier and facilitator, noting that resources in the research setting were generally
adequate but more preparation time would have been useful. Aphasia LIFT clinicians
agreed with clinical stakeholders that support from allied health assistants and student
clinicians “seemed to work well (Cl04)”, and that easily accessible locations facilitated
 APHASIOLOGY 13

patient participation in the program. Unlike the clinical stakeholder participants, Aphasia
LIFT clinicians did not identify organisational process constraints or cultural barriers, as
they were not employed within existing healthcare organisations during the delivery of
the program.
While the ‘Aphasia LIFT innovation’ itself was perceived as another key barrier for
clinical stakeholders, Aphasia LIFT clinicians perceived the program’s structure in a more
mixed manner (i.e., as both a barrier and facilitator). Similar to clinical stakeholders,
Aphasia LIFT clinicians commented on the logistical difficulties of obtaining a cohort of
patients for the program. Another barrier identified by both groups was the perceived
lack of flexibility of the program, with one Aphasia LIFT clinician stating, “I felt like the
program didn’t allow the freedom to (change approaches) with the structuring that we had.”
(Cl03).” However, Aphasia LIFT clinicians also reported facilitators to the program’s com­
prehensive structure, commenting positively on the inclusion of both functional and
impairment-based therapy, stating that “ . . . having that line between impairment-based
therapy and functional therapy is really good (Cl01).”
The ‘skills’ domain was both a barrier and facilitator for both participant groups who
both expressed that training was important prior to implementation; “It would be great if
there was a set training package for clinicians.” (Cl01). Additionally, both groups agreed
that “an observation of LIFT beforehand would be helpful” (Cl02). Although ‘knowledge’ was
a key influencing factor for the clinical stakeholder group, described previously, this
domain was not reported to influence the Aphasia LIFT clinician groups’ practice.
Two of the key facilitators were the same, with both groups having positive ‘beliefs
about consequences’ and describing positive ‘social influences’. However, while clinical
stakeholders discussed the ‘social influences’ of their colleagues on implementation, the
Aphasia LIFT clinicians particularly highlighted the importance of support from the
research team and the opportunity to “bounce ideas” and “troubleshoot” as a group.
One notable difference between the two groups was that the ‘social/professional role and
identity’ domain was a key facilitator for the clinical stakeholder group but not the
Aphasia LIFT clinicians, who did not mention this factor as influencing their practice.
Instead, the final key facilitator for Aphasia LIFT clinicians was the ‘emotion’ domain. For
example, several clinicians reported their overall enjoyment of the program, and some
described an emotional investment in the patient’s progress, where witnessing their hard
work and improvement gave them a sense of pride.

Phase 2: Design of implementation intervention

Once specific consideration was given to the implementation context and participant
quotes (see supplementary table 4), six intervention functions linked to the four TDF
barriers identified in Phase 1 (‘environmental context and resources’, ‘beliefs about
capabilities’, ‘knowledge’ and ‘skills’) were selected: education, training, persuasion, mod­
elling, environmental structuring, and enablement. Thirty-two relevant BCTs were then
considered with reference to the implementation context and participant quotes (see
supplementary table 5), leading to the selection of 29 BCTs for inclusion.
Barriers related to the ‘Aphasia LIFT innovation’ itself and ‘patient factors’ were mapped
to five relevant CFIR domains/constructs of intervention adaptability, intervention com­
plexity, compatibility of the innovation, patient needs and resources, and patient/
14 K. SHRUBSOLE ET AL.

customer engagement processes. The subsequent CFIR-ERIC query function revealed 34

ERIC strategies (shown in supplementary table 6). Of these, six strategies were endorsed
by >50% of expert panellists and subsequently incorporated into the implementation
intervention (Promote adaptability; Conduct local needs assessment; Involve patients/
consumers and family members; Obtain and use patients/consumers and family feedback;
Prepare patients/consumers to be active participants; Intervene with patients/consumers
to enhance uptake & adherence, shown in supplementary table 7). Following the proce­
dure outlined in the Methods section, selected BCTs and ERIC strategies were integrated
where possible and developed into the final intervention components as shown in table 2.
The six main components chosen for the implementation intervention were:

