Communication partner training for student health and social care professionals engaging with people with stroke acquired communication difficulties: A protocol for a realist review.

Background Stroke acquired communication impairments impede effective communication. Consequently, in stroke care, communicative interactions can be challenging for both patients and staff and can predispose patients to increased risk of preventable adverse events. Communication partner training (CPT) can mitigate such negative outcomes by optimising communicative interactions. Providing CPT to student health and social care professionals (SH&SCPs) has the potential to enhance their clinical expertise and experiences and enhance the future clinical care of patients with stroke acquired communication impairments. This research aims to expand our understanding of how CPT is operationalised for SH&SCPs in higher education institutions and determine: what works; for whom; in what contexts; how and why? Methods This review is Phase 1 of a research project employing a realist approach with public and patient involvement (PPI). It incorporates five iterative steps: 1.) Clarifying the scope; 2.) Searching for evidence; 3.) Selecting and appraising evidence; 4.) Data extraction; 5.) Synthesising data and developing a middle range theory explaining how CPT is expected to work for SH&SCPs. An advisory panel, including PPI advisors, content advisors, student advisors, realist advisors and educationalist advisor has been set up to consult throughout the review and collaboratively agree the middle range theory. Discussion While there is an evolving evidence base for CPT, including stroke specific CPT for SH&SCPs, it is acknowledged that there are challenges to its implementation in complex real-world settings. In combining empirical evidence with theoretical understanding, realist review permits synthesis of data from diverse sources and goes beyond determining efficacy to explore generative causation and solutions for real world practice. A middle range realist programme theory that coherently explains how CPT is expected to work when teaching SH&SCPs to communicate with people with stroke acquired communication impairments will provide educators with new insights into CPT development and implementation in their higher education institutions.


Methods
This review is Phase 1 of a research project employing a realist approach with public and patient involvement (PPI).It incorporates five iterative steps: 1.) Clarifying the scope; 2.) Searching for evidence; 3.) Selecting and appraising evidence; 4.) Data extraction; 5.) Synthesising data and developing a middle range theory explaining how CPT is expected to work for SH&SCPs.An advisory panel, including PPI advisors, content advisors, student advisors, realist advisors and educationalist advisor has been set up to consult throughout the review and collaboratively agree the middle range theory.

Discussion
While there is an evolving evidence base for CPT, including stroke specific CPT for SH&SCPs, it is acknowledged that there are challenges to its implementation in complex real-world settings.In combining empirical evidence with theoretical understanding, realist review permits synthesis of data from diverse sources and goes beyond determining efficacy to explore generative causation and solutions for real world practice.A middle range realist programme theory that coherently explains how CPT is expected to work when teaching SH&SCPs to communicate with people with stroke acquired communication impairments will provide educators with new insights into CPT development and implementation in their higher education institutions.

Stroke acquired communication impairments
In 2019 the global incidence of stroke was reported to be 12.2 million and stroke was reported as the third leading cause of death and disability resulting in 143 million people living with "disability-adjusted life-years" (Stark et al., 2021, p. 795).Among these life adjusting disabilities are the communication impairments aphasia, dysarthria, apraxia of speech and cognitive communication disorders (Baker et al., 2022).These impairments (overviewed in Table 1) can occur in isolation or in varying combinations and with varying severities.Their incidence and prevalence will increase in the coming decades in line with the predicted increased incidence of stroke world-wide (Stark et al., 2021).Specific to the European Union, Wafa et al. (2020) anticipate that the people living with stroke will have increased by 27% between 2017 and 2047.Studies reporting on the specific incidence and prevalence of stroke acquired communication impairments are variable, for example, they differ in geographical origins, number of participants and designs and methods (Frederick et al., 2022;Mitchell et al., 2021).Hence, there are variations across reports with aphasia impacting 7% to 77%, dysarthria impacting 24% to 69% and a combination of dysarthria and aphasia impacting 4% to 29% ( Data on incidence of stroke acquired apraxia of speech is sparse and challenging to report on given that acquired apraxia of speech rarely exists in isolations but typically co-occurs with aphasia and/or dysarthria (Duffy, 2020).Regarding cognitive communication disorders associated with acute stroke, Riepe et al. (2004) reported that up to 77% exhibited cognitive impairment.
The stroke acquired communication impairments outlined in Table 1 present chronic, multifaceted challenges for the Table 1.Overview of stroke acquired communication impairments.

Impairment
Common clinical manifestations Aphasia Aphasia can impair an individual's ability to express themselves; understand what others are saying or read and write.In mild cases there can be word finding difficulties and difficulty understanding complex written and/or verbal instructions.In severe cases, it may be difficult to verbalise, write or understand even single words.

