Implementing Montessori Methods for Dementia™ in Ontario long-term care homes: Recreation staff and multidisciplinary consultants’ perceptions of policy and practice issues

Abstract

Montessori-based activities use a person-centred approach to benefit persons living with dementia by increasing their participation in, and enjoyment of, daily life. This study investigated recreation staff and multidisciplinary consultants’ perceptions of factors that affected implementing Montessori Methods for Dementia™ in long-term care homes in Ontario, Canada. Qualitative data were obtained during semi-structured telephone interviews with 17 participants who worked in these homes. A political economy of aging perspective guided thematic data analysis. Barriers such as insufficient funding and negative attitudes towards activities reinforced a task-oriented biomedical model of care. Various forms of support and understanding helped put Montessori Methods for Dementia™ into practice as a person-centred care program, thus reportedly improving the quality of life of residents living with dementia, staff and family members. These results demonstrate that when Montessori Methods for Dementia™ approaches are learned and understood by staff they can be used as practical interventions for long-term care residents living with dementia.

Keywords

culture change long-term care Montessori Methods for Dementia person-centred care program implementation

Background

The majority of residents in Canadian long-term care (LTC) homes are older adults living with dementia (57%), of whom 37% experience severe or very severe cognitive impairment (Canadian Institute for Health Information, 2010). Residents living with dementia tend to spend their days in LTC alone, with few opportunities for meaningful activity and social interaction, which negatively affects their well-being, and can trigger responsive behaviours they use to communicate unmet needs (Brooker, Wooley, & Lee, 2007; Dupuis & Luh, 2005; Dupuis, Wiersma, & Loiselle, 2012; Schreiner, Yamamoto, & Shiotani, 2005). Since LTC residents are largely dependent on staff for assistance with daily activities and routines, their lives become regimented by LTC institutional practices. Residents can be objectified by staff and institutional policies as the regulations and delivery of LTC emphasize meeting their bodily needs appropriately, safely and cost-efficiently (Lanoix, 2005; Wiersma & Dupuis, 2010). Caring requires relationship building whereas work in LTC is mainly task-oriented and can be conducive to an apathetic staff attitude (Wiersma & Dupuis, 2010). The focus on tasks has detrimental consequences for residents as it leads staff to view them as ‘institutional bodies’ with their physical needs taking priority over their psychosocial ones (Wiersma & Dupuis, 2010).

In gerontological research, in recent decades there has been a movement away from providing services and care for older adults living with dementia based on a reductionist biomedical model of care, which essentially views dementia as a neurologic phenomenon, to a more holistic, person-centred understanding that takes into account the other aspects of the individual such as her or his perspective, well-being, strengths, dignity and independence (Brooker, 2004; Dupuis, Gillies, et al., 2012; Edvardsson, Winblad, & Sandman, 2008; Kitwood, 1997). Essentially, person-centred care is a holistic philosophy and way of life that values personhood and the need for social interaction regardless of one’s physical or cognitive abilities (Kitwood, 1997). The person-centred care philosophy has been expanded to include relationship-centred care that highlights even further the relational nature of care (Nolan, Davies, Brown, Keady, & Nolan, 2004). Relationship-centred care emphasizes the caring relationships and interdependence between everyone involved, rather than solely the person living with dementia, so that the contributions and experiences of all partners in care, including family members and formal care partners, are valued (Dupuis, Gillies, et al., 2012; Nolan, Ryan, Enderby, & Reid, 2002; Nolan et al., 2004).

Likewise, the term ‘responsive behaviours’ is relatively new in the health and aging literature replacing demeaning and objectifying terms such as ‘disruptive’, ‘challenging’ or ‘aggressive’ to describe the behaviours of persons living with dementia. From this perspective the reasons or ‘triggers’ for behaviours are located outside of the biomedical aspects of a dementia diagnosis, such as in the person’s physical or social environment. This allows practitioners and other partners in care, such as family members, to identify the source of the behaviour and address unmet personal needs (Dupuis & Luh, 2005; Murray Alzheimer Research and Education Program, 2015). A responsive behaviour philosophy is consistent with person-centred care as it focuses on holistically understanding the meaning behind the behaviours and the needs of persons living with dementia from their perspectives (Dupuis, Wiersma, et al., 2012).

Montessori-based activities can help address responsive behaviours experienced by LTC residents living with dementia by increasing their participation in and enjoyment of daily life while decreasing fear, anger, anxiety, agitation and social withdrawal (Giroux, Robichaud, & Paradis, 2010; Jarrott, Gozali, & Gigliotti, 2008; Judge, Camp, & Orsulic-Jeras, 2000; Orsulic-Jeras, Judge, & Camp, 2000; Schneider & Camp, 2002). Montessori activities align with person-centred care values as both emphasize respect, dignity and independence, and thus can be used with persons of all ages. Montessori-based activities provide more structure, individualized attention, opportunities for interaction, and adequate sensory and cognitive stimulation for persons living with dementia than traditional LTC activities (Camp & Mattern, 1999; Judge et al., 2000; Orsulic-Jeras, Schneider, Camp, Nicholson, & Helbig, 2001), such as bingo or music, which typically involve a large group of residents that can be difficult for persons living with advanced dementia to participate in (Giroux et al., 2010; Orsulic-Jeras et al., 2000; Volicer, Simard, Heartquist Pupa, Medrek, & Riordan, 2006).

Montessori-based activities utilize the personalized learning principles originally created by childhood educator Dr Maria Montessori and further developed by gerontologist and psychologist Dr Cameron Camp to engage persons living with dementia through task breakdown, guided repetition and matching the demands of the activity to the abilities, skills and interests of the person (Camp, 2006; Malone & Camp, 2007). Montessori activities are designed to use procedural memory, which is more readily accessed by persons living with dementia, while supporting declarative memory and minimizing language demands and complex cognitive processing, by placing external cues in the person’s environment (Giroux et al., 2010; Malone & Camp, 2007). Declarative memory refers to the conscious acquisition and recollection of facts, experiences and information, whereas procedural memory refers to unconscious task performance, such as routines and skills (Butters, Delis, & Lucas, 1995). Structured repetition is a key part of the Montessori activity process for persons living with dementia as they can learn new procedures via repeated practice since procedural memory remains intact during the course of the disease (Skrajner, Malone, Camp, McGowan, & Gorzelle, 2007). Basically, Montessori activities for persons living with dementia are created as per the individual’s abilities using familiar and attractive materials that can be modified to fit the person’s needs while allowing for self-correction since their external cues compensate for cognitive impairments (Malone & Camp, 2007; Orsulic-Jeras et al., 2001). Realizing that person-centred programs using Montessori-based methods are a way to increase the confidence and abilities of persons living with dementia, gerontologist and dementia specialist Gail Elliot introduced the work of Dr. Camp to Ontario LTC homes. Montessori Methods for Dementia™ (MMD) were developed by Gail Elliot at McMaster University in conjunction with Dr Camp and is delivered in a two-day, 15-hour workshop that is recognized as a dementia care best-practice educational program by the Ontario Ministry of Health and Long-Term Care (DementiAbility, 2015). In the first day of the workshop participants learn about dementia, responsive behaviours, memory and Montessori principles and activities, while the second day is interactive so that participants put these concepts into practice for specific clients, activities and environments (DementiAbility, 2015). MMD are research-based, person-centred approaches that staff, family members and volunteers can use to create activities, roles and routines based on the unique needs and history of persons living with dementia.

MMD activities are created and presented using the following three steps. 1. First, question why the person living with dementia is behaving in certain ways, such as through apathetic, melancholic, frustrated or repetitive behaviours (Elliot, 2011). 2. Then CREATE the Montessori activity by: Considering the needs, interests, skills and abilities of the person to design meaningful activities that will support independence; Removing unnecessary markings and clutter to ensure materials can be clearly seen and are easily recognizable; ensuring the activity is Error-free so that the focus is on the process of the activity, rather than an outcome; providing All required materials that are attractive to the person and are progressively modifiable from simple to more complex; providing Templates, items and environmental cueing to support declarative memory loss; Evaluating whether the activity has been created using the aforementioned principles (Elliot, 2011). 3. Finally, PRESENT the Montessori activity by: Preparing the environment with a choice of two activities; setting up the Room by removing any distractions and arranging seating; Extending an invitation for the person to participate in an activity with you; Showing what the activity comprises by demonstrating the activity step-by-step using as few words as possible and then suggesting the person try the activity; ensuring the activity is Error-free so that the focus is on enjoying it and offering assistance if necessary; modifying the activity to suit the person’s Needs, interests, skills and abilities in that moment; Thanking the person for participating in the activity and asking if he or she would like to do it again sometime (Elliot, 2011). For detailed examples of Montessori-based activities for persons living with dementia, see Malone and Camp (2007), Orsulic-Jeras et al. (2001) and www.dementiability.com.