(1) Executive, leadership and stakeholder support: Facilitated by SLP directors/man­

agers who wish to implement Aphasia LIFT, local stakeholders such as the health
service executive and members of the multidisciplinary team will be consulted, and
a needs assessment will be conducted to determine which program elements
could be tailored to meet local needs. Support from executive and leadership will
be obtained, involving a formal agreement to deliver Aphasia LIFT, and formation
of a committee to promote and oversee the programs outputs.
(2) Allocation of clinical staff: Funding for sufficient clinical staff to deliver Aphasia
LIFT will need to be sourced. Temporary program support can be sourced from
a variety of options including partnering with a university to apply for grants, using
healthcare site specific grants if available, and using private health funding if
available. Permanent change in staffing support to promote ongoing implementa­
tion of the Aphasia LIFT will need to be sought through a business case for service
model change including increased staffing. Optimising use of Allied Health
Assistants and/or students to help provide program elements can also be explored.
(3) Interactive education and training program: An experienced Aphasia LIFT clin­
ician will deliver a full-day workshop including education about the program
elements and the clinicians’ role, training in using specific resources and demon­
stration of therapy approaches, application of skills through role-play and case
study activities, and persuasive communication in the form of compelling patient
and clinician feedback. The workshop will also include initial problem-solving, goal-
setting and action planning. There will be additional opportunities for training
provided at the request of clinicians as further needs are identified.
(4) Resource procurement and provision: Written protocols for Aphasia LIFT will be
provided in addition to templates, therapy resources such as manuals and proto­
cols, and computer programs. Sufficient space to provide individual, groups and
computer therapy sessions will be secured for the program’s duration, through
negotiation with relevant local stakeholders including clinical and operational
leads, and processes for coordinating bookings with other disciplines will be
arranged.
(5) Ongoing implementation support (facilitation & enablement): An external clin­
ical expert facilitator will support the implementation of Aphasia LIFT and provide
coaching to clinicians about the program, in addition to opportunities for discus­
sion and action planning. This will occur through formal weekly debriefs in the first
Aphasia LIFT cohort in addition to ad hoc support. Facilitation is a known enabler of
Table 2. Implementation intervention components
Intervention component
Component 1: Executive/
leadership and stakeholder
support
Component 2: Allocation of
clinical staff
Intervention Summary of suggested implementation intervention elements (associated BCT strategy) (ERIC
function/s strategy) Barriers addressed
Environmental ● Obtain organisational support/commitment from executive and/or leadership to deliver Aphasia Environmental Context and
restructuring LIFT (12.1) Resources
○ Develop business plan outlining program benefits, number of repetitions of the program Intervention adaptability,
possible annually, revenue and costs. complexity & compatibility
○ Form committee/working group to oversee program. Include Aphasia LIFT clinician represen­
tative and executive/director in committee, plus other relevant stakeholders such as program
coordinators and health fund negotiators.
● Conduct local needs assessment by describing usual care and seeking opinions of colleagues on
implementation barriers and level of support
● Promote adaptability of Aphasia LIFT by identifying ways it could be tailored to meet local needs
while still delivering core elements
Environmental ● Allocate sufficient clinical staff to deliver program by a) accessing new funding (12.5) or b) using Environmental Context and
restructuring available staffing differently (12.2), for example: Resources
○ Apply for grants, specific health-fund program funding or partner with universities to increase
funding and/or staffing
○ Consider use of Allied Health Assistants or students to provide elements of Aphasia LIFT
(Continued)
APHASIOLOGY
15