Dysarthria
Dysarthria, an umbrella term for a group of speech disorders, reflects abnormalities in strength, speed, range, steadiness, tone, or accuracy of movements required for speech production (Duffy, 2020, p. 3).Intelligibility of speech is impacted.Speech may be imprecise, slow, monotonous or low in volume.In mild cases an individual may have to occasionally repeat themselves to be understood.In severe cases speech may be entirely unintelligible.

Acquired Apraxia of Speech
Typically an individual knows what they want to say, but cannot produce and sequence sounds correctly in words.Speech can be slow and monotonous with reduced intelligibility.Automatic speech is better preserved than volitional speech.In mild cases intelligibility may be minimally impaired.In severe cases an individual may have difficulty producing any sounds or words.Acquired apraxia of speech rarely occurs in isolation, but co-exists with aphasia or dysarthria.

Cognitive Communication Disorder
Cognitive communication difficulties result from impairment to underlying cognitive functions such as memory, executive function, and attention.They have variable presentations and can include difficulties turn-taking in conversation; staying on topic; attending to and recalling specific details and giving information in the correct sequence.

Amendments from Version 1
In response to the reviewers' feedback we have added additional information, in the introduction, on incorporating PPI in this review including a newly added figure, Figure 1.We have provided further explanation on terminology used with regard to student health and social care professionals and the review's advisory panel (formerly advisory group).We have also changed some of our terminology to increase clarity for the reader.An additional table has been added (Table 3) to our methods.It provides an overview of the advisory panel including rational for including the specific advisors and their expected roles throughout the review process.Additional detail on how PPI advisors with communication difficulties are supported throughout the review process has also been added to methods.
We have relocated our review questions to Step 1 to enhance general understanding of the review process and added additional explanation to two of the review questions to ensure clarity.Finally, we have included additional supporting materials in the extended data to increase transparency of the review process Also please see:  .Consequently, they can limit their time interacting with people with communication impairments (Carragher et al., 2020).Student health and social care professionals (SH&SCPs) who may also, in contexts where professional registration is required, be referred to as pre-registration professionals, experience similar emotions.Over the course of their clinical training these students may be exposed to a variety of pedagogies and engage in a range of clinical activities and placements involving people with stroke acquired communication difficulties.Rathiram et al. (2022, p. 5) reported that SH&SCPs felt "emotionally strained, frustrated and helpless" when they could not understand their patients.In order to prevent these negative experiences health and social care professionals and SH&SCPs want to learn how to communicate successfully with people with communication difficulties (Carragher et al., 2020;Hur & Kang, 2022).Furthermore, people with aphasia believe that training health care professionals in the use of communication strategies is important in enabling them to live successfully with the communication impairment (Manning et al., 2019).CPT can provide the necessary learning opportunities.

Communication Partner Training (CPT)
CPT is defined by Cruice et al. (2018, p. 1) as an "umbrella term for a complex, behavioural intervention" that has many interacting components that are delivered in flexible ways.The need to explore an approach to data synthesis that can accommodate all valuable research data is highlighted by Simmons-Mackie et al. (2016).In their updated systematic review, the authors reported on the emergence of studies addressing the efficacy of CPT use with the broader range of stroke acquired communication impairments and a promising new trend of studies, attempting to manage clinical reality and the feasibility of CPT implementation in complex settings.However, all of these studies were rated too low It may be proven/disproven/amended during the synthesis process.

Middle range programme theory
The term "middle -range" is an adjective used to describe the level of abstraction of a theory.At the middle-range there is abstraction, but the theory is close enough to observable data to be usable and enable empirical testing.(Merton, 1967; http://www.ramesesproject.org/media/RAMESES_II_Theory_in_realist_evaluation.pdf).It is expressed as CMOCs.

Programme theory
An
on the American Academy of Neurology levels of evidence (2011) for efficacy or effectiveness to provide recommendations for clinical practice.Given that realist review accommodates the synthesis and evaluation of data of diverse methodologies and origins, it can build on existing empirical findings from systematic reviews; overcome the challenge of accommodating all valuable research findings in the final analysis, and provide clinicians and educators with augmented theoretical and practical guidance for the development and implementation of CPT.

Incorporating PPI in realist review
While engagement of experts and stakeholders is commonplace in a realist review (Saul et al., 2013), the inclusion of PPI is at an evolutionary stage (Abrams et al., 2021).There is variability in all terms used to describe the realist review's advisors or contributors and PPI tends to be subsumed into pre-existing structures or groups including "stakeholder, expert or advisory panels" (Abrams et al., 2021, p. 243).In this review, to support clarification for the reader, we use the term PPI advisor to denote people with stroke acquired communication impairments and their significant others.They, in collaboration with content advisors, relaist advisors, student advisors and an educationalist comprise this realist review's advisory panel (see methods, Table 3).