MMD have the potential to improve the quality of life of persons living with dementia while broadening care partners’ understanding of both the person and the disease (Elliot, 2011). Quality of life can be described as the subjective feeling of well-being, satisfaction of personal needs, and contentment with good living conditions (Robichaud, Durand, Bedard, & Ouellet, 2006). Although research has been conducted on Montessori-based activities with older adults living with dementia, no studies have been conducted on MMD specifically. Furthermore, a scoping review recently completed at the University of Toronto recommends researchers investigate barriers and facilitators to implementing MMD in Canadian care settings (S. Glass, personal communication, April 5, 2015). This exploratory qualitative study aimed to fill these research gaps.

Purpose

Despite the potential benefits of engaging residents living with dementia with MMD activities, little is known of the challenges faced and supports needed by Canadian LTC staff. This study investigated recreation staff and multidisciplinary consultants’ perceptions of factors that affect the implementation of MMD in LTC homes in Ontario, Canada.

Theoretical perspective

The theoretical perspective used to inform this study was the political economy of aging (Estes, 2001). It reveals the implications of structural forces and processes that contribute to the social constructions of older adults, aging and social policy (Estes, 2001). The political economy of aging highlights the interconnections between the individual, organizational, institutional and societal aspects of aging. Critiques focus on biomedicalization; a “process by which medical definitions and practices are applied to behaviours, psychological phenomena and somatic experiences not previously within the conceptual or therapeutic scope of medicine” (Davis, 2010, p. 211), leading to medical management, treatment and transformation of them (Davis, 2010; Clarke & Shim, 2011). Thus, the political economy of aging theory provided insight into how the multilevel and interdependent relations between individuals, organizations, institutions, social policies and social structures influenced putting MMD into practice. It also assisted with revealing how pervasive medical policies, practices and beliefs are within LTC homes and how the biomedical culture of care affects residents living with dementia, staff and family members and seemingly creates resistance to new cultures of care, such as person-centred care. This was reflected in the culture change tensions between the traditional, task-oriented biomedical model care, which focuses on the physical aspects of care, and the relational, holistic aspects of person-centred care that participants described when implementing MMD.

Research methods

Sampling and recruitment

Purposive sampling was employed so that respondents were selected to acquire information on the processes being studied (Neutens & Rubinson, 2002; Silverman, 2010). Respondents who worked in an Ontario LTC home and who completed a MMD workshop in September 2009 to August 2011 through the Gilbrea Centre for Studies in Aging at McMaster University were contacted for an interview via email. Only those participants who participated in workshops taught by the Assistant Director of the Gilbrea Centre were selected in order to standardize the educational content and to obtain information on the experiences of those who recently completed the training so that they could more easily remember and report on their experiences. Accordingly, 17 participants at various stages of implementing MMD were purposively sampled from the selected workshops to provide a variety of experiences.

Participants

As stated in Table 1, participants were classified into two groups: ‘recreation staff’ and ‘multidisciplinary consultants’ as LTC staff members from other disciplines did not respond to the study’s invitation email. The term ‘recreation staff’ denotes those staff members who worked in the recreation/programs/activities department in a management or supervisory position, or were a recreation/programs/activities assistant in a LTC home. The term ‘multidisciplinary consultants’ represents those participants who worked in various LTC homes as a regional manager/educator or as a regulated health care professional. The majority of participants (71%) were recreation staff and the rest were multidisciplinary consultants.

Table 1.

Demographics of participants.

Demographics of participants	Recreation staff, n = 12	Multidisciplinary consultants, n = 5
Gender
Female	n = 12 (100%)	n = 5 (100%)
Male	—	—
Average age	35.8 years	52 years
Education level
University	n = 5 (42%)	n = 4 (80%)
College	n = 7 (58%)	n = 1 (20%)
Post-graduate diploma(s)/degree(s)	n = 4 (33%)	n = 4 (80%)
Member of professional organization(s)	n = 11 (92%)	n = 5 (100%)
Taken other dementia care workshops or in-services	n = 11 (92%)	n = 5 (100%)
Position in LTC home recreation/programs department
Manager/Supervisor/Director/Coordinator (R3, R4, R6, R7, R8, R9, R11, R12)	n = 8 (67%)	N/A
Assistant (R1, R2, R5, R10)	n = 4 (33%)	N/A
Consultant position
Regional manager/educator (C1, C2, C3, C4)	N/A	n = 4 (80%)
Regulated health care professional (C5)	N/A	n = 1 (20%)
Average number of years worked at current company	5.8 years	6.7 years
Average number of years worked in LTC	9.2 years	22.6 years
Percentage of time spent directly with residents	50%	27%
Works in LTC home(s) in
Southwestern Ontario	n = 2 (17%)	n = 2 (40%)
Central Ontario	n = 9 (75%)	n = 3 (60%)
Southeastern Ontario	n = 1 (8%)	—
Northern Ontario	—	—
LTC home size and profit status
Small non-profit/charitable/municipal < 150 beds	n = 2 (17%)	N/A
Large non-profit/charitable/municipal 150 or > beds	n = 3 (25%)	N/A
Small for-profit < 150 beds	n = 4 (33%)	N/A
Large for-profit 150 or > beds	n = 3 (25%)	N/A
Non-LTC home company profit status
Non-profit/charitable/municipal	N/A	n = 3 (60%)
For-profit	N/A	n = 2 (40%)
First heard about MMD™ through
Employer/supervisor	n = 6 (50%)	n = 2 (40%)
Colleagues	n = 3 (25%)	n = 2 (40%)
Alzheimer society/psychogeriatric resource consultant	n = 2 (17%)	n = 1 (20%)
Nursing/LTC Magazine	n = 1 (8%)	—
MMD™ workshop paid by
Employer	n = 11 (92%)	n = 4 (80%)
Participant	n = 1 (8%)	n = 1 (20%)
Took MMD™ workshop
Fall 2009	n = 1 (8%)	—
Spring 2010	n = 2 (17%)	—
Spring 2011	n = 5 (42%)	n = 3 (60%)
Summer 2011	n = 4 (33%)	n = 2 (40%)

Ethical issues

This study was reviewed and approved by the McMaster University Research Ethics Board. Consent was obtained from participants at the beginning of the interview and recorded in a log. This study posed minimal risk to participants as no deception was involved, the research questions were not of a personal nature other than to gather some basic demographic information, participants’ identity and responses were confidential, and all data were made anonymous by using informant codes with no identifying information.

Interview procedures

Telephone interviews were conducted with participants from mid-September to mid-November 2011. Participants were asked mainly open-ended semi-structured questions regarding their experiences with implementing MMD in LTC homes (Table 2). Additional questions and topics were explored as a result of journaling and memo writing where concepts from previous interviews were raised in subsequent interviews to provide greater insight (Charmaz, 2006; Garrison 2011a, 2011b). The length of the interviews ranged from 23.5 to 75 minutes depending on the breadth of responses from each participant as well as their availability. The average interview length was 44 minutes. All interviews were audio-recorded with permission from the participants and transcribed.

Table 2.

Telephone interview guide.