Table 2. (Continued).
Intervention component
Component 3: Clinician training Education
Component 4: Resource
procurement and provision
16
Intervention Summary of suggested implementation intervention elements (associated BCT strategy) (ERIC
function/s strategy) Barriers addressed
● Provide background and overview of Aphasia LIFT (5.1, 2.7) Knowledge, Beliefs about
● Educate about evidence underlying program Aphasia LIFT (5.1, 2.7) capabilities
● Educate about outcomes for patients, services and clinicians (5.1, 5.3)
● Educate about specific therapy techniques if required and provide prompts/reminders on how to
provide these (7.1)
● Promote self-reflection on current practice and whether this aligns with program (2.3)
K. SHRUBSOLE ET AL.
Training and ● Provide training on key elements (including how to use specific resources including goal setting Skills, Environmental Context and
modelling and group therapy resources) (4.1) Resources, Beliefs about
● Demonstrate key elements (e.g., goal setting and group – consider developing videos) (6.1) capabilities
● Incorporate role-play or cases to practice elements, building from simple to more complex cases Patient needs and resources,
(8.1, 8.7) Patient engagement
● Provide feedback on specific tasks within the training session and discuss how this could impact
outcomes (2.2, 2.7)
● Include training on promoting Aphasia LIFT to patients/families to encourage adherence and
discussions around patient readiness, motivation and other therapy commitments (Prepare
patients/consumers to be active participants, intervene with consumers to enhance uptake and
adherence)
Persuasion ● Training conducted by credible source with experience in delivering Aphasia LIFT program (9.1) Beliefs about capabilities
● Incorporate persuasive information about consequences of Aphasia LIFT into training from
credible sources (e.g., video testimonials, patient and clinician quotes) (2.7, 5.1, 5.2, 5.3, 5.6)
● Incorporate persuasive positive feedback about how implementing Aphasia LIFT was/is possible
and reframe perceived challenges into achievable steps (13.2, 15.3)
● Identify local champions to promote Aphasia LIFT to key stakeholders and potential clients, and
to encourage SLPs delivering it (13.1, 15.1, 1.9. 12.1)
Enablement ● Provide support to set goals and develop actionable tasks (1.1, 1.3, 1.4) Beliefs about capabilities,
● Provide support by promoting discussion about perceived challenges, needs, answering ques­ Environmental Context and
tions based on previous experiences (3.1) Resources
Environmental ● Obtain necessary resources to deliver program (computer programs, therapy resources) (12.5) Environmental Context and
restructuring ● Ensure sufficient space to provide individual, groups and computer therapy sessions (12.2) Resources
● Develop and provide access to therapy manuals/protocols (12.2)
● Develop and provide access to resources to support structure of program and bookings – such as
letters, example timetables (12.2, 12.5)
● Develop systems or processes of coordinating bookings with other disciplines (12.1)
● Provide prompts/reminders on how to provide specific therapies (7.1)
(Continued)
Table 2. (Continued).
Intervention Summary of suggested implementation intervention elements (associated BCT strategy) (ERIC
Intervention component function/s strategy) Barriers addressed
Component 5: External/internal Enablement ● Ongoing facilitation and support from external research team (regular phone-calls/visits) (3.2) Beliefs about capabilities,
implementation support ● Research-team support for clinical planning in first cohort then ongoing embedded dedicated Environmental Context and
clinical planning within service (3.2) Resources
● Daily/weekly debriefs in first Aphasia LIFT cohort (3.2)
● Within services, SLPs to meet after Aphasia LIFT goal setting, then initially each day to trouble­
shoot and brainstorm (1.2, 12.1)
● Ongoing team-based goal-setting and action planning to overcome problems eg choosing a start
date etc, overcoming issues with transport and booking group rooms (12.1, 1.5, 1.7)
● Research team to provide resources to structure program and booking (12.5)
Component 6: Consumer N/A ● Collect feedback and testimonials on program at the end of each cohort (Obtain and use Patient needs and resources, Patient
engagement and promotion patients/consumers and family feedback) engagement
● Celebrate success of program with face-to-face social functions or newsletters (Involve patients/
consumers and family members)
BCT = Behaviour Change Technique; ERIC = Expert Recommendations for Implementing Change
APHASIOLOGY
17
18 K. SHRUBSOLE ET AL.

implementation and aims to promote contextualised support though interactive

problem solving and a supportive interpersonal relationship (Powell et al., 2012).
Within services, Aphasia LIFT clinicians will support each other through regular
informal and formal troubleshooting and planning meetings and support from
their department directors.
(6) Consumer engagement and promotion: Throughout implementation, consumer
feedback will be collected and incorporated into future training and program
modifications. The program will be promoted through a variety of means, includ­
ing newsletters, media, and engagement with relevant consumer advisory
boards.