Level of PPI advisors' involvement in this realist review
In general, PPI can occur at different levels (e.g.consultation, defining scope, collaboration) and at different stages (e.g.design, project advisor, dissemination) of a research cycle (McMenamin et al., 2022).Specific to realist review Abrams et al. (2021) found that PPI contributor roles included informing and developing programme theory and advising over the course of the review.
Developing research questions, sourcing literature and data extraction tend to be performed by advisors such as academics or clinicians.These traditional roles are reflected in the level of involvement expected from this review's advisory panellists (see methods, Table 3).More broadly, across different types of research, there are a range of conceptual models overviewing different levels of involvement and power sharing in PPI, many of which have been influenced by Arnstein's Ladder of Public Participation (1969) (McMenamin et al., 2022).In this realist review, we adopt the PPI Spectrum of Involvement in Research Model (IHRF, 2015 https://hrci.ie/about-us/ourwork/ppi/).This model, depicted in Figure 1, illustrates that the PPI advisors on this review are involved at a consultative level.

Aims and objectives
This review protocol overviews a realist review, the first phase of a PhD project.Figure 2 overviews the realist review in the context of the wider project.The wider project aims to employ a realist approach, including realist review (Phase  1) and realist evaluation (Phase 3), in combination with PPI (Phase 1-PPI advisors on review's advisory panel and Phase 2-PPI Advisory Group).The primary aim of this realist review (Phase 1) is the synthesis of secondary data from varied relevant sources into a plausible and coherent middle range theory.This theory will explain how CPT is expected to work when teaching SH&SCPs to communicate with people with stroke acquired communication impairments.As stated above, the middle range theory developed will be close enough to observable data to be usable and permit empirical testing.It will undergo further appraisal and development during realist evaluation, the third phase of this project, in consultation with the PPI advisors who are consulting across all phases of this project.
A protocol for this review has been registered on PROSPERO on 01/05/2023 (CRD42023418951).
Steps in this realist review While there are guiding principles around conducting a realist review there is no one prescribed method (Hunter et al., 2022) and this can result in variability across reviews and lack of clarity on key stages in the review process (Booth et al., 2019) (2018).Also integral to this review is the establishment of an advisory panel to consult over the course of the review and collaboratively agree the finalised middle range programme theory.At this point, the advisory group has been established and Step 1 of the review has been completed.Step 2 is underway.Given that the review process is iterative, overlap across steps and backward forward movement is anticipated throughout the process.

Set up review advisory panel
Duddy and Wong (2023, p. 1) describe realist review as a "flexible, iterative and practical" approach to evidence synthesis that draws on the expertise of a variety of relevant stakeholders.Consequently, when undertaking a realist review a high level and variety of knowledge and expertise is required (Saul et al., 2013).In order to realise such expertise and knowledge, this review adopted a collaborative model incorporating an advisory panel (Davies et al., 2019; Shé et al., 2018).The composition of this advisory panel is overviewed in Table 3 with rational for inclusion of the specific advisors and summary of their expected roles.Also, a summary of the advisory panel meetings throughout Step 1 of the realist review is included in extended data.• Reviewing and refining the initial programme theory (Step 1B) • Reviewing and refining the middle range programme theory (Step 5)

