The review question addressed was: How is the process of assessment, goal setting, intervention and reassessment applied by interdisciplinary teams in the rehabilitation of stroke patients with aphasia?

Searches were conducted in online databases (Embase, Ovid Medline, Cinahl, Cochrane Library, Proquest and Web of Science). The following key-words were systematically searched for, both separately and in combination with AND and OR: stroke, aphasia, communication impairment, language tests/hearing test, communication, speech, language, hearing, verbal, evaluation, mapping, assessment, check-up, examination and screening. The first search, which was broad, took place in January 2015 in three databases, Embase, Ovid Medline and Cochrane Library, and resulted in 1206 hits. The second search in March, 2015 was refined and key search terms included: stroke, aphasia, communication, interdisciplinary and rehabilitation. The MeSH headings and free text terms were combined to form the more specific terms mentioned above. An example of the search in one of the main databases, Ovid MEDLINE is presented in Table 1.

Studies of aphasia due to causes other than stroke were excluded, as were studies conducted before 2005. Two of the authors (S.V., T.O.) assessed the data extracted. A total of 248 titles met the inclusion criteria, of which nine were included for quality assessment. One study [14] was acquired at the Norwegian Stroke Conference 2015, which we attended. The retrieval process is presented in Figure 1.

The inclusion criteria were: 1) peer-reviewed research; 2) published in the English language; 3) studies focusing on the stroke rehabilitation process; 4) studies from the perspective of interdisciplinary teamwork in the rehabilitation process; and 5) studies that focused on experiences of communication with patients with aphasia. Supplements, theoretical frameworks, review articles and grey literature were excluded.

Each identified article was appraised using the PRISMA checklist of items to describe and analyse the quality [16] . All included articles were reviewed twice by the first two authors, after which they were checked by the third author in order to achieve consensus on the selection.

The papers were read thoroughly several times by the first two authors (S.V. & T.O.) both separately and together. The content was discussed and reread before data extraction. Data were extracted from the nine papers by systematizing: author, country, year of publication, design, sample, analysis, aim and main findings. Details of the studies included in the review are presented in Table 2, and main findings are highlighted by cursive italic fonts.

The methodological quality of the included studies was thoroughly assessed by two of the authors (SV, TKO) using a modified version of the Norwegian Knowledge Centre for Health Services (NOKC) check-list for cross sectional studies [17] . This check-list is a tool for assessing the degree to which the methodology of the studies encompasses the risk of systematic bias. The check-list contains eight questions assessing: 1. Population, 2. Sampling methods, 3. Comparison of respondents and non-respondents, 4. Response rate, 5. Data collection procedures, 6. Reliability and validity, 7. Statistical methods and 8. Ethical considerations. Studies that fulfilled more than 50% of the criteria were rated as “Acceptable”. Although one study was rated “Low” in terms of methodological quality as the methodology used did not appear to match the check-list criteria, it was deemed important to include its content. When in doubt, we consulted the third author (ES). No studies were excluded due to low quality. Methodological shortcomings mainly concerned criteria 3 and 8, and demonstrated in Table 3.

Opportunities for and barriers to an optimal rehabilitation are interpreted and presented under the following headings; assessment and assessment tools, goal setting, interventions and reassessment. A brief outline of the main positive and negative out- comes of rehabilitation of stroke patients with aphasia is presented in Table 5.

Interdisciplinary teamwork is a prerequisite for rehabilitation. The included studies highlight the variety of healthcare professionals involved in the rehabilitation of stroke patients with aphasia. The studies refer to SLTs, rehabilitation assistants, physiotherapists, occupational therapists, SCCs, nurses, nurse assistants, senior care assistants, healthcare assistants, dieticians, medical experts/physicians, social workers, a psychologist, an engineer and technical support. Some studies described next to kin as useful collaborative partners.

There is an unmet need for learning more about interdisciplinary teamwork among senior care assistants and nursing home nurses [23] . The benefits of interdisciplinary teamwork became more integrated after a staff training programme, which led to team- work competence and job satisfaction [22] . Allied health staff, nurses, health care assistants and therapy assistants also had formal sessions guided by psychologists, an occupational therapist and SLTs. This training resulted in increased knowledge and confidence, integrated team-working and the holistic management of patients [11] . An interdisciplinary training programme entitled “Training the trainers” was developed to support fragile communication following stroke and former stroke patients were involved in designing it. The result was less avoidance of communication with patients with aphasia and more support being offered [22] .

Nursing home staff required more knowledge about interdisciplinary activities [23] , as well as training and education in stroke assessment, utilizing assessment tools and goal-setting. Senior care assistants needed better skills in communicating with dysphasic patients [23] , while nursing home nurses requested accredited education [23] . The interdisciplinary team needs training, while continuity can be ensured by using the same assessment tool and referral system every time. Healthcare professionals require knowledge about how cognition and fatigue influence interventions for persons with aphasia [18] . Ross’ study developed an interdisciplinary training programme to increase staff knowledge in terms of recognition and basic management of emotional, cognitive and communication problems following stroke [22] . After completing the programme the interdisciplinary team members reported improved assessment skills and better management of mood, cognition and communication [22] .

A problem is that healthcare professionals can misinterpret patients who suffer from aphasia after stroke. The aphasia might be understood as a vague response or lack of interest and cooperation [14] . This misinterpretation on the part of staff members can cause them to devote less attention and interaction time to patients [14] , and difficulty reaching the point at which to start rehabilitation. Moreover, the emotional stress and social limitation experienced by patients with aphasia can be ignored from the start [5] . The fact that patients with aphasia are not informed about their status and prognosis might be demotivating for them [14] . When healthcare professionals’ pattern of care is weak in the area of rehabilitation, it must be strengthened. As communication is a reliable key to social participation, patients with aphasia are dependent on tailored rehabilitation [4] [5] [9] .

