Culture Change is a Clinical Skill, Too


Imagination is the highest form of research.

-Albert Einstein

by Heather Jeng

At SLPs in the SNF, we’re always pretty excited about research, and reading other people’s Research Tuesday blogs, and (when we don’t procrastinate too much!) writing our own Research Tuesday blogs. But today we are super-excited. This article is amazing, and we think all y’all need to read it just so we have people to talk to about it with!

Usually research articles report studies, which are exciting in their own way. At the end of the study, human knowledge about one super-specific thing has advanced! But sometimes, researchers stop to look at the big picture and imagine what could be. This is one such article.


Bourgeois, M. S., Brush, J., Elliot, G., & Kelly, A. (2015). Join the Revolution: How Montessori for Aging and Dementia can Change Long-Term Care Culture. Seminars in Speech and Language, 36, 3, 209-214.

Bourgeois et al. review the rise of person-centered care in dementia long-term care models. (You might be familiar with the Eden Alternative, Green House, or Pioneer Network, who issued the new Dining Practice Standards.) Person-centered care puts the person – their choices, desires, and need to lead a meaningful life – ahead of institutional convenience. Logistically for a facility, it’s convenient to serve breakfast once, say, at 8:00 am. But if Doris is used to eating promptly at 6:00, and Stan likes to sleep in and have a leisurely cup of coffee at 9:30, the 8:00 breakfast makes neither of them happy with their morning.

The other key factor in current long-term care culture (at least, the norm in the United States) is a combination of over-developed fear of liability and misplaced desire to protect the vulnerable from life itself. The authors give examples of caregivers doing purposeful daily activities such as pouring drinks, making beds, preparing food, and washing dishes for long-term care residents with dementia. Why, they point out, can’t they do these themselves, within an environment structured for their success? The Montessori model is organized around our very human need for independence and meaningful activity as a member of society, balanced with our capabilities. When we take meaningful activity away from people with dementia — however well-intentioned our efforts — what kind of life are we leaving them with?

Bourgeois et al. review two examples of a new way forward. The first is the ABLE model, implemented in a facility in Australia, and the other is the DementiAbility Methods: The Montessori Way model, implemented in a facility in Ontario.

At the ABLE facility, residents engaged in activities such as setting the table, sorting silverware, polishing shoes, washing dishes, and rolling bandages, largely unprompted by staff. Some residents had further duties, depending on capability, such as making their bed, passing out beverages to other residents, updating the wall calendar, and even giving hand massages to other residents. (Who wouldn’t want to work in this facility?!) Results? Total elimination of antipsychotic medications, which we know aren’t generally good for elders, and significant decrease in the use of sedatives. Significant decrease in “resident-responsive behaviors due to unmet needs.” Increased staff knowledge and positive attitude toward dementia. And family members were thrilled with the changes. Check out this video for examples of the Montessori-prepared environment at this facility.

At the DementiAbility facility, similar efforts were made to engage residents with dementia in activities they had done all their lives, such as folding laundry or saying grace before a meal. After rolling out the DementiAbility Method, the facility saw a big drop in number of medications per resident (from an average of 11 to an average of 4!), as well as decreases in falls and infection rates.

They briefly profiled a facility in Miami whose administrator formed a (wait for it…) “memory book team.” Imagine how different life in skilled nursing could be…

We were very intrigued by the authors’ statement that changing long-term care culture “is accomplished through gaining the commitment of the facility’s leaders, training staff, and monitoring program implementation.” Is speech-language pathology training and clinical experience preparing us for these skills? How exactly do we go about getting facility leaders on board? If we don’t have these workplace organization skills, how can we develop them? ASHA and state speech-language-hearing associations need to hear that we want – and need – these skills, and graduate education needs to include training in them. They’re part and parcel of implementing evidence-based treatment.

We would love to hear success stories of gaining the commitment of facility leaders! How have you and your colleagues worked toward culture change in your own facilities? What are the barriers? How can we best advocate for person-centered dementia care?


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