Medical educationalist (n=1)
Professor in medical education.
Provides in-depth and up to date knowledge from an educational perspective.
• Reviewing and refining the initial programme theory (Step 1B) giving extra time to process information; supplementing conversation and verbal questions and instructions with written words and symbols; facilitating the use of a variety of non-verbal modes of communication including a communication folder, smart phone and tablet.
• PPI Advisor 2 -giving extra time to process verbal and written information, presenting verbal questions and instructions "one at a time".
Time was also dedicated to the third advisor, the spouse of contributor 1, to ensure there was shared understanding of what engaging in the review entailed.She was provided with written information and engaged in discussion around the requirements of the project.
With regard to adopting a flexible approach, it was collaboratively agreed by YF and PPI advisors that meetings should be face to face and conducted separately with the the single advisor and the dyad (person with communication impairments and his significant other).This was due to their significantly different communication impairments and supportive requirements and to facilitate optimal use of everyone's time.
Step 1 A. Clarify scope The review questions were conceptualised by the content advisors and refined in consultation with the realist advisors.The questions aim to address shortcomings in the current knowledge base and facilitate realist enquiry.In order to determine how SH&SCPs learn to communicate optimally with people with stroke acquired communication impairments, we posed the following questions: • What CPT interventions are used for SH&SCPs in higher education institutions?
• What are the desired, achievable outcomes of CPT in higher education institutions?Preliminary IPTs were developed by content advisors, guided by their insights into CPT, their knowledge of literature on the topic, and an additional literature scoping exercise (see extended data).YF formulated initial theories in the form of "If.., then…" statements.These were modified and refined iteratively over a five-month period in consultation with the other content advisors.This process generated nine "if.., then…" statements which were presented in context, mechanism, outcome configurations (CMOCs).In consultation with the realist advisors the CMOCs were developed further and amalgamated into a graphically presented, overarching IPT.This overarching graphic was additionally reviewed by a medical educationalist.Narrative and graphic IPTs were then presented to student advisors and PPI advisors for review and revision.Final revisions were agreed in consultation with content and realist advisors (see extended data).Narrative IPTs are presented in Table 4. Figure 4, graphically presents the amalgamated IPT, theorising how SH&SCPs can progress to being positive, productive communication partners, or not, and the reasoning and responses enacted along the way.
Step  5).The search strategy will subsequently be refined iteratively and collaboratively with the advisory group.The searches will include peer reviewed journals, international best practice statements and clinical guidelines and conference proceedings.The following electronic data bases will be searched: Medline, EMBASE, CINAHL, APAPsycINFO and Web of Science.As outlined in our review protocol registered on PROSPERO (CRD42023418951), building from previous reviews (Simmons-Mackie et al., 2010; Simmons-Mackie et al., 2016; Tessier et al., 2020) searches of peer reviewed literature will be limited to the English language and by date -from January 2019 to the time of the review.Relevant studies in the previous reviews will be included for analysis.Supplementary searches will include hand searches of reference lists, and requests for unpublished studies/programmes from key authors.Search alerts will be in place to identify studies relevant for inclusion prior to final analysis.
Step 3 Select and appraise evidence YF will perform the Title/Abstract screening and select documents consistent with preliminary inclusion criteria, that is, CPT for health and social care professionals or SH&SCPs addressing stroke acquired communication impairments.A random 20% selection will be reviewed by RMcM.Potential disagreements will be resolved through discussion and consensus of a third author as required.Endnote 20 will be the reference management system used and Covidence 2.0 systematic review software will be used to screen titles and abstracts.
In realist reviews, inclusion of data is determined by their ability to assist in the development and refinement of programme theory or theories.Hence, multiple and varied data sources are considered for inclusion (Wong, 2018).Applying quality scales or tools to such data sources risks excluding data that are essential for programme theory development.Therefore, in line with Price et al. (2021) in their realist review on remediating doctors' performance to restore patient safety, formal quality appraisal tools will not be used in this review, on the basis that they are not sensitive to    amended as indicated following the pilot searching, and iteratively thereafter in line with evolving insights and understanding.Once coded with respect to richness, relevance and rigour sufficiently rigorous data will be prioritised and assigned conceptual labels relating to CMOCs or components thereof.Less rigorous data will also be interrogated and undergo a triangulation process prior to contributing to programme theory refinement.
Step • Juxtaposition of data sources through comparing and contrasting data across documents • Reconciliation of contradictory or differing data through further analysis, investigation and explanation.
• Consolidation of evidence sources where adjudications around demi-regularities can be made.
Matrices will be devised to facilitate this analysis.Analysis, judgement and synthesis will be a collaborative and iterative group process, see Figure 6.Throughout this process uncertainties will be resolved through discussion, debate and group consensus.

Study status
As outlined in Figure 2, this realist review comprises the first step of this project.
Step one of the review has been completed and step two is underway.
Plan for dissemination This protocol will be submitted for publication to a peerreviewed publishing platform.The findings of the completed review will be presented in a second article, adhering to the RAMESES publication standards for realist synthesis, and submitted for publication to a peer-reviewed journal.Also, following consultation with the advisory panel other relevant platforms including conferences, workshops, media platforms, and special interest groups will be explored for dissemination.

Ethical approval
Ethical approval is not required for this review.No data will be collected from the advisory panel.

Discussion and conclusion
This protocol provides an argument for using a realist approach, in conjunction with PPI, to enhance stroke specific CPT development and implementation for SH&SCPs in higher education institutions.It specifically details the first phase of this project -the realist review.People with stroke acquired communication impairments, often excluded from research that requires active participation, are consulting as members of the review's advisory panel to improve the quality, relevance and impact of the review.They will continue to consult as PPI advisors across all phases of the project.

Introduction
The rationale justifies clearly and convincingly the relevance of conducting the proposed research project.The literature review is exhaustive and is supported by relevant sources in the field.I particularly appreciated that the authors explained the realist review methodology in sufficient detail in the introduction, as it is a methodology that I was not familiar with.This study addresses clinical and scientific needs to identify realistic ways to implement CPT in different settings (here for student health and social care professionals).I noticed a few typos that could be corrected: Table 1 → Aphasia → spelling mistake "it may be difficult to verbalize" and not "difficulty".