Discussion
This study sought to identify clinicians’ perceptions of factors influencing implementation
of Aphasia LIFT (a modified ICAP) into clinical practice and develop a tailored, theory-
informed implementation intervention. Factors influencing implementation were identi­
fied using the TDF. The clinical stakeholder participant group identified four key barriers
(‘environmental context and resources’, ‘patient factors’, ‘beliefs about capabilities’, and
‘the Aphasia LIFT innovation’) and two domains that acted as both barriers and facilitators
(‘knowledge’ and ‘skills’). The Aphasia LIFT clinicians identified two key barriers (‘patient
factors’ and ‘beliefs about capabilities’) and three domains that acted as both barriers and
facilitators (‘skills’, ‘environmental context and resources’, and ‘the Aphasia LIFT
innovation’).
The predominant barrier identified by clinical stakeholders was the nature of the
‘Aphasia LIFT innovation’ itself, due to the perceived lack of flexibility with the program
and challenges with achieving a patient cohort. This finding aligns with Trebilcock et al.
(2019) where the concept of implementing an entire ICAP was seen as unachievable for
most clinicians. The ‘Aphasia LIFT innovation’ barrier interconnected with the overall
‘beliefs about capabilities’ barrier for both participant groups, where there was a sense
of disempowerment and lack of behavioural control in implementing the program in its
entirety. Clinical stakeholders’ self-efficacy was also influenced by ‘environmental context
and resources’ constraints, similar to barriers reported elsewhere, including an organisa­
tional culture focussed on discharging a patient from the service (Trebilcock et al., 2019),
lack of specific treatment guidance (Trebilcock et al., 2019), and insufficient staff and
funding (Rose et al., 2021; Trebilcock et al., 2019), The initial costs of establishing an ICAP
are high (Boyer et al., 2020), and ICAPs are known to be resource and staff intensive in
both the US (Boyer et al., 2020) and UK (Leff et al., 2021). A cost analysis of Aphasia LIFT has
not yet been conducted, but would enable informed planning of Aphasia LIFT implemen­
tation and it is recommended a cost analysis is conducted in the next phase of this
research. Both participant groups in the current study identified ‘patient factors’ as a main
implementation barrier, due to the variation in the patient’s level of family support,
presence of comorbidities, the impact of fatigue on therapy participation, and their
perceived ‘readiness’ for Aphasia LIFT. This is consistent with previous research where
clinicians perceived patient motivation, health status and readiness for therapy as poten­
tial implementation barriers (Trebilcock et al., 2019). However, although clinicians were
concerned that Aphasia LIFT would be too intensive for some patients, people with
 APHASIOLOGY 19

aphasia in a previous ICAP study reported that fatigue was not a major concern overall as
the intensity allowed patients to see progress more quickly (Babbitt et al., 2021). Further
research into the potential impact of fatigue and patient profiles on patient participation,
and the ideal timing of an ICAP is required.
Although there were similarities between the participant groups in this study, some
key differences were noted. For example, the ‘emotion’ domain was not a key influencing
factor for the clinical stakeholder group but facilitated practice for the Aphasia LIFT
clinicians, perhaps reflecting the rewarding experience of delivering an ICAP. This finding
aligns with previous clinician feedback on ICAPs, where clinicians felt rewarded by their
ability to provide in-depth treatment and seeing their patients improve (Babbitt et al.,
2013). In addition, the ‘social/professional role and identity’ domain was a key facilitator
for the clinical stakeholder group but not for the Aphasia LIFT clinician group, who did not
mention this factor as influencing their practice (as either a barrier or facilitator).
Interestingly, this domain was identified as a barrier in Trebilcock et al’s (2019) study,
reinforcing the importance of determining barriers in the specific implementation con­
text, so that implementation interventions do not target irrelevant barriers unnecessarily.
Similar to Trebilcock et al. (2019), the domains ‘skills’ and ‘knowledge’ acted as both
barriers and facilitators in our study, supporting the need for ICAP implementation
interventions to include educational and training elements. However, also like the
Trebilcock et al. (2019) study, we found additional barriers that would not be sufficiently
addressed by training alone. For example, environmental restructuring (in the form of
obtaining organisational commitment and allocating sufficient staff) was considered an
essential component of our Aphasia LIFT implementation intervention. This finding
reinforces the concept that an overreliance on education and training in healthcare
could lead to missed opportunities in designing a potentially effective intervention
(Atkins et al., 2020), and that prospective tailoring to identified barriers is necessary
(Baker et al., 2015).
To the authors’ knowledge, this is the first published study to prospectively develop
a tailored implementation intervention for a specific ICAP/mICAP. The resulting proposed
implementation intervention includes six intervention functions (education, training,
persuasion, modelling, environmental structuring, and enablement) linked to the four
TDF barriers, plus six ERIC strategies to address the ‘Aphasia LIFT innovation’ and ‘patient
factors’ barriers. Although our proposed intervention includes some similar elements to
Trebilcock et al.’s (2021) online intervention (e.g., education, persuasion, modelling and
enablement), the key difference was the inclusion of face-to-face training in our interven­
tion. Training was identified as an important component by participants in both studies,
but Trebilcock’s participants felt that training was neither feasible nor practical to include
in an online intervention and should “happen more locally” (Trebilcock et al., 2021,
page 5). This could suggest that while general overarching principles for ICAP implemen­
tation are possible without training, it is necessary to include training and more localised
support for specific programs such as Aphasia LIFT. In addition, our implementation
intervention used two theoretical frameworks; this has the potential to target identified
organisational and patient-related barriers more comprehensively (Ahmet et al., 2020),
and may result in greater uptake of Aphasia LIFT.
20 K. SHRUBSOLE ET AL.

