Walking in Another's Shoes: Encouraging person-centred care through an experiential education programme Author

 
Walking in Another's Shoes: Encouraging person-centred care through an experiential education programme Author
Walking in Another’s Shoes: Encouraging person-centred
care through an experiential education programme

Author
Susan Gee (centre), Maria Scott (right) and Matthew Croucher (left), Canterbury District Health Board

Introduction
Person-centred care, which focuses on the
individual living with dementia and their needs and
preferences, has been called the ‘gold-standard’ for
residential care for people with dementia
(Evardsson, Fetherstonhaugh, McAuliffe, Nay, &
Chenco, 2011). Staff training is unanimously seen
as one of the keys to ensuring such high standards
of care (Ballard, O’Brien, James, & Swann, 2001).
The aim of person-centred education moves beyond simply imparting knowledge to encouraging a
paradigm shift to person-centred care in attitudes and practice. It follows that the training methods must
similarly move beyond traditional didactic methods to student-centred adult learning, integrating
reflection and experience. The Walking in Another’s Shoes programme exemplifies this approach,
promoting a person-centred approach to dementia care for the dementia care workforce.

This publication opens by establishing the important role of this type of education. In the main body, we
outline the Walking in Another’s Shoes programme and how it is designed and delivered to provide
student-centred experiential and inquiry-based learning. We then briefly summarise the evidence for the
effectiveness of the programme. This paper focuses on our experience with dementia-specialty
residential care workers.

Background: Why provide a person-centred dementia care
education programme for carers?
So-called ‘unskilled’ carers provide the majority of direct care to people living with dementia in
residential care facilities. Although they are often portrayed as lacking status and control in their work
roles, these carers paradoxically have the power to be a key influence on the quality of life of the older
people living with dementia with whom they work (Ballard et al., 2001; Nolan et al., 2008). One of the

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underlying drivers of our education initiative for dementia carers is a fundamental recognition that carers
are important.

Why person-centred?
The traditional model of residential care emphasises achieving tasks such as washing, dressing, feeding
and toileting residents. The person receiving care may accordingly be treated as little more than an
object. It can be easy to overlook their emotional needs, needs that still include love, comfort,
attachment, inclusion, occupation, and identity. Unmet needs may become apparent through behaviours
that can be challenging or distressing for the carer or other people.

Person-centred care offers a different paradigm of dementia care in which the person comes first. There
are four cornerstones of person-centred care:
      • valuing people living with dementia and those who care for them
      • treating people living with dementia as individuals and taking an individualised approach to
           assessing and meeting their needs
      • looking at the world from the perspective of the person living with dementia
      • recognising the importance of relationships and interactions with other people and their
           potential to promote well-being (Brooker, 2004; Kitwood, 1997).

Person-centred care has been associated with benefits not only for residents but also for staff. Person-
centred care can have positive effects on the general job satisfaction and personal accomplishment of
carers (Evardsson et al., 2011; Moyle, Murfield, Griffiths, & Venturato, 2011; van dern Pol-Grevelink,
Jukema, & Smits 2012; Zimmerman et al., 2005), with improved staff retention and reduced
absenteeism (Gee, Scott, & Croucher, 2012).

Why education?
A person-centred approach to care can be successfully cultivated through education and support
initiatives, improving carers’ person-centred attitudes and behaviour (Featherstone, James, Powell,
Milne, & Maddison, 2004; Smith, Kerse, & Parsons, 2005) and the well-being of residents (Chenoweth
et al., 2009; Fossey et al., 2006). The British Commission for Social Care Inspection found that all of the
facilities that they rated most highly for social care had consistently invested in training in dementia
awareness and person-centred care, and furthermore, there was a statistically significant relationship
between the quality of staff training and the residents’ well-being (Commission for Social Care
Inspection, 2008). Person-centred training may also enable carers to feel assured in their role and to
provide care that is rewarding and meaningful to them as a person (Kitwood, 1997; Van der Pol-
Grevelink, 2012).