Without an appropriate assessment there is no basis for rehabilitation, thus all approaches will be random. As time is a crucial factor, the assessment must start as soon as possible for in-patients [21] . Competence and confidence are required to make optimal use of the wide variety of available assessment tools. Evidence reveals that knowledge and training are essential for enabling staff members to utilize assessment tools [23] . Existing assessment tools and the ACAS were not always considered appropriate for stroke patients with aphasia or severe aphasia [2] [18] . The ICF seems to incorporate relevant factors for the assessment procedure, thus it is necessary to develop a new sustainable assessment tool based on the ICF [19] [24] . It is challenging to construct a user-friendly tool based on the ICF [20] [24] . The PSC was intended to focus on long-term assessment with an interdisciplinary approach based on the 11 relevant ICF areas for persons with impairment after stroke [20] . A prerequisite for successful rehabilitation of persons suffering from aphasia appears to be employing the ICF framework as a base for assessment by operationalizing the main components of functioning, disability and health. There is no doubt that for patients with aphasia, SLTs are the most competent professional category to carry out the assessment, set goals and decide how to intervene. The core improvements for persons with aphasia concern how language is transferred and applied to their real life [24] . Threats state that the question is how the ICF can contribute to improving the quality of life for persons with aphasia. Environmental factors influence patients’ situation and have an impact on the assessment. The patient’s condition can hinder or promote a successful assessment. Fatigue, depression, hunger, lack of sleep, pain, etc. can make a valid assessment impossible [23] . As patients with aphasia spend most of their time with nurses and senior care assistants, members of these two professional categories are essential for detecting such factors, thus facilitating a valid assessment.

Impairments following a stroke are complex and require a highly complicated and specific rehabilitation, which must be provided by an interdisciplinary care team [4] . Of the healthcare professionals mentioned as part of the interdisciplinary teams that provide care to stroke patients, SLTs have the highest competence in the area of speech and language impairments. As nurses and nurse assistants spend a great deal of time close to patients with aphasia [22] , they can facilitate continuity in the assessments, intervention and reassessment. Patients with aphasia receive less attention and are often negatively labelled [14] . This demands improved awareness and attention on the part of the nurses and nurse assistants to ensure that the patients are seen and communicated with.

This close relationship means that nurses are in a special position to assess the patients and conduct interventions in daily care situations [21] , thus they have a central role inthe interdisciplinary team. However, stroke unit nurses did not appear to be well integrated in the interdisciplinary team [25] . There is an urgent need to re-examine the role of nurses in stroke rehabilitation to enable them to make a substantial contribution to the interdisciplinary work [11] . Nurses are not always aware of this responsibility. In-patients with stroke expected nurses to be the main information provider [14] . The fact that this is not the case means that there is unused potential in the rehabilitation process.

Different professional categories have a role in supporting the rehabilitation of patients with stroke [18] . However, the care team does not always function as an operational interdisciplinary team [11] [21] . While the interdisciplinary approach appears to function for patients with severe sequelae, our findings reveal that it tends not to function as well for patients with milder complications [2] [11] [18] [19] [23] . The question is which priority is given to active interdisciplinary rehabilitation for the group with milder complications and whether the team is designed to be goal oriented. Inefficient rehabilitation strategies could result in unused potential and reduce the patients’ chances of regaining their ability to communicate. The time at which the intervention takes place and the amount of training are important for successful rehabilitation of aphasia after stroke. To achieve the best possible result, the whole team, including nurses and nursing assistants, must collaborate closely with each other and actively motivate, guide and stimulate the patient. Utilizing periods when the patient is awake, alert and motivated is crucial for success as it enables the amount of training to be increased and exercises to be transferred to different situations.

In our opinion, a successful rehabilitation team for persons with complications after stroke, especially those who suffer from aphasia, is one that collaborates closely and is co-located. Being unable to express oneself must be so full of hopelessness and fear that interpreting and facilitating rehabilitation best practice in stroke units and the community health services should be a high priority for closely collaborating interdisciplinary teams. To achieve this all health professionals, including nurses, must be integrated in the team, seize the right moments, take responsibility and interpret their role as important for the rehabilitation. A prerequisite for successful further rehabilitation in the community health service is the design of functional interdisciplinary teams that include nurses and nursing assistants.

A need for more education and training was one of the major findings in this review [2] [11] [18] [22] [23] . Studies show that the level of staff competence influences how patients with aphasia are communicated with [21] - [23] . A skilled team increases confidence and safeguards the quality of the rehabilitation process for stroke patients [11] [21] [22] . Results reveal greater confidence in communication with patients, use of assessment tools and in interdisciplinary collaboration after completion of a training programme [22] [23] . Staff members exhibited greater recognition and acceptance of the patients’ speech problems, frustration and distress. Care for families and next of kin strengthened mutual collaboration and improved rehabilitation [14] [23] . Competence in using devices and confidence in the shared goals and strategies facilitated collaborative practice and improved the overall outcome for the person with aphasia [21] .

Another way of increasing competence involves sharing professional knowledge by working in opportunistic dialogue [11] . In the team, the effect of learning and working together by sharing core skills led to a common understanding instead of professional defence. The whole team was aware of and shared the patients’ goals, thus the members made a concerted effort to work towards them together, leading to successful rehabilitation. Sharing knowledge in the team increased motivation and engagement, while alternative ways of conceptualizing the rehabilitation interventions proved beneficial for patients [11] . Work satisfaction and enthusiasm make staff desirous for training [23] .

Some studies mentioned experiences of designing and running training programmes [22] . To achieve a really practical and useful content, one study described how former stroke patients were recruited to assist in designing the training programme, as well as presenting some parts of it [22] . This was evaluated as a success.