Overall, the use of a theoretical framework to guide the interviews, analysis, and
intervention mapping was a strength of this study as it allowed for a systematic and
replicable approach. In addition, the clinical stakeholder sample included a variety of
demographic considerations enhancing the richness of the data and applicability of the
findings to similar contexts (i.e., metropolitan health services within the Australian
healthcare context). However, it is unlikely that findings will be generalisable to other
contexts such as rural settings, or countries with different healthcare contexts including
those with increased capacity to provide community services. In addition, with only one
community and two private settings included in our sample, the implications for Aphasia
LIFT implementation in these settings are less well understood. The funding implications
highlighted by the private setting clinical stakeholders indicated that there would likely
need to be different funding considerations for private patients; future implementation
research should explore this context in more detail.
Furthermore, the sample size of Aphasia LIFT clinicians was modest; while the
results for this group should be interpreted with some caution, the similarities
between the two participant groups provides some confidence in the findings. It
should also be noted that the interviews were conducted prior to the Covid-19
pandemic, and therefore prior to significant health service disruptions (e.g., shift
towards virtual care), and it is unclear whether the key barriers have since changed.
This impact of Covid-19 on service delivery will need to be considered in implemen­
tation efforts conducted during or after the pandemic, with efforts to deliver Aphasia
LIFT via telerehabilitation likely required.

Clinical Applications
The next steps in this research will be to engage with local end-users (clinical services
and clinicians) to seek feedback on the specific BCTs included in the implementation
intervention, and then piloting the Aphasia LIFT implementation intervention. It is
anticipated that there would need to be variations in the implementation strategies
across different types of health care services in terms of funding models and who needs
to give organisation support or approval before a program can be implemented. This
process of engaging with end-users is recommended as a critical component of design­
ing organisation and system-level implementation interventions (Colquhoun et al.,
2017). Following this, a larger-scale hybrid implementation-effectiveness study is
planned to evaluate which implementation components are effective. Clinical services
interested in implementing elements of our proposed intervention could similarly
decide which behaviour change strategies are most feasible, acceptable, and relevant
to their local context.

Conclusion
Implementation of Aphasia LIFT (a modified ICAP) and ICAPs more broadly into clinical
practice may optimise the quality of aphasia care and improve patients’ outcomes. The
key barriers identified as influencing clinical Aphasia LIFT implementation in the
Australian healthcare context included environmental context and resources, beliefs
about capabilities, the Aphasia LIFT innovation, patient factors, knowledge, and skills.
 APHASIOLOGY 21

Mapping these barriers to BCTs and implementation strategies resulted in a theory-

informed implementation intervention considered likely to be feasible and effective in
enhancing the uptake of Aphasia LIFT within clinical services. The effectiveness of the
proposed implementation intervention will be evaluated in a hybrid effectiveness-
implementation trial.

Acknowledgement
The authors wish to thank all the speech language pathologists who participated in this study. In
addition, we thank and acknowledge Emma Caird and Dr Sarah Wallace for their input into the interview
guide. Finally, we thank and acknowledge the contribution of Annabel Dunphy, Amanda Holland and
Grace Kim, speech-language pathology students who contributed to coding the participant data.

Data Availability
The data that supports the findings of this study are available in the supplementary material of this
article.
Correspondence details for this paper are: Dr Kirstine Shrubsole, Faculty of Health, Southern Cross
University, Gold Coast, Qld 4225, Australia. E-mail: kirstine.shrubsole@scu.edu.au

Disclosure of interest
Authors LW, DC and AR were involved in the development of the Aphasia LIFT program.
All other authors report no conflict of interest.

Declarations

● All authors read and approved the final manuscript.

● Ethics approval and consent to participate: The study had approval by a Human
Research Ethics Committee.

Disclosure Statement
No potential conflict of interest was reported by the authors.

ORCID
Kirstine Shrubsole http://orcid.org/0000-0002-7805-2447
David Copland http://orcid.org/0000-0002-2257-4270
Annie Hill http://orcid.org/0000-0003-3907-8369
Asaduzzaman Khan http://orcid.org/0000-0003-4188-2065
Melissa Lawrie http://orcid.org/0000-0002-0763-874X
Denise A. O’Connor http://orcid.org/0000-0002-6836-122X
Elizabeth C. Ward http://orcid.org/0000-0002-2680-8978
Linda Worrall http://orcid.org/0000-0002-3283-7038
Marie-Pier McSween http://orcid.org/0000-0003-1614-5127
22 K. SHRUBSOLE ET AL.