Topic	Question
Individual/demographic questions	1. In what year were you born?
	2. What is the highest level of education you have achieved?
	a. Do you have any professional or formal designations? (Probe: Such as RN, OT, PSW, Activity professional, etc.?)
	b. Other than Montessori Methods for Dementia™, have you taken any other dementia care courses or workshops?
	i. If so, which ones?
	3. What is your position/role where you work?
	a. How long have you worked there?
	b. Approximately what percentage of your time is spent working directly with persons with dementia?
	c. Approximately how many people are in your care where you work?
	d. How many years have you worked in dementia care?
Experience with the Montessori Methods for Dementia™ workshop and resources	4. What drew you to the Montessori Methods for Dementia™ workshop? (Probes: What was it about this particular workshop that appealed to you? Why did you attend the workshop?)
	a. How did you hear about it?
	b. Who paid for your Montessori Methods for Dementia™ training?
	5. Did you find the Montessori Methods for Dementia™ workshop/training useful or effective?
	a. If so, in which ways did you find it useful or effective? (Probes: What did you learn from the training? How was your experience of the training?)
	b. If not, why not? (Probes: What did you hope to learn from the training? How was your experience of the training?)
	c. What could have been done differently? (Probe: Do you have any suggestions for how the workshop could be improved?)
	6. Have you purchased or needed any Montessori Methods for Dementia™ resources?
	a. Did you purchase the Montessori Methods for Dementia™ Montessori kit?
	i. If so, has it been useful for you?
	ii. If you didn’t purchase the kit, why not?
	b. Have you purchased any other Montessori Methods for Dementia™ materials, such as the Montessori Methods for Dementia: Focusing on the Person and the Prepared Environment book, reading books, memory book, or The Memories Ain’t Gone DVD?
	i. If so, which have been useful for you?
	ii. If you haven’t purchased any other materials, why not?
	c. Have you needed any follow-up assistance or support from the Montessori Methods for Dementia™/McMaster University Gilbrea Centre for Studies in Aging staff?
	i. If so, what for?
	ii. If not, why not?
	iii. Are there any forms of follow-up assistance or continuing education regarding Montessori Methods for Dementia™ that would be useful for you? (Probe: Such as a refresher session in-person or online, networking opportunities, or online resource area?)
Experience implementing the Montessori Methods for Dementia™ program	7. What is the history of Montessori Methods for Dementia™ where you work? (Probe: Was Montessori Methods for Dementia™ already being used where you work or were you the first person to try and put it into practice there?)
	a. If it was already being used where you work, how did you help put it into practice? (Probe: What was your role in implementing it?)
	b. If you were the first person to try and put it into practice, how did you go about doing that?
	c. Were you able to successfully put Montessori Methods for Dementia™ into practice where you work?
	i. If so, please explain.
	ii. If not, please explain.
	iii. Do you use it will all persons in your care or just some?
	iv. If you use it with just some persons, why is that?
	8. Were there any factors or things that helped make Montessori Methods for Dementia™ easier to implement where you work?
	9. Were there any barriers or challenges you encountered when putting/attempting to put Montessori Methods for Dementia™ into practice where you work?
	a. How did you address these barriers or challenges? (Probes: Were you able to overcome any of these barriers or challenges? If so, how?)
	i. Do you still face some of these barriers? If so, which ones?
	ii. How would you suggest overcoming these barriers? (Probe: What would you like to do to overcome these barriers?)
	Ask if not already addressed:
	10. Did you receive any support from your supervisor/manager when implementing Montessori Methods for Dementia™ where you work?
	a. If so, what types of support did you receive, and in which ways?
	b. If you didn’t receive any support from your supervisor/manager, why do you think that is?
	11. Did you receive any support from fellow staff members when implementing Montessori Methods for Dementia™ where you work?
	a. If so, what types of support did you receive, and in which ways?
	b. If you didn’t receive any support from your colleagues, why do you think that is?
	12. Were there any structural or organizational challenges that you faced when implementing Montessori Methods for Dementia™ where you work? (Probe: For instance, did you have enough funding, space and/or other resources, such as materials or equipment?
	a. If so, in which ways?
	i. How did you address these barriers or challenges? (Probes: Were you able to overcome any of these barriers or challenges? If so, how?)
	ii. Do you still face some of these barriers? If so, which ones?
	iii. How would you suggest overcoming these barriers? (Probe: What would you like to do to overcome these barriers?)
	b. If not, why do you think that is?
Changes you have noticed since implementing the Montessori Methods for Dementia™ program	13. Were there any changes or results you noticed since using Montessori Methods for Dementia™ where you work? (Probe: Changes with yourself, residents and their families, and other staff that were positive and negative?)
	a. Has it enhanced the quality of life of residents?
	i. If so, in which ways?
	b. Has it worsened the quality of life of residents?
	i. If so, in which ways?
	c. Has it enhanced the work life of staff, including yourself?
	i. If so, in which ways?
	d. Has it worsened the work life of staff, including yourself?
	i. If so, in which ways?
	e. Has it enhanced the care experiences of family members?
	i. If so, in which ways?
	f. Has it worsened the care experiences of family members?
	i. If so, in which ways?
Last question	14. Is there anything we haven’t talked about regarding putting/attempting to put Montessori Methods for Dementia™ into practice where you work that you feel is important and would like to discuss?

Data analysis

Data analysis involved: developing familiarity with the data (Charmaz, 2006), reflexivity and field note journaling (Charmaz, 2006; Garrison, 2011a, 2011b), memo writing (Charmaz, 2006; Braun & Clarke, 2006) and six phases of thematic analysis (Braun & Clarke, 2006). The primary investigator, Kate Ducak, developed a close familiarity with the data since she was the one who conducted all of the interviews, transcribed them, and then verified and cleaned the transcriptions. After each interview Kate recorded her reflections and field notes (Charmaz, 2006; Garrison, 2011a, 2011b) in one journal and memos (Charmaz, 2006, 2008) in a separate journal. Memo writing focused on ideas and how the data were and could be coded, whereas reflexive and field note journaling pertained to the context of the interviews, how they were conducted and with whom, and the information gained from them. Thematic analysis (Braun & Clarke, 2006) was employed during data collection involving writing and reporting of the themes and their meaning in relation to the research topic, questions and literature. Thematic analysis was an on-going and recursive process where Kate continuously shifted back and forth between the complete data set, coded portions, memos and the analysis of them (Braun & Clarke, 2006). Thematic analysis comprised six phases (Braun & Clarke, 2006) which were applied to suit the research purpose, method of data collection and theoretical framework (Patton, 1990). NVivo qualitative data management software (QSR International, 2015) was used to manually organize the coding framework during each phase.

Results

Seven themes in four categories emerged from the thematic analysis: 1) Limiting Factors (Regulating and Funding Medical Practices), 2) Enabling Factors (Educating and Understanding, Seeing Results is Believing, Being Supported), 3) LTC Culture Change Tensions (Shifting Practice Amidst Resistance to Change) and 4) Positive Outcomes ((Re-)Connecting People and Passions, Improving Residents’ Quality of Life). Overall, staff’s perceptions of issues that affect the implementation of MMD in Ontario LTC homes reveal that there were culture change tensions between limiting factors and enabling factors. Positive outcomes that improved the quality of life of residents living with dementia, staff and family members were possible when sufficient support was available to recreation staff. These findings are depicted as a conceptual model in Figure 1 and will be described in relation to the resultant themes below. Regarding the labelling used for quotations, recreation staff are identified with ‘R’, and multidisciplinary consultants are denoted with ‘C’.

Figure 1.

Implementing MMD in Ontario LTC homes conceptual model.

Limiting factors

The limiting factors are encompassed in the theme Regulating and Funding Medical Practices where staff perceptions of Ministry regulations and funding contributed to the medicalized and task-oriented LTC practices that participants described. For instance, ‘there’s such a routine, a rigid routine, like meals are this time and bath is this time and, personal care is this time’ (R2). All staff were driven by Ministry of Health and Long-Term Care (Ministry) regulations which seemingly place a priority on attending to the medical status of residents rather than ensuring their quality of life. According to one participant (R2), staff’s preoccupation with regulations and the physical needs of residents:

… stems from staff needs, hours of service, how they document what they do with their time, how fast things have to get done, their schedule, keeping to the Ministry of Health standards, you know, so many people have to be toileted and bathed and everything else.

Staff in LTC homes must follow Ministry regulations in order to maintain the home’s funding and to avoid being internally and publically sanctioned by Ministry inspectors. Participants, such as a recreation manager (R11), expressed how all staff adhere to Ministry regulations, but that nursing staff were particularly driven by them and did not want to implement Montessori-based activities out of fear that inspectors would disapprove. She stated:

Some of the barriers [are], you know, nursing being task-oriented and thinking that the Ministry is not going to allow for this. Everybody’s nervous, you know, and I’ll just say in our area … residents … like to do household chores. So that would take over some of our staff’s chores if they allowed them to, but they’re so nervous of the Ministry. … Like if they make the bed and not do it correctly. I know that they’re driven by the Ministry of Health, and so are we, but if [residents] don’t make the bed properly they figure if an inspector comes in and trying to explain that would just be way harder than just doing it themselves.

A consultant (C5) encountered similar difficulties when trying to encourage nursing staff to incorporate MMD principles and activities into their routines:

Staff buy-in is another problem where I go in and I say, “I would like you to try this.” And they’re like, “Well, I have to get eleven people out of bed. I’m not doing that for him.” It’s a very task-oriented work environment and so to add something that is sort of unique or a little bit out of the box is threatening to some of the staff, especially those who have been there forever … So staff attitudes is a big deal.