Methods
The study design is appropriate for the research question and the methodology is described in detail.I particularly appreciated the numerous methodological references that the authors draw upon and the figures summarizing the processes and results that the team has obtained so far.However, I must mention again that I am not familiar with the realist review methodology.Therefore, I am not able to judge if important points in explaining the methodology are missing.Nevertheless, in my opinion, the methodology is sufficiently detailed and referenced to allow replication based on the protocol and the studies cited.
I have some questions and suggestions for clarification for the methodology section of the protocol: Research The introduction provides a clear overview of communication impairments after stroke and communication partner training.The introduction to the approach of realist review is reasonably clear to me as a reader who is not familiar with this area.Could the authors support their explanation with an illustrative example of how this approach has been used in a similar field?A definition of the term "middle range theory" would also be useful to add to the text in this section.I would also suggest moving Table 2 to be referenced in this section of the introduction, as these definitions will be helpful to readers unfamiliar with this topic.
Methods: The research questions are clearly articulated, and methods are well described and rationalised.I noted the following queries regarding this section: -Aims and objectives: Figure 1 clearly outlines the phases and steps of the project, but this could be described more clearly in the text.For example, the first phase and third phase of the project are defined in the text, but the second and fourth phases are not mentioned.The reference to Figure 1 could also be moved to this section.
-Questions: Could you provide some examples of "contexts" (in the same way that you have given some examples of what is meant by "whom" in the previous question.)-Review advisory group: I was interested in a little more information on how the advisory group works (e.g., How often does the group meet?In-person or online?Are all members present at all meetings, or are there smaller sub-groups which meet to discuss specific issues?Are there any reimbursement arrangements in place?).I was also interested to know if all the student advisors all from an SLT program, or are they from other backgrounds?
Step 1: Table 3 is well presented and illustrates the IPT concepts well.I had more difficulty following Figure 3. Could you share more about the process that lead to grouping the C/M/O elements in this way?Do learners always start in the top left hand box, or can they start in any box?
Step 2: The search terms appear to focus on student health care professionals, rather than social care professionals.Were other search terms considered (e.g., social work, psychology, counselling, etc?) Discussion: The authors conclude with a reflection on the benefits of a realist approach for addressing the research questions.The primary point mentioned here is the benefit for educators.I would be interested to read more on the authors' thoughts about the potential benefits of this project for students and for people with communication impairments.
Minor typographical errors: In the introduction, "real word complexity" should be "real world complexity" In the final sentence, "subsequent" I wish the authors success with this important project and hope that this feedback is helpful as you continue your work in this area.
Is the rationale for, and objectives of, the study clearly described?The authors effectively contextualize in the introduction the importance of communication rehabilitation for individuals who have had a stroke.They also emphasize the crucial role of communication partner training, particularly for student health and social care professionals.The review's methodology is considered appropriate.Also, the authors suggest using a Patient and Public Involvement (PPI) approach throughout the research process, which is suitable for the project's scope.However, the introduction lacks important information on PPI.To make the manuscript more informative for the reader on PPI, I suggest adding the following to the introduction: The definition of PPI (National Institute of Health Research, 2014 or other relevant sources), 1.
A brief description of the different types/levels of PPI (Arnstein's work on the ladder of participation in 1969), 2.
An explanation of why the formation of the 'advisory groups' was selected compared to active PPI partnership (Charalambous et al., 2022;Mc Menamin et al., 2022).

3.
Additionally, it would be helpful to add a paragraph in the methods section specifically explaining the following: How were the advisory groups created?It seems that the advisory groups do not participate equally in the project.

1.
Did other advisors besides the content and realist advisors play any role in formulating the research questions and deciding on the design of the study? 2.
What were the participatory methods employed in the project?3.
What is the PPI framework that the authors will use to design and monitor the contributions of the 'people with lived experience of stroke acquired communication impairments/PPI advisors'?Referring to the PAOLI framework developed by Charalambous and colleagues in 2023.

4.
How will the authors approach the PPI patients in all advisory groups to avoid tokenism, especially those with communication difficulties?

5.
What are the obligations of the 'People with lived experience of stroke acquired communication impairments/PPI advisors' in the research team?

6.
What are the contributions expected from all PPI advisory groups in each phase of the project?Please briefly explain how involving PPI will improve the study's impact and the implementation of the results.