It is widely recognised that ‘chalk and talk’ didactic methods of instruction are unlikely to be effective in
instilling this type of conceptual shift (Ballard et al., 2001; Innes, 2001; Nolan et al., 2011), yet this is still
a common approach in practice. A survey of educational provision in Australia, for example, critiqued
much of the workforce education for dementia care for its continued reliance on teacher-centred delivery
methods using knowledge-based materials, and the poor integration of practical experience and real-life
context (Department of Health and Ageing, 2006).

Adult learning theories, in contrast, place the student and their experiences at the centre of the learning
process to create student-centred learning (Innes, 2001). Research suggests that small group

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experiential training with ongoing enabling in the workplace is more effective than traditional didactic
training for dementia carers (Kuske et al., 2007; Mason & Adeshina, 2011) and preferred by
stakeholders (Beer et al. 2009; Department of Health and Ageing, 2006).

The Walking in Another’s Shoes programme
The Walking in Another’s Shoes programme for carers is a small group experiential training programme
with workplace facilitation to promote a person-centred approach to dementia care and to behaviours
that challenge. It was developed by Maria Scott in the Canterbury District Health Board and is offered
free to the carers (including activity officers) who work with people living with dementia in residential
facilities in the region.

In order to bring about changes in practice, a person-centred approach is an underlying theme
throughout Walking in Another’s Shoes as opposed to it being a one-off topic during the course (Beer et
al., 2009; Loveday, 1998). Walking in Another’s Shoes meets the identified educational needs of carers
(Beer et al., 2009), and it incorporates suggestions from participants and ongoing reflexive
improvements. The programme encourages the knowledge, skills, and insight to understand and
respond in a positive way to:

     •   the individual perspective of the resident living with dementia
     •   behaviours that communicate needs
     •   the neurological impact of dementia
     •   the potential role of environmental factors in behaviour and functioning
     •   physical factors, depression, and delirium
     •   organisational culture
     •   communication skills
     •   one’s own feelings and stresses as a paid carer
     •   working with families
     •   team work in dementia care.

The purpose of the training approach is not to provide a “cookbook” to follow. The purpose is to educate
reflective practitioners, who can respond in creative person-centred ways to each unique individual and
situation (Innes, 2001; Loveday, 2011), through a learning environment based on experiential learning
and affirmative inquiry.

Underlying principles of design and delivery
Experiential learning
The Walking in Another’s Shoes programme provides students with experiences and encourages
reflection on these experiences to develop person-centred insight, skills, attitudes, and ‘ways of thinking’
(Lewis & Williams, 1994). Kolb’s influential theory of experiential learning sets out a four-stage cycle of
effective learning. The aim of the programme is to encourage each step of this cycle; that is to:

     •   build on carers’ experiences
     •   promote reflection upon their experiences and current practices
     •   help them reconceptualise their roles and interactions with residents
     •   help them to experiment with new forms of practice (Kolb, 1984; Ballard et al., 2001).

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This learning spiral is encouraged in the Walking in Another’s Shoes programme by small group
classroom and individual workplace experiences, with action and reflection integral to both over the
eight-month course.

Each month there is a six-hour workshop integrating lectures with interactive activities and discussion.
The same group of up to 20 students participate together in the series of workshops, enabling the
students to connect with and support each other and each other’s learning (Caffarella & Barnett, 1994).
The didactic components are balanced with opportunities to think, feel, and do. At a practical level, this
helps to maintain interest and engagement (Loveday, 2011). At a deeper level, this helps to address
different learning styles or intelligences, and to recognise that effective experiential teaching must
involve the whole person and not just the intellect (Andresen, Boud, & Cohen, 2000; Braun, Cheang, &
Shigeta, 2005). The exercises have a common emphasis on working and debriefing/reflecting as a
group, but vary widely from problem solving around a case study to a practical session with a walking
frame, from role plays to relaxation, from poems to planning one’s own care plan. A case-based
approach helps to minimise the gap between the classroom and the real world experience of the
students. This involves the facilitator “using examples and sharing anecdotes that help to bring learning
points to life, providing case studies and scenarios to help generate learning through discussion and
reflection, and – essentially – encouraging care home staff to talk about the residents they work with”
(Loveday, 2011: 330).