References
Ahmed, S., Zidarov, D., Eilayyan, O., & Visca, R. (2020). Prospective application of implementation
science theories and frameworks to inform use of PROMs in routine clinical care within an
integrated pain network. Qual Life Res, 30(11), 3035–3047. https://doi.org/10.1007/s11136-020-
02600-8
Atkins, L., Sallis, A., Chadborn, T., Shaw, K., Schneider, A., Hopkins, S., Bunten, A., Michie, S., &
Lorencatto, F. (2020). Reducing catheter-associated urinary tract infections: A systematic review
of barriers and facilitators and strategic behavioural analysis of interventions. Implementation
science, 15(1), 1–22. https://doi.org/10.1186/s13012-020-01001-2
Babbitt, E. M., Worrall, L., & Cherney, L. (2013). Clinician perspectives of an intensive comprehensive
aphasia program. Top Stroke Rehabil, 20(5), 399–408. https://doi.org/10.1310/tscir2001-398
Babbitt, E. M., Worrall, L., & Cherney, L. R. (2015). Structure, processes, and retrospective outcomes
from an intensive comprehensive aphasia program. Am J Speech Lang Pathol, 24(4), S854–S863.
https://doi.org/10.1044/2015_AJSLP-14-0164
Babbitt, E. M., Worrall, L., & Cherney, L. R. (2021). “It’s like a lifeboat”: Stakeholder perspectives of an
intensive comprehensive aphasia program (ICAP). Aphasiology, 1–23. https://doi.org/10.1080/
02687038.2021.1873905
Baker, R., Camosso-Stefinovic, J., Gillies, C., Shaw, E. J., Cheater, F., Flottorp, S., Robertson, N.,
Wensing, M., Fiander, M., Eccles, M. P., Godycki-Cwirko, M., Lieshout, J. v., & Jager, C. (2015).
Tailored interventions to address determinants of practice. Cochrane Database Syst Rev, 4(4),
CD005470–CD005470. https://doi.org/10.1002/14651858.CD005470.pub3
Boyer, N., Jordan, N., & Cherney, L. R. (2020). Implementation cost analysis of an Intensive
Comprehensive Aphasia Program. Arch Phys Med Rehabil. https://doi.org/10.1016/j.apmr.2020.
09.398
Brady, M. C., Kelly, H., Godwin, J., Enderby, P., Campbell, P., & Brady, M. C. (2016). Speech and
language therapy for aphasia following stroke. Cochrane Database Syst Rev, 2016(6), CD000425–
CD000425. https://doi.org/10.1002/14651858.CD000425.pub4
Brady, M. C., Ali, M., VandenBerg, K., et al. (2021). Dosage, intensity, and frequency of language
therapy for aphasia: A systematic review-based, individual participant data network
meta-analysis. Stroke, https://doi.org/10.1161/STROKEAHA.121.035216
Brown, S. E., Brady, M. C., Worrall, L., & Scobbie, L. (2021). A narrative review of communication
accessibility for people with aphasia and implications for multi-disciplinary goal setting after
stroke. Aphasiology, 35(1), 1–32. https://doi.org/10.1080/02687038.2020.1759269
Cane, J., O’Connor, D., & Michie, S. (2012). Validation of the Theoretical Domains Framework for use
in behaviour change and implementation research. Implement Sci, 7(1), 37–37. https://doi.org/10.
1186/1748-5908-7-37
Cherney, L. R. (2012). Aphasia treatment: Intensity, dose parameters, and script training. Int J Speech
Lang Pathol, 14, 424–431. https://doi.org/10.3109/17549507.2012.686629
Colquhoun, H. L., Squires, J. E., Kolehmainen, N., Fraser, C., & Grimshaw, J. M. (2017). Methods for
designing interventions to change healthcare professionals’ behaviour: A systematic review.
Implement Sci, 12(1), 30–30. https://doi.org/10.1186/s13012-017-0560-5
Curran, G. M., Bauer, M., Mittman, B., Pyne, J. M., & Stetler, C. (2012). Effectiveness-implementation
hybrid designs: Combining elements of clinical effectiveness and implementation research to
enhance public health impact. Med Care, 50(3), 217–226. https://doi.org/10.1097/MLR.
0b013e3182408812
Dignam, J., Copland, D., McKinnon, E., Burfein, P., O’Brien, K., Farrell, A., & Rodriguez, A. D. (2015).
Intensive versus distributed aphasia therapy: A nonrandomized, parallel-group,
dosage-controlled study. Stroke, 46(8), 2206–2211. https://doi.org/10.1161/STROKEAHA.115.
009522
Eccles, M., Grimshaw, J., Walker, A., Johnston, M., & Pitts, N. (2005). Changing the behavior of
healthcare professionals: The use of theory in promoting the uptake of research findings. J Clin
Epidemiol, 58(2), 107–112. https://doi.org/10.1016/j.jclinepi.2004.09.002
 APHASIOLOGY 23