7.
This information will ensure transparent documentation of PPI and especially patient advisors' contributions.It would be useful to include a table showing expected/completed PPI contributions from each advisor group in each project phase.
It would be helpful to provide additional demographic data on the two PPI advisors who have lived experience of stroke and related communication impairments.This data could include information such as the type and severity of the communication impairment, time since the stroke, previous and current employment, marital status, level of education, and psychosocial information.This information would provide the reader with a clearer understanding of the patient advisors' level of involvement within the research team.
While the review is yet to reveal its findings, the anticipation is high for insights that extend beyond mere program efficacy.By exploring the 'why' and 'how' behind communication partner training effectiveness, the study has the potential to provide actionable recommendations for refining and tailoring interventions to the unique needs of individuals with stroke-induced communication impairments.To ensure that the findings of the study are robust and applicable across diverse contexts, it's crucial to acknowledge and address several factors such as the diversity in stroke manifestations, varying communication needs, and the dynamic nature of healthcare settings.
It is suggested that the authors provide a more comprehensive explanation of their approach to supporting PPI patient advisors throughout phase 2 of the project, with particular attention to addressing their communication challenges.This information will be useful for other researchers who wish to learn how to better support team members with communication difficulties.Finally, including patients and the public in research communication and dissemination strategies helps bridge the gap between scientific findings and the broader community.Please describe how the two PPI advisors who have lived experience of stroke and related communication impairments will be involved in disseminating the project's outcomes.I hope that the suggestions I have provided will be helpful.Good luck with your project.

Are the datasets clearly presented in a useable and accessible format? Yes
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Patient and Public Involvement (PPI) in stroke and aphasia research I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
abstracted description and/or diagram that describes what an intervention or family of interventions comprises and how it is expected to work (Duddy & Wong, 2023).

5
Analyse and synthesise data Data synthesis centres on programme theory refinement (Hunter et al., 2022; Pawson et al., 2005; Rycroft-Malone et al., 2012).Once thoroughly familiar with the extracted data sets, interpretations and judgements will be made around: • Partial or complete CMOC of included data • How these data impact the refinement of the initial CMOCs developed in Step 1 and their development into middle range theory • Whether further searching is required in response to developing insights and understanding The following analytical process adapted from Pawson (2013) by Papoutsi et al. (2018, p. 16) will inform analysis and judgement throughout the synthesis process:

Figure 6 .
Figure 6.Group analysis, judgement and synthesis process.
Halloran et al., 2012).Additionally, there is increased risk of depression and anxiety (Shehata et al., 2015; Zanella et al., 2023).When communication with patients is challenging, health and social care professionals (i.e., professionals with formal clinical training, e.g., doctors, nurses, physiotherapists, psychologists) can experience emotions such as frustration, impatience and guilt (Carragher et al., 2020; Hur & Kang, 2022 Authors' detailed response to the review by Marina Charalambous Authors' detailed response to the review by Rachael Rietdjjk Authors' detailed response to the review by Alexandra Tessier Authors' detailed response to the review by Ariné Kuyler Any further responses from the reviewers can be found at the end of the article individuals presenting with the impairment/s and for those interacting with them (Ali et al., 2015; Chang et al., 2018; Mitchell et al., 2021; Wray et al., 2019).They can mask the individual's inherent competency and result in communicative interactions that are negative for all interlocutors (Carragher et al., 2020; Kagan et al., 2001; Kagan et al., (Beeke et al., 2018;Cameron et al., 2018;Forsgren et al., 2017;non-verbal cues such aKagan et al., 2001;ing; personally relevant communication books and folders; applications on smart devices; writing; visual aids (e.g., maps, photo diaries) and modified verbal expression (e.g., slowed rate, using key words and short phrases).CPT can be successfully employed with multiple communication partners including health and social care professionals, SH&SCPs, family members, volunteers and people with communication impairments(Beeke et al., 2018;Cameron et al., 2018;Forsgren et al., 2017; Isaksen et al., 2023;Kagan et al., 2001; Rayner & Marshall, 2003).Importantly, CPT has the potential to pre-empt communicative challenges for our future frontline staff and enhance future clinical care for patients with stroke acquired communication impairments.Employing realist review in CPT researchRealist terminology relevant to this realist review and all other phases of this research project is presented in Table 2 below.Realist review is a systematic, "theory driven, interpretative" approach (Duddy & Wong, 2023, p. 1; Jagosh et al., 2014, p. 131) that facilitates the synthesis and evaluation of data of diverse methodologies and origins.It focuses on combining empirical evidence with theoretical understanding (Schick-Makaroff et al., 2016) in programme theory development.As Wong et al. (2012, p. 93) state, the premise underpinning realist review is that a specific intervention or class of interventions "trigger particular mechanisms somewhat differently in different contexts", hence, as is the case in CPT research, outcomes vary across contexts.During programme theory development context, mechanism and outcome configurations (CMOCs) are employed to coherently explain how and why contextual variables influence intervention outcomes.Ontologically rooted in realism and aligned with Bhaskar's stratified reality (Bhaskar, 1997), realist review explores both the visible and hidden forces that generate the outcomes of interest (Jagosh et al., 2014).From a realist standpoint, a behavioural intervention such as CPT is conceptualised to operate in open systems where the intervention changes the system and the system changes the intervention (Pawson et al., 2004; Pawson et al., 2005).Realist review aims to address the real world complexity and fluidity of these operating systems by going beyond simply asking if an intervention works and exploring generative causation to determine for whom it works, under what conditions, to what extent, how and why?Employing a realist approach has the potential to enhance existing knowledge and practice in stroke specific CPT for SH&SCPs.It can build on the current evidence base,