The facilitator visits students at their workplace each month to enable experimentation with and
consolidation of attitudes and skills. The visits include reflective discussion and a combination of one-on-
one techniques that can be tailored to the learning style of the student. For example, the facilitator and
student might engage in guided discovery to explore what it might “feel” like for a resident who resists
showering and what they could do differently to change the sensations or emotions associated with the
showering, or they might engage in a hands-on showering session with a resident to try out a new
approach.

The experiential learning spiral is further encouraged by the structured integration or ‘leapfrogging’ of
the classroom and workplace components (Lee & Caffarella, 1994). Each workplace visit by the
facilitator begins with reflection about what resonated in the workshop. This leads to the development of
individualised learning objectives and action plans for the month, to encourage the student to
experiment with the concepts in their real-life work context. Each group workshop begins with a shared
half-hour session of “good news stories” to reflect on this workplace practice over the intervening month
and celebrate positive change.

Appreciative inquiry
Training involves creating an environment that helps change people’s perspectives and behaviour
(Ballard et al., 2001). Appreciative inquiry holds that, at its best, change is a process of inquiry grounded
in affirmation and appreciation (Whitney & Trosten-Bloom, 2010). Some of the core principles of the
appreciative-inquiry approach can be seen in the facilitation style used in Walking in Another’s Shoes.

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Appreciation
The progamme is a chance to provide recognition of the carers and help them work from their strengths
in a role they find valuable (Whitney & Trosten-Bloom, 2010). The facilitator seeks to establish a sense
of trust, respect, openness, and concern for the well-being of the students (Andresen et al., 2000;
Loveday, 1998). The students are respected as experienced adults, and their contributions are
recognised and valued as a resource to be shared in a collaborative facilitation style. The programme
encourages the students to recognise the importance of what they do and their potential to make a
difference. Indeed, empowerment can be seen as a key concept in the programme (Loveday, 2011).

Words create worlds
The facilitation style recognises that how we talk about behaviours in dementia care influences how we
understand and respond to these behaviours. Behaviours, and in turn the people involved, can be
viewed as a problem that needs to be managed rather than understood. A person-centred paradigm
instead seeks to understand and respond to the meaning of a behaviour that is challenging (Dupuis,
Wiersma, & Loiselle, 2012). The facilitator consciously models this shift by talking about how we can
understand and respond to behaviours that challenge us, rather than how we deal with problem
behaviours or difficult residents. This is reinforced through experiential learning and reflective
discussion. One student, for example, changed her understanding and talk about a resident who had
been reluctant to sleep in his bed: “I used to see this gentleman as aggressive, but now I see him as
frightened”.

Inquiry creates change
The facilitation style in Walking in Another’s Shoes is about asking questions, not providing solutions.
Reflective, person-centred care, and hence person-centred training, can be seen as a process of
inquiry:

     •   The process of asking questions helps us to get to know the resident as an individual, their
          history, and their likes and dislikes, and to see from their perspective and to search for
          meaning: “How would I feel if it was me / someone I love?” ,“What is it about their home or
          previous roles they miss?”, “What are they used to?”. This can help the carer find unique
          ways to make activities and communication meaningful and shift the emphasis from the task
          to the relationship. For example, a student working with a resident who resisted showering
          discovered that this individual had a longstanding passion and talent for singing. When they
          began to sing together during showering, the experience was transformed.
     •   The process of ‘detective work’ (Loveday, 2011; Featherstone et al., 2004) can help us place
          the dementia in context as just one factor that may help us to understand behaviours that
          challenge. What needs might that behaviour be communicating? This may be as simple as
          one student’s discovery that a person banging on walls was trying to find the toilet.
     •   The process of asking questions helps us to recognise what we are doing well and reflect on
          how we can do things even better.

Positive questions inspire positive change
The facilitation style accentuates positive potential, rather than identifying and analysing problems.
While problems are not ignored, the facilitator uses guided discovery through positive questions to move
the focus towards the potential for change.