The medicalized nature of LTC and adherence to routines based on Ministry standards influenced how staff cared for residents. A consultant (C2) commented on how nursing staff regarded responsive behaviours from a medical perspective: ‘behaviours are presented but they’re looked at as behaviours that need to be treated rather than looking at what causes these behaviours’. As a result of the medical structure of LTC, participants reported that the medical needs of residents took priority over their quality of life which made it challenging to implement programs such as MMD and ensure their sustainability. A recreation manager (R12) concurred that introducing person-centred MMD activities and altering the deeply ingrained medical nature of LTC is difficult:

We’re just dealing with a primarily medical environment, right? And, while even the government’s trying to get away from that it’s hard when you’re dealing with people who have been in nursing for 20 years and suddenly be open to this whole other way of nursing.

Similarly, Ministry regulations and medical practices seemed to create a hierarchy in LTC homes where the caring roles of nursing staff were deemed more important than the activities that recreation staff provided. Some participants described what they believed was the source of nursing staff’s lack of respect for recreation staff and activities, which was corroborated by a consultant (C5) who aimed to improve interdisciplinary collaboration in LTC. She said:

My heart goes out to the recreation staff because it seems they really just lack credibility with the nursing staff … They put them lower down on the totem pole, unfortunately. … I think the rec staff know what they do but I don’t know that in their training they have that extra level of understanding the medical side of things, so sometimes that’s where the downfall is … And so over my years when I’ve been consulting to the recreation department, it’s even simply changing their language or understanding a diagnosis more because if you ask an RN [Registered Nurse] to explain what’s going on medically they’re happy to share it, but I think the rec staff get scared … the nurses … can talk down to them, so I understand their fear too.

Another participant (R6) found that MMD was very effective in the dementia care neighbourhood she worked in, but noted the challenge was the limited time available for recreation staff to implement programs: ‘it’s hard because we only have three programs in there a day so it’s … nursing staff and PSWs [Personal Support Workers] that are there with them all the time but we’re having a hard time getting them on board.’ A consultant (C3) also reported challenges with trying to get nursing staff to use MMD activities with residents:

… everybody can do this, it’s not just programming, PSWs can do these activities, the registered nurse when she’s going by with the med cart can … it’s getting everybody’s buy-in that they’re all responsible. They really still think it’s just programs’ and recreation’s job.

The unwillingness of nursing staff to use MMD either because they did not value the advice of recreation staff or because they felt that their role did not encompass activities was usually ameliorated when consultants suggested they try using MMD activities. This is likely because nursing staff viewed the consultants as experts.

C4: I think sometimes it’s better to have an outside source come in and promote it. And then they see that it’s something that the resident needs rather than something that the activity department is responsible for. … a lot of times it’s easier to say, “Oh, that’s her job, not mine.” But if I come from the outside, I’m hoping that the nursing staff will do it more. … And the nursing staff that I’ve talked to have been very supportive about it. They really liked it.

Another consultant (C5) agreed that nursing staff respect the advice of consultants over recreation staff: ‘they just find it’s more credible under sort of a professional designate I think is what it is … So when consultants come in, you’re given that automatic respect’.

Participants also noted how Ministry funding was insufficient for their program materials, staffing ratios, and staff training to provide residents living with dementia with individualized MMD activities. The ability of recreation staff to purchase materials for activities and programs like MMD was largely determined by the funding provided to them from the Ministry. Participants reported that the funding available to them for program materials was insufficient as they either had to slowly purchase items over time or request donations from families. When asked whether funding for materials or equipment was challenging, one participant (R1) replied: ‘It’s always an issue … We’re trying to make the best out of what we have’. A consultant (C5) corroborated participants’ accounts of having to make a limited budget work with various activities and she suggested they look to other sources for funding, such as from restorative nursing, volunteer assistance, or ask for donations from families. Ministry funding also affected the ratios of recreation staff-to-residents since LTC homes employ certain numbers of staff based on the funding they receive. Participants reported that they typically had a very low staff-to-resident ratio which made it difficult to provide residents with MMD activities as they work best on a one-to-one basis rather than in a small or large group of residents. According to a recreation manager (R12) regarding whether she and her staff used MMD with all or some residents:

… the one-to-one sort of really intense programming, I would say, about 10 percent. Because it comes down to those ratios and the time, however, we do try to apply it to all the programs, well OK, say 80 percent of the programming we provide.

Some participants mentioned that they began implementing MMD in their dementia care neighbourhood where there was also a very low ratio of one recreation staff member to at least 25 residents which presented challenges. A recreation manager (R7) remarked:

… our dementia unit is quite active right at the moment and at this point it’s attention span and staffing levels. Because there’s only one activation person to 28 [residents] so … if she’s not monitoring for agitation or aggressive people then the person’s able to utilize the Montessori but it, sometimes their role has to be different than programming.

Aside from difficulties due to insufficient Ministry funding to purchase materials and recreation staff to provide activities, participants also noted that they did not have an adequate budget for staff training. Participants thought that sending all of the recreation staff to a MMD workshop would be useful but that it was not possible due to budget constraints. According to one participant (R4): ‘I think some of our barriers here are more financial barriers because I think it would be beneficial to send more staff to the workshop but financially that’s not feasible’. A recreation assistant (R5) similarly agreed: ‘… we have six people in our department and they couldn’t afford to send every one of us’. In summary, the Ministry’s inclination towards Regulating and Funding Medical Practices greatly affected staff’s perceptions of policy and practice issues and the ability of LTC recreation staff to implement MMD.

LTC culture change tensions

Regarding culture change tensions in LTC homes, the theme Shifting Practice Amidst Resistance to Change depicts how recreation staff wanted to transition to smaller more effective quality programming using MMD because traditional large group activities were not well-suited for the unique needs and abilities of residents living with dementia. Recreation staff revealed how they transitioned from the typical large group activities format to smaller groups or more one-on-one MMD activities that best met the needs of residents. Some participants, such as a recreation assistant (R5) described why large group activities, like bingo, were not suitable for some residents living with dementia due to their varying levels of ability and attention spans. Instead, she had been:

… breaking down the [large] groups into smaller groups and focusing more specifically on the residents’ needs … sometimes it’s been a five minute program and sometimes it’s been a 15 minute program … because then you get the true attention and the true participation from the residents.

A recreation manager (R3) described how the use of MMD throughout the home grew based on the results they witnessed and the involvement of volunteers to help facilitate more one-to-one activities with residents. Her process was to talk with recreation staff:

… about who would be good candidates on their floors … for Montessori and … which of the activities that we could do with them. … And then they would do the program and see if it worked or not. … Now they actually do a one-hour program where they pair up a volunteer with a resident and then they show them what the activity is and let them do it with them. … So instead of having a one-hour program where they have 20 people attending a music program they would do a one-hour Montessori hour … so that the staff can have more than one person going on at the same time.

While shifting their programming practices, recreation staff encountered resistance to change from staff and family members who were used to residents being together in large group activities as well as from recreation staff who were taught that large social events are best. A recreation manager (R7) explained the reaction she received from nursing staff as she and her staff transitioned to smaller Montessori programs for residents:

Nursing staff have so much that they need to accomplish in a shift that they … wanted to see large group programs … everybody involved … The small programs of short duration is hard for people to buy into because we’ve always been, you know, {chuckles} big group, get them all involved … So to get that buy-in from, just to change that expectation of staff.

Similarly, another recreation manager (R12) described how families reacted when her staff began to switch the majority of their programs from large groups to smaller Montessori-based activities in order to meet the needs of all residents:

… we did receive a lot of resistance from certain families because they expect to come in, and the program staff have someone playing a piano and everyone’s singing and dancing and piled in a big room all the time. And it’s recognizing that do you do that in your own life? Like, do you do that every day? … Because then with our [staffing] ratios we’re not providing that quality programming to everybody else that doesn’t attend.

To sum up, the theme Shifting Practice Amidst Resistance to Change reveals how participants noticed that not all residents living with dementia were receiving therapeutic value from traditional large group programs in LTC, and that smaller group or one-on-one MMD activities were more appropriate for their unique needs and abilities.