Fetters, M. D., Curry, L. A., & Creswell, J. W. (2013). Achieving integration in mixed methods
designs-principles and practices. Health Serv Res, 48(6pt2), 2134–2156. https://doi.org/10.1111/
1475-6773.12117
Glasgow, R. E., Lichtenstein, E., & Marcus, A. C. (2003). Why don’t we see more translation of health
promotion research to practice? Rethinking the efficacy-to-effectiveness transition. Am J Public
Health, 93(8), 1261–1267. https://doi.org/10.2105/AJPH.93.8.1261
Graneheim, U. H., & Lundman, B. (2004). Qualitative content analysis in nursing research: Concepts,
procedures and measures to achieve trustworthiness. Nurse Educ Today, 24(2), 105–112. https://
doi.org/10.1016/j.nedt.2003.10.001
Griffin-Musick, J. R., Off, C. A., Milman, L., Kincheloe, H., & Kozlowski, A. (2021). The impact of a
university-based Intensive Comprehensive Aphasia Program (ICAP) on psychosocial well-being in
stroke survivors with aphasia. Aphasiology, 35(10), 1363–1389. https://doi.org/10.1080/02687038.
2020.1814949
Hersh, D., Worrall, L., Howe, T., Sherratt, S., & Davidson, B. (2012). SMARTER goal setting in aphasia
rehabilitation. Aphasiology, 26(2), 220–233. https://doi.org/10.1080/02687038.2011.640392
Hoover, E. L., Caplan, D. N., Waters, G. S., & Carney, A. (2017). Communication and quality of life
outcomes from an interprofessional intensive, comprehensive, aphasia program (ICAP). Top
Stroke Rehabil, 24(2), 82–90. https://doi.org/10.1080/10749357.2016.1207147
Huijg, J. M., Gebhardt, W. A., Dusseldorp, E., Verheijden, M. W., van der Zouwe, N.,
Middelkoop, B. J. C., & Crone, M. R. (2014). Measuring determinants of implementation behavior:
Psychometric properties of a questionnaire based on the theoretical domains framework.
Implement Sci, 9(1), 33–33. https://doi.org/10.1186/1748-5908-9-33
Lanyon, L. E., Rose, M. L., & Worrall, L. (2013). The efficacy of outpatient and community-based
aphasia group interventions: A systematic review. Int J Speech Lang Pathol, 15(4), 359–374.
https://doi.org/10.3109/17549507.2012.752865
Leff, A. P., Nightingale, S., Gooding, B., Rutter, J., Craven, N., Peart, M., Dunstan, A., Sherman, A.,
Paget, A., Duncan, M., Davidson, J., Kumar, N., Farrington-Douglas, C., Julien, C., & Crinion, J. T.
(2021). Clinical effectiveness of the Queen Square Intensive Comprehensive Aphasia Service for
patients with poststroke aphasia. Stroke, 52(10), E594–E598. https://doi.org/10.1161/STROKEAHA.
120.033837
Michie, S., Johnston, M., Abraham, C., Lawton, R., Parker, D., & Walker, A. (2005). Making psycholo­
gical theory useful for implementing evidence based practice: A consensus approach. Qual Saf
Health Care, 14(1), 26–33. https://doi.org/10.1136/qshc.2004.011155
Michie, S., Richardson, M., Johnston, M., Abraham, C., Francis, J., Hardeman, W., Eccles, M. P., Cane, J.,
& Wood, C. E. (2013). The Behavior Change Technique Taxonomy (v1) of 93 hierarchically
clustered techniques: Building an international consensus for the reporting of behavior change
interventions. Ann Behav Med, 46(1), 81–95. https://doi.org/10.1007/s12160-013-9486-6
Michie, S., Atkins, L., & West, R. (2014). The behaviour change wheel: A guide to designing Interventions.
Silverback.
Monnelly, K., Marshall, J., & Cruice, M. (2021). Intensive Comprehensive Aphasia Programmes:
A systematic scoping review and analysis using the TIDieR checklist for reporting interventions.
Disability and Rehabilitation, ahead-of-print, 1–26. https://doi.org/10.1080/09638288.2021.
1964626
Pierce, J. E., O’Halloran, R., Menahemi-Falkov, M., Togher, L., & Rose, M. L. (2021). Comparing higher
and lower weekly treatment intensity for chronic aphasia: A systematic review and meta-analysis.
Neuropsychological rehabilitation, 31(8), 1289–1313. https://doi.org/10.1080/09602011.2020.
1768127
Powell, B. J., McMillen, J. C., Proctor, E. K., Carpenter, C. R., Griffey, R. T., Bunger, A. C., Glass, J. E., &
York, J. L. (2012). A compilation of strategies for implementing clinical innovations in health and
mental health. Med Care Res Rev, 69(2), 123–157. https://doi.org/10.1177/1077558711430690
Proctor, E. K., Landsverk, J., Aarons, G., Chambers, D., Glisson, C., & Mittman, B. (2008).
Implementation research in mental health services: An emerging science with conceptual,
methodological, and training challenges. Adm Policy Ment Health, 36(1), 24–34. https://doi.org/
10.1007/s10488-008-0197-4
24 K. SHRUBSOLE ET AL.