Table 2 . Explanation of realist terminology employed across all phases of research project.
The value of theory driven CPT interventions and implementation strategies is increasingly recognised in the literature (Chang et al., 2018; Cruice et al., 2018; Shrubsole et al., 2023).However, theoretical approaches are not in mainstream use and given the vast array of behaviour change and implementation theories in existence it is a challenge for researchers to select the best fit (Eccles et al., 2012; , or part of reference groups, involved in key discussions and decisions, sharing their unique knowledge, expertise and perspective" (Staniszewska et al., 2018, p. 1).Originating from the disability and advocacy movements, it emphasises knowledge sharing between "lay people" and "the professionals" (McMenamin et al., 2022, p. 31).PPI benefits the research process, the researcher and the PPI contributors and there is increasing expectation for PPI in health and social care research (Hersh et al., 2021; McMenamin et al., 2022).It improves quality, relevance, impact and integrity of the research process.It promotes waste avoidance and embraces active involvement including shared decision making across the research cycle (Dawson et al., 2020; Hersh et al., 2021; McMenamin et al., 2022; Staniszewska & Denegri, 2013).It promotes inclusion, validation and understanding of the lived experience (Pearl & Cruice, 2017; Turk et al., 2017).
Shrubsole et al., 2019).Shrubsole et al. (2019) argue that the potential contribution of different theories is unclear given that they have not been consistently applied to health professional's behaviour or in this case, we argue, SH&SCPs' behaviour.Also, as McGowan et al. (2020) point out, selecting only one or a few theories in behaviour change research and intervention puts the researcher at risk of omitting relevant factors.Notably, frameworks such as the Behaviour Change Wheel (BCW) (Michie et al., 2011) and the Theoretical Domains Framework (TDF) (Atkins et al., 2017; Cane et al., 2012; Michie et al., 2005), developed from synthesising theories and constructs, are being used more frequently in CPT research and other general research in acquired communication disorders (Behn et al., 2020; Chang et al., 2018; Johnson et al., 2017; van Rijssen et al., 2021).A realist approach considers existing substantive theories in programme theory formation.Consequently, it has the potential to overcome "best fit" challenges while building on existing theoretical understanding.Also, unlike other theoretical approaches, which can be limited in their ability to address multiple pertinent questions, realist review applies realist logic to answer the necessary range of pertinent questions -what works, for whom, under what conditions, to what extent, how and why? (Pawson et al., 2004; Wong et al., 2012; Wong et al., 2013).Answering such questions can strengthen current CPT research and practice by explaining "the success, failure" and "mixed fortunes" of this complex intervention (Wong et al., 2013, p. 1).Importantly, addressing these questions allows us to look beyond determining efficacy to determining necessary solutions for real world practice in higher education institutions.The anticipated outcome of this review, a middle range programme theory (defined in Table2) ,while abstract, will be close enough to observable data to be usable and enable empirical testing.Patient and Public Involvement (PPI)PPI refers to research that is conducted 'with' or 'by' members of the public rather than 'to', 'about' or 'for' them (https:// www.invo.org.uk/).It involves "working in collaboration or partnership with patients, carers, service users or the public" (https://hseresearch.ie/patient-and-public-involvement-in-research/).They may become "members of the research team . This protocol aims to present a clear and transparent review process guided by Pawson et al.'s (2005) five key iterative steps in realist review; the Realist And