Enabling factors

Enabling factors include the theme Educating and Understanding which denotes how staff and family needed to be educated on the philosophy, use and benefits of MMD in order to understand why recreation staff were using it with residents. For instance, participants realized that some staff were used to doing things for residents rather than giving them the opportunity to do it themselves. This difference in approach seemed to be a matter of how they were trained:

R4: … some of the things that we’ve encountered is just the knowledge base of the staff … we focus on different areas and so some people don’t understand when we’re trying to allow them to be successful and trying to focus on the positive. We’ve hit some resistance with some of the staff that they don’t understand why we just don’t do it for them. {chuckles}

Likewise, another recreation manager (R7) found that some staff members did not understand how the process and engagement in a Montessori activity was more beneficial for residents than the activity’s outcome. She also noted how staff who were not familiar with MMD thought it was inappropriate for residents living with dementia:

… when I brought home all of the resource materials from the course I sat down with my staff and we … went through each one as to how it would benefit or how they would explain it to other staff if they said, well, you know, “Why are you scooping golf balls into a muffin tin?” So we rationalized … “OK, that motion will maintain dexterity so that they can continue to feed themselves.” So that makes sense to a nurse, to a PSW, so because there’s always that thought, “Well, this is childish or this is not appropriate.” Or that type of thing.

Education helped to change the negative attitudes towards MMD and activities that some staff and family members had while highlighting the benefits of meaningfully engaging residents living with dementia with activities. MMD provided a way to communicate with and engage residents so that staff did not have to constantly address repetitive questions or other behaviours. One consultant (C3) explained the usefulness of MMD to staff and how it could save them time as a way of counteracting negative attitudes. She noted that understanding the theory behind MMD is important:

… you can either spend the time responding to those behaviours OR you can implement the little two second activity and let them work on it for half an hour … Again they need that theory and the training and repetitive reminders as to it really isn’t time consuming – where do you want to spend YOUR time?

Staff and family members could be educated by taking the MMD workshop off-site or they could be informed about it in their LTC home through in-services or other group or one-on-one education sessions facilitated by consultants or recreation staff. A participant (R8) recounted what information she provided to staff during a MMD in-service and that it was inclusive for staff from all disciplines:

… give them the background of Montessori, how it came about, why it’s effective, why we should be using it in all areas of care, not just recreation, but in terms of nursing care or housekeeping, how we approach the residents, that kind of thing.

Another way for staff in LTC to be educated on MMD within the home is through consultants who are typically requested by the home’s management team to come in and assist with a particular issue or to provide an in-service on a certain topic. A consultant (C2) explained her role: “is to increase capacity of the staff in working with people living with dementia. So, therefore, I do education and case consultations.” Another consultant (C3) described her process for educating staff on MMD since some may need more assistance and support:

With adults you have to visually demonstrate, then support them while they try, and then let them go and try it themselves, and be there for support if they need it. That’s kind of my three steps to training. Just doing a lecture will not work with our health care staff. Many still have literary problems, for some English is a second language, so that demonstration-type education breaks through those barriers.

Similar to the ways that staff are educated on MMD it is also important to educate families about how they might use the techniques in their roles. Family members can be taught about MMD through in-services and other group or one-on-one formats at the LTC home. A recreation manager (R8) described them as: ‘educational sessions for the families, kind of getting a whole home approach to Montessori’. One consultant (C5) used her MMD training to educate families about dementia while also providing them with roles and routines and enabling them to feel comfortable when visiting their relatives in LTC. In review, the theme Educating and Understanding provides insight into how staff and family members were more likely to support and use MMD in LTC homes when they were educated on its purpose and techniques.

The theme Seeing Results is Believing details how some staff and family members needed to witness the positive effects of MMD for themselves in order to be convinced that it works, which then made it easier for recreation staff to put into practice. The main impressive results that changed sceptical attitudes were seeing residents living with dementia become more engaged in activities and daily life in the home as well as seeing MMD assist with responsive behaviours. Several participants remarked that ‘seeing is believing’ was a very effective way to change negative attitudes. A consultant (C1) noticed if sceptics are:

there and seeing it work and seeing the residents get engaged and smiling and taking part in an activity, especially residents when they don’t think that they’re capable really of doing much of anything … it’s a bit of a shocker when they hear a resident being the first to call out the answer to something when they thought all they could do was repeat the same sentence or phrase over and over again and actually to see that those memories are there … we just have to know how to get them to surface.

Similarly, a recreation manager (R7) described how having staff or families witness the positive results of MMD enabled them to know that it works:

The reading program I would have to say is the biggest win that we’ve had not only for the resident themselves but to actually promote our department, like activation with nursing staff and families, and it’s like, “Ah, she reads! Oh my!” … it really is truly amazing to listen to someone who may not have put two words together in such a long time and then be able to actually concentrate and read those words.

Aside from seeing the positive results that MMD activities had on residents, staff and family members were also more likely to accept MMD as a beneficial technique and way of life for residents when they saw how it alleviated responsive behaviours. A consultant (C1) gave an example:

… there’s always people that are kind of set in their ways and the naysayers … in particular the doll therapy where they thought it was infantilizing somebody to give them a doll, but again, when they see how they react to the doll and that it brings them joy … they’re more likely to come on board with it.

Another consultant (C5) found that others were more likely to accept and use MMD techniques after they noticed how it eased responsive behaviours. Her approach was to:

… focus on what will be successful immediately for the family and the staff, and then once I gain credibility I can then move on to the other areas of programming. … I try to focus on fixing, assisting with those programming ideas using the Montessori Methods because nurses really respond well when I’ve reduced repetitive questioning or asking to go to the washroom, so those are some of the hot spots I usually choose first before I go and say, “Let’s set up a reading group. Or let’s set up a memory sort.”

To sum up, Seeing Results is Believing demonstrated how witnessing positive results changed the negative or indifferent attitudes that some people had towards MMD.

The theme Being Supported specifies the various forms of support that participants required to put MMD into practice. Support from staff, colleagues, management, consultants and family members helped recreation staff implement MMD for the benefit of residents living with dementia and their relationships with those who work with and visit them. Recreation staff and management tended to receive the most support from within their department. Regarding her staff, one recreation manager (R9) said: ‘they’re very supportive … eager to implement the program and work with each other to make sure it was implemented’, while another (R3) noted: ‘[support] from my staff it’s been great and from some people it’s been great, but we have had quite a bit of resistance from people who aren’t from our department’. Being supported from the upper levels of staff within the LTC home – from management – was another common way that helped participants put MMD into practice. About finding support from management to ensure that staff would be cooperative, one of the consultants (C5) noted:

… making sure from top-down in the long-term care facility that there’s administrative buy-in that the management staff, the director of care buys into this too, because … it’s a bottom-up training so it’s at the field level, anybody can use it, we just need the top-down to support it.

Likewise, a consultant (C2) found that supportive management helped put MMD into practice since there are so many other competing priorities in LTC homes:

… any given day there could be so many emergencies and so many crisis situations because … they don’t have [adequate] resources … this Montessori for example, goes under unless there is a manager who is very strong and who can very determinedly take the agenda forward.

Other types of support included guidance for staff when they needed a different perspective or idea with an issue they were having. A consultant (C3) spoke of why she would turn to others for advice:

… sometimes it’s just an ear when I want to vent and say, “What do you think about this?” And sometimes it’s validation, like they’ve been certified and can go, “No let’s go back to the theory and practice.” You know, to get me back on the right track.

Families also provided support for implementing MMD in LTC homes in various ways. They contributed financially by covering material costs, they helped put MMD into practice by participating in the activities with their relatives, and they supported staff during meetings. A consultant (C4) noted that she asked families to pay for MMD activity materials since the organization she worked for and the LTC homes could not always afford to:

… we do run into who pays for it. In this case though, the families have never had a problem with that because really it’s never very expensive, it’s usually less than 20 dollars, and they, the families, love the individualized attention.

To summarize, the theme Being Supported details the various ways that participants sought assistance with putting MMD into practice in LTC homes.

Positive outcomes

The enabling factors led to many positive outcomes as a result of MMD which were identified in the themes (Re-)Connecting People and Passions, and Improving Residents’ Quality of Life. (Re-)Connecting People and Passions captured how staff were able to use MMD to foster meaningful connections with residents living with dementia that they had trouble communicating with or had difficulty finding an activity they enjoyed. Participants recounted how they were pleasantly surprised to find that MMD helped them connect with residents who tend not to communicate verbally and were still very capable despite what they or other people assumed. One participant (R6) described a breakthrough she had with a resident who staff had difficulty connecting and communicating with:

We’ve had one resident in particular who, she’s nonverbal, and so it’s really hard to communicate with her and often times she just sits perfectly still and we put her up to a table with, we were doing some flower arranging and she just reached out and started doing it and we were kind of all shocked, like we didn’t know that she had the capability of doing this.

MMD activities also facilitated meaningful family-resident connections which improved their relationships. A consultant (C3) described how using a Montessori-based daily activity planner provided a family with ideas of what to do when visiting their mother because:

sometimes families get lost when they come in as to how to have a quality visit with their loved one when “mom doesn’t even recognize me”. So this gives them a tool also to have that visit in a meaningful manner.