QSR International Pty Ltd. (2018). NVivo qualitative data analysis software (Vol. Version 12).
Rodriguez, A. D., Worrall, L., Brown, K., Grohn, B., McKinnon, E., Pearson, C., Van Hees, S., Roxbury, T.,
Cornwell, P., MacDonald, A., Angwin, A., Cardell, E., Davidson, B., & Copland, D. A. (2013). Aphasia
LIFT: Exploratory investigation of an intensive comprehensive aphasia programme. Aphasiology,
27(11), 1339–1361. https://doi.org/10.1080/02687038.2013.825759
Rose, M. L., Cherney, L. R., & Worrall, L. E. (2013). Intensive Comprehensive Aphasia Programs: An
international survey of practice. Top Stroke Rehabil, 20(5), 379–387. https://doi.org/10.1310/
tsr2005-379
Rose, M. L., Pierce, J. E., Scharp, V. L., Off, C. A., Babbitt, E. M., Griffin-Musick, J. R., & Cherney, L. R.
(2021). Developments in the application of Intensive Comprehensive Aphasia Programs: An
international survey of practice. Disability and Rehabilitation, 1–15. https://doi.org/10.1080/
09638288.2021.1948621
Rosewilliam, S., Roskell, C. A., & Pandyan, A. D. (2011). A systematic review and synthesis of the
quantitative and qualitative evidence behind patient-centred goal setting in stroke rehabilitation.
Clin Rehabil, 25(6), 501–514. https://doi.org/10.1177/0269215510394467
Simmons-Mackie, N. (2018). The state of aphasia in North America: A white paper. Moorestown, NJ:
Aphasia Access.
Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting qualitative research
(COREQ): A 32-item checklist for interviews and focus groups. Int J Qual Health Care, 19(6),
349–357. https://doi.org/10.1093/intqhc/mzm042
Trebilcock, M., Worrall, L., Ryan, B., Shrubsole, K., Jagoe, C., Simmons-Mackie, N., Bright, F., Cruice, M.,
Pritchard, M., & Le Dorze, G. (2019). Increasing the intensity and comprehensiveness of aphasia
services: Identification of key factors influencing implementation across six countries.
Aphasiology, 33(7), 865–887. https://doi.org/10.1080/02687038.2019.1602860
Trebilcock, M., Shrubsole, K., Worrall, L., & Ryan, B. (2021). Development of an online implementation
intervention for aphasia clinicians to increase the intensity and comprehensiveness of their
service. Disabil Rehabil, 1–10. https://doi.org/10.1080/09638288.2021.1910867
Waltz, T. J., Powell, B. J., Fernández, M. E., Abadie, B., & Damschroder, L. J. (2019, 2019/04/29).
Choosing implementation strategies to address contextual barriers: Diversity in recommenda­
tions and future directions. Implementation Science, 14(1), 42. https://doi.org/10.1186/s13012-
019-0892-4
Winans-Mitrik, R. L., Hula, W. D., Dickey, M. W., Schumacher, J. G., Swoyer, B., & Doyle, P. J. (2014).
Description of an intensive residential aphasia treatment program: Rationale, clinical processes,
and outcomes. Am J Speech Lang Pathol, 23(2), S330–S342. https://doi.org/10.1044/2014_AJSLP-
13-0102
World Health Organization. (2001). International classification of functioning, disability and health:
ICF. World Health Organization.
Zheng, C., Lynch, L., & Taylor, N. (2016). Effect of computer therapy in aphasia: A systematic review.
Aphasiology, 30(2–3), 211–244. https://doi.org/10.1080/02687038.2014.996521