Table 3 . Realist Review Advisory Panel: Composition, inclusion rationale and overview of expected roles.
Advisors with content expertise and in-depth and up to date knowledge of the subject matter are pivotal to the successful execution of the realist review (Ní Shé et al., 2018; Saul et al., 2013).• Directing and managing the review • Engaging in all steps of the review process • Facilitating programme theory development, review and refinement • Co-authoring academic paper • Dissemination planning and execution Realist advisors (n=3): Advisors with expertise in the realist approach.
(Hersh et al., 2021)lvement of PPI advisors in realist reviewIn order to ensure the PPI advisors, especially those with communication impairments, engage actively and authentically on this advisory panel it is important to adapt a flexible and facilitative approach(McMenamin et al., 2022).Successfully negotiating complexity, such as realist theory development and refinement, with people with stroke acquired communication impairments, requires careful consideration and accommodations(Hersh et al., 2021).In this project the PhD candidate YF, is an experienced speech and language therapist who has worked with people with acquired communication difficulties for over 30 years.This according to Cascella & Aliotta, 2014 renders her uniquely skilled in facilitating inclusive communicative interactions with people with acquired communication impairments.Annually, YF, RMcM and both PPI advisors with communication impairments co-deliver CPT to student speech and language therapists at the University of Galway.All are experienced in using supportive communication techniques and strategies to ensure active and reciprocal involvement during the training module.These communicative supports, tailored to the needs of each individual PPI advisor (one presenting with mild expressive aphasia and one with severe expressive aphasia and severe apraxia of speech), are being employed across this realist review to ensure understanding of the review process; clarity around the commitment and work required; active collaboration, and that there is shared understanding among the researchers and the PPI advisors.
• Reviewing and refining the middle range programme theory (Step 5)• PPI Advisor 1 -Presenting information pictorially and in short written phrases (See sample in extended data);

Table 4 .
question 4 (For whom…), in the examples, when you say "people with communication difficulties", what do you mean?Like, with what types of communication difficulties do CPT have effects?Or what type(s) of communication difficulties are addressed in CPT? It's not quite clear to me what this example evokes here.In the paragraph where supported conversation is mentioned to support the participation of people with communication disability on the advisory board: what are the "top tips" that you adhere to (McMenamin et al., 2021)?Since I am not familiar with the article in question, I would have appreciated a summary of what it specifically entails.if the research questions presented in the second part of the method should rather be presented under "step 1".That way, we would know upfront who developed the questions and their objectives before reading them.I don't think it would impair my understanding of the method if it were moved down, and it would thus follow the chronological order of the process in the presentation, which I believe would aid in the general understanding of the methodology.In concept 2, could it be relevant to add to the search strategy "communication disability*" and "communication impairment*"?

Yes Is the study design appropriate for the research question? Yes Are sufficient details of the methods provided to allow replication by others? Partly Are the datasets clearly presented in a useable and accessible format? Yes Competing Interests:
No competing interests were disclosed.

have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.IntroductionPlease very clearly define who you refer to when using the terms student health and social care professionals, as individuals from different countries or backgrounds can interpret this differently.You mention that student health and social care professionals engage with people with stroke-acquired communication disorders in tertiary education.However, it is unclear in what context these individuals are accessed.Do the individuals with stroke receive therapy or some form of social support or community engagement at the institution??? Or are you referring to student undergraduate education on CPT for persons with stroke?Additionally, are the student health and social care professionals acting as communication partners?Are they familiar or unfamiliar to the person and also what care pathway is taken for persons with stroke-acquired communication disorders to end up with these professionals?What CPT interventions are used for SH & SCPs in higher education institutions?To read as follows: What CPT interventions are included in undergraduate curriculums for SH and SCPs at higher education institutions?Additionally, are you also thinking of how knowledge and skills taught in CPT are maintained after the intervention is completed?
○ ○ ○ Also, you interchangeably refer to student health and social care professionals and healthcare providers, please use one term consistently throughout your manuscript.○Youmention that this review may enhance and potentially accelerate development and implementation specific to CPT related to stroke in clinical education.How will the review accomplish this? ○ All healthcare providers worldwide are required to provide ethical and evidence-based practice.I can understand that a realist view can be of benefit but how does a realist view correlate with actual evidence-based practice?To provide ethical services a combination needs to be used of theory, clinicians' experience and the reported needs of individuals with stroke and their family members.I am unsure how you are incorporating these aspects.○Questions:Areyoulooking at the actual implementation of CPT in higher education settings or what the students for example in speech-language pathology are being taught during their undergraduate degree???○ Please specify the context as your questions are too broad and unclear.○ Rephrase the question: ○ Rephrase What contexts are enabling/inhibitory?To read as What contexts act as facilitators or barriers for the successful implementation of CPT? ○ How these interventions work is a very broad question.Are you referring to the ○ characteristics of the programme?? ○ Is

the rationale for, and objectives of, the study clearly described? Partly Is the study design appropriate for the research question? Yes Are sufficient details of the methods provided to allow replication by others? Yes Are the datasets clearly presented in a useable and accessible format? Yes Competing Interests:
No competing interests were disclosed.
Reviewer Expertise: Communication-partner training; adults with acquired neurogenic communication disorders; palliative care; ICU care; family-centred care I confirm that I