After being inspired at a MMD workshop, one participant (R5) created a sitting area at the end of a hallway with travel books and magazines so residents and family members could spend time together and connect through familiar activities that did not require conversation.

MMD reconnected staff with their confidence, passion and purpose for wanting to work in LTC. Participants explained how the positive results of using MMD reconnected their passion for working with residents living with dementia. According to one participant (R3): ‘you see improvement in people and you see people who maybe aren’t always actively engaged, really engaged and that’s good because it makes you want to come to work’. Another participant (R5) commented regarding MMD: ‘it’s really motivated me to get new ideas, and basically a fresh outlook … It [the MMD workshop] was new ideas and new concepts, so it basically got me excited about my job again’. Likewise, a recreation manager (R6) found that:

I feel like you’re not just going in there anymore and just doing a program for the sake of doing a program, you’re actually doing something that’s meaningful, and you’re getting positive responses from residents instead of just a lot of blank stares.

Another positive outcome of implementing MMD in LTC homes is that it improved residents’ quality of life by providing them with activities and roles and enriching their relationships which enabled them to enjoy life again. One participant (R11) expressed why person-centred activities like MMD are so important for residents: ‘we are in a home … I think that’s the biggest part with Montessori, you know, is that they’re not just here to die, they’re actually here to have a quality life’. Regarding whether MMD enhanced the quality of life of residents, a recreation manager (R6) remarked how it gave their lives purpose and meaning: ‘it’s definitely given them some meaning to their life, something to do again, that it’s given them purpose. They’re not just sitting there, you know, hour after hour with nothing to do’. A recreation manager (R9), who had been tracking the impact of MMD activities, also noticed the beneficial effects that MMD had on residents, such as their increased engagement in activities and involvement in daily life:

… they come out of their rooms more on their own, walk around the home a little bit more on their own, whereas before they would just keep themselves in their room all day, not speak to anybody. They initiate conversation on their own more. And they have a higher level of engagement during the activity as well. … they’re much more engaged, content, not so apathetic or isolating themselves.

Likewise, a participant (R4) explained how MMD activities gave residents a way to be an active part of the home based on the previous roles they had before moving into LTC:

… it has allowed them to increase their self-esteem and self-confidence and also allowed them to feel as if they’re able to engage in the community here. Some of the tasks that they have are roles … that they might have done in their previous life and therefore is helping the home, and so then they feel like they’re accomplishing something.

The quality of life of residents living with dementia was also improved through the reduction in boredom by engaging in MMD activities which reduced the responsive behaviours that staff observed. A consultant (C2) explained why boredom in LTC homes typically causes responsive behaviours and how MMD activities provided a means for residents to re-engage in life:

They’re showing behaviours because their needs are not met, they are frustrated, they feel bored, and they have no control … if they’re engaged in activities that are of interest to them and have a role to function in then that will make a difference … I see people just sitting in the hallways waiting after breakfast. They are waiting for another meal to happen, nothing happens in between. There are recreational activities but not enough, they are really not as much as they should be … people who didn’t have behaviours before can develop behaviours because they are so bored, they are so disengaged in life; they’re just existing rather than living.

Another consultant similarly described how she saw MMD enrich the quality of life of both residents and staff by giving residents activities and roles they enjoyed:

C1: … a lot of times you would see the residents sitting bored or coming up to the desk and repetitively asking questions of the staff and the staff are getting frustrated where now the staff, you know, can give these residents something to do where they feel useful and they’re enjoying their time as opposed to, you know, maybe looking for negative attention.

In review, the theme (Re-)Connecting People and Passions illustrated how participants used MMD as a way to engage with residents who they previously had difficulty connecting with.

Results summary

There were culture change tensions between the limiting factors and enabling factors that affected the implementation of MMD in Ontario LTC homes. The enabling factors facilitated beneficial outcomes for residents living with dementia, staff and family members. The limiting factors were largely structural challenges or barriers that participants were able to overcome with the organizational, financial, educational and individual support of staff, management, consultants and family members. Enlisting sufficient support enabled recreation staff to put MMD into practice which reportedly improved the quality of life of residents living with dementia, the staff who work with them and family members.

Discussion

Four key aforementioned factors, tensions and outcomes will now be briefly discussed as per this study’s purpose and in relation to existing research.

The challenges staff experience when implementing MMD in Ontario LTC homes

The two main challenges for recreation staff and multidisciplinary consultants when implementing MMD in Ontario LTC homes were (1) the ingrained culture of care that emphasizes meeting residents’ medical needs more so than other aspects of their lives, and (2) the insufficient funding of recreation staff, training and materials. These were structural factors that contributed to organizational and individual barriers to the provision of person-centred care.

The medical priority over quality of life in Ontario LTC homes not only made it difficult for nursing staff to meet the needs of residents holistically in a person-centred manner, it also contributed to the sense that nursing staff and duties were more important than recreation staff and activities. Staff hierarchies in LTC homes are not compatible with person-centred care as it requires shared decision-making and power among everyone who works, lives and visits there, thus necessitating beneficial relationships and encouraging innovation (McCormack & McCance, 2006; McCormack et al., 2010). The valuing of medical practices over other aspects of life in LTC likely contributed to the attitude that activities should only be provided by recreation staff in large group formats and the resistance that nursing staff felt towards being involved with them (Skrajner et al., 2007; Volicer et al., 2006). The disrespect and undervaluing of recreation staff and MMD activities could be also due to a lack of knowledge about the importance of activities (Dupuis, Smale, & Wiersma, 2003; Smith, 2004) and MMD in LTC (Elliot, 2011).

The Ministry’s propensity to regulate and fund medical practices in Ontario LTC homes likely contributed to recreation staff and consultants reporting that they did not have sufficient finances to purchase materials for activities and hire and train staff. Insufficient funding was also found by Dupuis et al. (2003), previous MMD workshop participants (Elliot, 2011) and other LTC program implementation research (Nolan et al., 2008; Stolee et al., 2005) to be a significant challenge for staff implementing new programs or training in LTC. Lack of funding also contributed to the inadequate staff-to-resident ratios that participants described as this reduced their ability to provide residents with personalized MMD activities. Low recreation staff-to-resident ratios tend to result in less residents participating in activities (Dupuis et al., 2003) whereas higher staff-to-resident ratios enable staff to provide more individualized activities that match the needs and abilities of persons living with dementia (Volicer et al., 2006). In general, LTC homes in Ontario are under-funded which makes attending any form of training difficult (Stolee et al., 2005).

The supports available to or needed by staff who are using MMD in Ontario LTC homes

The two vital supports that enabled recreation staff and multidisciplinary consultants to implement MMD in Ontario LTC homes were (1) in-home staff education, and (2) support from management. The supports available to or needed by recreation staff and consultants who are using MMD in Ontario LTC homes include educational, organizational, financial and individual support.

Participants found that they could bring MMD education into their LTC home to educate staff who did not have time to attend the two-day MMD workshop off-site or who could not afford it. Recreation staff primarily used in-services as the way of educating other staff in the LTC home on MMD that either they or a consultant facilitated. Having trained staff conduct in-house educational sessions for other staff assists with the application of new knowledge and its long-term sustainability in LTC homes (McCainey et al., 2007; Nolan et al., 2008; Stolee et al., 2005, 2009). Holding multiple education sessions has been identified as another way to increase a program’s retention and application in the workplace (Gould & Reed, 2009; Hyer, Molinari, Kaplan, & Jones, 2010; Moyle, Hsu, Lieff, & Vernooij-Dassen, 2010; Rampatige, Dunt, Doyle, Day, & van Dort, 2009). Furthermore, conducting staff in-services or one-on-one MMD education sessions with consultants helped put MMD into practice as on-going expert assistance can effectively increase the uptake of education in LTC (Stolee et al., 2005). This corresponds with recommendations for LTC homes to have mentors to ensure new knowledge is effectively and sustainably put into practice (McCainey et al., 2007; Nolan et al., 2008; Stolee et al., 2005; 2009).