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Positive images of the future inspire present-day action
In keeping with the appreciative inquiry approach, the programme helps students to develop a vision of
what good person centred care might be like and helps them to find ways that successfully translate this
vision of possibilities into reality and beliefs into practice (Cooprrider, Whitney, Stavros, & Fry, 2008).
The training is both visionary and pragmatic – helping to inspire a larger vision of good person-centred
care, while also exploring the small practical steps that can be taken (Loveday, 2011). This process is
exemplified in the individualised learning objectives and action plans.

Evidence of effectiveness
Evaluation questionnaires indicate that the course is very well received. Across seven cohorts and over
100 participants, every participant rated the course as being very or extremely valuable overall and
indicated that they would recommend the course to others.

It has been a privilege to watch the journey of carers through the Walking in Another’s Shoes
programme. In the final workshop, participants present a case study and talk about how they used to
think about a particular person living with dementia, and how their understanding and response to this
individual has changed over the programme. These presentations are often genuinely moving. Themes
in the students’ written feedback include an increase in knowledge, skills, and ideas, particularly for
behaviours that challenge, alongside strong themes of person-centred insight in understanding the
individual, their history, needs, and reasons for behaviours.

Our quantitative measurement of outcomes continues to evolve. Ratings of the self-perceived impact of
the course are available for 67 participants from our four most recent cohorts. Participants rated the
course highly in the extent to which it improved their skills in working with people with dementia (an
average rating of M = 4.62 on a 5-point scale), their enjoyment and understanding of their job (M =
4.64), and their understanding of dementia (M = 4.57).

For the most recent cohort to complete the course, we administered two additional outcome measures
at the beginning of the programme and then again at the end of the programme to quantify changes in
attitude and behaviour. Participants completed the Approaches to Dementia Questionnaire (Lintern,
Woods, & Phair, 2000) to measure how positive and person-centred their attitudes to dementia care
were. Carers showed a significant improvement in positive attitude (M = 29.5 versus M = 26.9, t(20) =
4.00, p < 0.005), and person-centred attitude (M = 49.3 versus M = 47.9, t(20) = 2.11, p < 0.05). The
participant’s clinical manager was asked to complete a confidential rating of the student’s person-
centred care behaviour using part of the Person-Directed Dementia Care Assessment Tool (State of
Wisconsin, 2006). There was a significant improvement in the managers’ ratings of the person-
centredness of the care provided (M = 26.5 post-course versus M = 23.1 pre-course, t(15) = 3.45, p <
0.005).

We are currently introducing a six-month follow-up to assess whether change is sustained, a scale to
measure positive experiences of the care role, and a clinical scenario to assess preferred care
approaches.

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Looking to the future
Our experience suggests that it is possible to design and deliver an effective and enjoyable programme
based on adult learning principles that engages both hearts and minds (Loveday, 2011). The success of
Walking in Another’s Shoes brings a number of challenges for the future as the programme extends to
different groups and regions. As the programme rolls out via the South Island Regional Dementia
Initiative, content fidelity is supported by the collation of trainer manuals and interactive CDs of
component lectures. One fundamental question is how much of the success of Walking in Another’s
Shoes is attributable to our outstanding programme facilitator rather than the teaching package itself,
and how this can be carried over to new generations of the programme. To ensure a facilitation style
that embodies the vision of the programme, a “train the trainer” approach with ongoing mentoring is
being used. Another fundamental question is around how to encourage the organisational culture and
leadership needed to support the change to a more person-centred approach that Walking in Another’s
Shoes inspires in individuals. The team are exploring complementary initiatives, for example, introducing
group brainstorming sessions to encourage appreciative inquiry at a facility level or person-centred
leadership training.

As we look to the positive potential of the future and celebrate the journey of our students, we are
reminded of the words of T.S. Eliot (Little Gidding, 1942):

                                  We shall not cease from exploration
                                    And the end of all our exploring
                                   Will to be arrive where we started
                                  And know the place for the first time.

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