Aside from being supported by colleagues and consultants, participants described how receiving support from management in the LTC home was a practical way to implement MMD. Managers reportedly provided support by asking their staff to be cooperative and offering financial support and personal support in the form of encouragement. Such organizational support is a crucial factor for program implementation in LTC. Managerial support and long-term culture change have been found to determine whether person-centred programs, such as MMD, are put into practice in LTC more so than peer support (McCormack, Manley, & Walsh, 2008; McCormack et al., 2010; Murphy, Shea, & Cooney, 2007) and to successfully sustain them (Beeber, Zimmerman, Fletcher, Mitchell, & Gould, 2010; Corazzini et al., 2010; Mitchell, Zimmerman, & Beeber, 2010; Moyle et al., 2010; Stolee et al., 2009). This is because organizational policy and practice changes are needed to accommodate the new knowledge and practices among staff, such as prioritizing and funding training, providing materials, and adjusting staff’s schedules as needed (Nolan et al., 2008; Skrajner et al., 2007; Stolee et al., 2005). Management styles is another organizational factor that can affect the application of new knowledge and programs in LTC, such as MMD. Management can maintain task-oriented and hierarchical practices or they can be flexible and empowering to facilitate the individualized care and activities involved with person-centred programs (Bishop et al., 2008; Cohen-Mansfield & Bester, 2006; Corazzini et al., 2010; Murphy et al., 2007).

Limitations and suggestions for future research

There were limitations to this study that provide guidance for future research. Participants were predominantly recreation staff (n = 12 or 71% of participants), one of whom previously was a nurse, and most multidisciplinary consultants (n = 3 or 60% of consultants) were nurses or other medical health professionals. Thus, the views of recreation staff were mainly ascertained which led to a limited perspective and understanding of nursing roles and implementing MMD in Ontario LTC homes. The reason for the sample being largely comprised of recreation staff could be due to the fact that when this study was conducted it was mostly recreation staff who attended the MMD workshops as they primarily facilitate LTC activities (Elliot, 2011; Volicer et al., 2006). In recent years all LTC staff disciplines have attended MMD workshops (G. Elliot, personal communication, September 20, 2014). It would be useful for future research to investigate the experiences of nursing staff (including PSWs) since they and recreation staff frequently interact with residents and each other. LTC staff from housekeeping, dietary, social work and administration would also be valuable to include in future studies to examine outcomes of the team approach to implementation. As well, the experiences of residents and family members were reported based on participants’ observations so it would be beneficial to obtain their views by interviewing them individually or in dyads. Future research could involve residents living with advanced dementia, where the effects that MMD activities have on them are observed and assessed, such as their levels of enjoyment, agitation, engagement, passivity, etc., as other Montessori-based studies have done (Giroux et al., 2010; Judge et al., 2000; Orsulic-Jeras et al., 2000).

Another potentially limiting consideration is the amount of time that participants worked directly with residents. Sixty-seven percent of the recreation staff interviewed were recreation managers who, on average, spent 29% of their time working directly with residents while the remainder (33%) were recreation assistants who spent about 91% of their time working with residents (Table 1). The multidisciplinary consultants reported spending roughly 27% of their time working directly with residents since they mainly worked with LTC staff. Although the majority of participants spent less than half of their time working directly with residents, they provided rich accounts of their own experiences of using MMD with residents as well as recreation staff’s experiences that they observed and were told about. Nonetheless, the results may have more accurately depicted the experiences of staff implementing MMD in LTC homes if more staff who worked directly with residents were recruited.

Conclusions

This exploratory study identified recreation staff and multidisciplinary consultants’ perceptions of factors that affect the implementation of MMD in Ontario LTC homes as there was no existing research on this topic. The themes and factors reveal how ingrained organizational practices and individual beliefs are in LTC homes and how they can positively or negatively affect MMD program implementation. LTC culture change tensions seemingly exist between limiting factors and enabling factors. When the enabling factors were facilitated many positive outcomes for residents living with dementia, staff and family members were reported. The limiting factors were largely structural challenges or barriers that participants were able to overcome with the organizational, financial, educational and individual support of staff, management, consultants and family members.

The findings from this study provide evidence that the principles used to create MMD activities and implement them as a person-centred philosophy of care are possible when staff have a clear understanding of why and how to put these methods into practice and work together as a team with sufficient support to do so. The results can help ensure that MMD are as practical and easy to implement as possible despite perceived barriers so that persons living with dementia in LTC and their partners in care can have a good quality of life.

Footnotes

Acknowledgements

In-kind support for this research was provided by the Gilbrea Centre for Studies in Aging at McMaster University. The authors wish to thank Dr. Ellen Ryan, Professor Emeritus, Department of Health, Aging, and Society, and Department of Psychiatry and Behavioural Neurosciences at McMaster University, and Dr. Sherry Dupuis, Professor, Department of Recreation and Leisure Studies at the University of Waterloo, for their contributions as master’s thesis committee members upon which this article is based. They declined to be involved in the writing of this manuscript due to other obligations.

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: This article is based on the master’s thesis research conducted by Kate Ducak under the supervision of Margaret Denton with input from a committee member, Gail Elliot. The authors declare no conflict of interest as this research was conducted, supervised and advised for academic purposes. In order to avoid the appearance of a conflict of interest, it is important to note that Gail Elliot was the Assistant Director of the Gilbrea Centre for Studies in Aging when this research was conducted. Gail now is the CEO of a for-profit business that focuses on dementia education and resource development, including DementiAbility Methods: The Montessori Way™ (a revised, newer version of Montessori Methods for Dementia™). The Montessori Methods for Dementia™ program was developed at McMaster University prior to her retirement.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Financial support for this research was provided by the not-for-profit Alzheimer Society of Hamilton and Halton through a Student Research Award with no specific grant number.

Kate Ducak is a gerontologist and McMaster University alumni. She has over 15 years of professional and personal experiences in long-term care communities involving applied research, consulting, education, evaluation, volunteering and supporting her grandmothers. Her goal is to ensure that long-term care homes are enjoyable places to live, work and visit. She provides consulting services across the continuum of care.

Margaret Denton is professor emeritus in McMaster University’s Departments of Health, Aging and Society, and Sociology. She held research grants from many distinguished funding agencies. Her numerous research publications report on retirement, community support services for older adults, women’s health and health human resources. She is Vice President of the Hamilton Council on Aging leading Hamilton’s age-friendly community initiative.

Gail Elliot was the assistant director of the Gilbrea Centre for Studies in Aging at McMaster University for 17 years before her retirement. She then founded DementiAbility Enterprises, Inc., which focuses on providing education and resources for anyone supporting individuals living with dementia and persons living with dementia. She is known for her work internationally and has authored many publications.

References

Beeber

A. S.

Zimmerman

Fletcher

Mitchell

C. M.

Gould

(2010) Challenges and strategies for implementing and evaluating dementia care staff training in long-term care settings. Alzheimer’s Care Today 11: 17–39.

Bishop

C. E.

Weinberg

D. B.

Leutz

Dossa

Pfefferle

S. G.

Zincavage

R. M.

(2008) Nursing assistants’ job commitment: Effect of nursing home organizational factors and impact on resident well-being. The Gerontologist 48(Suppl. 1): 36–45.

Braun

Clarke

(2006) Using thematic analysis in psychology. Qualitative Research in Psychology 3: 77–101.

Brooker

(2004) What is person-centred care in dementia? Reviews in Clinical Gerontology 13: 215–222.

Brooker

D. J.

Wooley

R. J.

Lee

(2007) Enriching opportunities for people living with dementia in nursing homes: An evaluation of a multi-level activity-based model of care. Aging and Mental Health 11: 361–370.

Butters

Delis

D. C.

Lucas

J. A.

(1995) Clinical assessment of memory disorders in amnesia and dementia. Annual Review of Psychology 46: 493–523.

Camp

C. J.

(2006) Montessori-based activities for persons with dementia Vol. 2, Beachwood, OH: Menorah Park Press.

Camp

C. J.

Mattern

J. M.

(1999) Innovations in managing Alzheimer’s disease. In: Biegel

D. E.

Blum

(eds) Innovations in practice and service delivery across the lifespan, New York: Oxford University Press, pp. 276–294.

Canadian Institute for Health Information. (2010). Caring for seniors with Alzheimer’s disease and other forms of dementia. Retrieved May 25, 2015, from https://secure.cihi.ca/free_products/Dementia_AIB_2010_EN.pdf.

10.

Charmaz

(2006) Constructing grounded theory: A practical guide through qualitative analysis, London: Sage.

11.

Charmaz

(2008) Grounded theory as an emergent method. In: Hesse-Biber

S. N.

Leavy

(eds) Handbook of emergent methods, New York: Guilford Press, pp. 155–170.

12.

Clarke

A. E.

Shim

(2011) Medicalization and biomedicalization revisited: Technoscience and transformations of health, illness and American medicine. In: Pescosolido

B. A.

Martin

J. K.

McLeod

J. D.

Rogers

(eds) Handbook of the sociology of health, illness, and healing, New York, NY: Springer, pp. 173–199.

13.

Cohen-Mansfield

Bester

(2006) Flexibility as a management principle in dementia care: The Adards example. The Gerontologist 46: 540–544.

14.

Corazzini

K. N.

McConnell

E. S.

Anderson

R. A.

Reed

Champagne

M. T.

Lekan

Zimmerman

(2010) The importance of organizational climate to training needs and outcomes in long-term care. Alzheimer’s Care Today 11: 109–121.

15.

Davis

J. E.

(2010) Medicalization, social control, and the relief of suffering. In: Cockerham

W. C.

(ed.) The New Blackwell Companion to Medical Sociology, Malden, MA: Blackwell Publishers, pp. 211–241.

16.

DementiAbility. (2015). Montessori Methods for Dementia™. Retrieved May 25, 2015, from http://www.dementiability.com/.

17.

Dupuis

S. L.

Gillies

Carson

Whyte

Genoe

Loiselle

Sadler

(2012) Moving beyond patient and client approaches: Mobilizing ‘authentic partnerships’ in dementia care, support and services. Dementia 11: 427–452.

18.

Dupuis

S. L.

Luh

(2005) Understanding responsive behaviours: The importance of correctly perceiving triggers that precipitate residents’ responsive behaviours. Canadian Nursing Home 16: 29–34.

19.

Dupuis

S. L.

Smale

Wiersma

(2003) In-house and community access recreation programmes in long-term care facilities in Canada: Final report, Waterloo, ON: Murray Alzheimer Research and Education Program (MAREP), University of Waterloo.

20.

Dupuis

S. L.

Wiersma

Loiselle

(2012) Pathologizing behaviour: Meanings of behaviour in dementia care. Journal of Aging Studies 26: 162–173.

21.

Edvardsson

Winblad

Sandman

P. O.

(2008) Person-centred care of people with severe Alzheimer’s disease: Current status and ways forward. The Lancet Neurology 7: 362–367.

22.

Elliot

(2011) Montessori Methods for Dementia™: Focusing on the person and the prepared environment, Hamilton, ON: McMaster University, Gilbrea Centre for Studies in Aging.

23.

Estes

C. L.

(2001) The political economy of aging: A theoretical framework. In: Estes

C. L.

Associates (eds) Social policy and aging: A critical perspective, Thousand Oaks, CA: Sage Publications, Inc, pp. 1–22.

24.

Garrison

(2011a) The Art and Science of Research Interviewing, York, ON: Institute for Social Research, York University.

25.

Garrison

(2011b) Interpreting Qualitative Data: An Overview, York, ON: Institute for Social Research, York University.

26.

Giroux

Robichaud

Paradis

(2010) Using the Montessori approach for a clientele with cognitive impairments: A quasi-experimental study design. International Journal of Aging and Human Development 71: 23–41.

27.

Gould

Reed

(2009) Alzheimer’s Association quality care campaign and professional training initiatives: Improving hands-on care for people with dementia in the U.S.A. International Psychogeriatrics 21: S25–S33.

28.

Hyer

Molinari

Kaplan

Jones

(2010) Credentialing dementia training: The Florida experience. International Psychogeriatrics 22(Suppl. 6): 864–873.

29.

Jarrott

S. E.

Gozali

Gigliotti

C. M.

(2008) Montessori programming for persons with dementia in the group setting: An analysis of engagement and affect. Dementia 7: 109–125.

30.

Judge

K. S.

Camp

C. J.

Orsulic-Jeras

(2000) Use of Montessori-based activities for clients with dementia in adult day care: Effects on engagement. American Journal of Alzheimer’s Disease 15: 42–46.

31.

Kitwood

(1997) Dementia reconsidered: The person comes first, Buckingham, UK: Open University Press.

32.

Lanoix

(2005) No room for abuse. Cultural Studies 19: 719–736.

33.

Malone

M. L.

Camp

C. J.

(2007) Montessori-Based Dementia Programming®: Providing tools for engagement. Dementia 6: 150–157.

34.

McCainey

C. A.

Stolee

Hillier

L. M.

Harris

Hamilton

Kessler

Le Clair

(2007) Evaluation of the sustained implementation of a mental health learning initiative in long-term care. International Psychogeriatrics 19: 842–858.

35.

McCormack

Dewing

Breslin

Coyne-Nevin

Kennedy

Manning

Slater

(2010) Developing person-centred practice: Nursing outcomes arising from changes to the care environment in residential settings for older people. International Journal of Older People Nursing 5: 93–107.

36.

McCormack

Manley

Walsh

(2008) Person-centred systems and processes. In: Manley

McCormack

Wilson

(eds) International practice development in nursing and healthcare, Oxford: Blackwell Publishing, pp. 17–41.

37.

McCormack

McCance

T. V.

(2006) Development of a framework for person-centred nursing. Journal of Advanced Nursing 56: 472–479.

38.

Mitchell

C. M.

Zimmerman

Beeber

A. S.

(2010) Dementia care training for long-term care staff. If you provide it, will they come? Alzheimer’s Care Today 11: 40–50.

39.

Moyle

Hsu

M. C.

Lieff

Vernooij-Dassen

(2010) Recommendations for staff education and training for older people with mental illness in long-term aged care. International Psychogeriatrics 22: 1097–1106.

40.

Murphy

Shea

E. O.

Cooney

(2007) Quality of life for older people living in long-stay settings in Ireland. Journal of Clinical Nursing 16: 2167–2177.

41.

Murray Alzheimer Research and Education Program (2015) Understanding Responsive Behaviours. Accessed May 25, 2015, from, https://uwaterloo.ca/murray-alzheimer-research-and-education-program/research/projects/responsive-behaviours.

42.

Neutens

J. J.

Rubinson

(2002) Research techniques for the health sciences, (3rd ed.). San Francisco, CA: Benjamin Cummings.

43.

Nolan

M. R.

Davies

Brown

Keady

Nolan

(2004) Beyond ‘person-centered’ care: A new vision of gerontological nursing. International Journal of Older People Nursing 13: 45–53.

44.

Nolan

Davies

Brown

Wilkinson

Warnes

McKee

Stasi

(2008) The role of education and training in achieving change in care homes: A literature review. Journal of Research in Nursing 13: 411–433.

45.

Nolan

Ryan

Enderby

Reid

(2002) Towards a more inclusive vision of dementia care practice and research. Dementia 1: 193–211.

46.

Orsulic-Jeras

Judge

K. S.

Camp

C. J.

(2000) Montessori-based activities for long-term care residents with advanced dementia: Effects on engagement and affect. The Gerontologist 40: 107–111.

47.

Orsulic-Jeras

Schneider

N. M.

Camp

C. J.

Nicholson

Helbig

(2001) Montessori-based dementia activities in long-term care: Training and implementation. Activities, Adaptation and Aging 25: 107–120.

48.

Patton

M. Q.

(1990) Qualitative evaluation and research methods, (2nd ed.). Newbury Park, CA: Sage.

49.

QSR International. (2015). NVivo Products. Retrieved May 25, 2015 from, http://www.qsrinternational.com/products.aspx.

50.

Rampatige

Dunt

Doyle

Day

van Dort

(2009) The effect of continuing professional education on health care outcomes: Lessons for dementia care. International Psychogeriatrics 21: S34–S43.

51.

Robichaud

Durand

P. J.

Bedard

Ouellet

J.-P.

(2006) Quality of life indicators in long term care: Opinions of elderly residents and their families. The Canadian Journal of Occupational Therapy 73: 245–251.

52.

Schneider

N. M.

Camp

C. J.

(2002) Use of Montessori-based activities by visitors of nursing home residents with dementia. Clinical Gerontologist 26: 71–84.

53.

Schreiner

A. S.

Yamamoto

Shiotani

(2005) Positive affect among nursing home residents with Alzheimer’s dementia: The effect of recreational activity. Aging and Mental Health 9: 129–134.

54.

Silverman

(2010) Doing qualitative research, (3rd ed.). Thousand Oaks, CA: Sage Publications, Ltd.

55.

Skrajner

M. J.

Malone

M. L.

Camp

C. J.

McGowan

Gorzelle

G. J.

(2007) Montessori-Based Dementia Programming®. Alzheimer’s Care Quarterly 8: 53–64.

56.

Smith, M. (2004). Commitment to care: A plan for long-term care in Ontario. Toronto, ON: Ministry of Health and Long-Term Care. Retrieved May 25, 2015, from http://www.health.gov.on.ca/en/common/ministry/publications/reports/ltc_04/mohltc_report04.pdf.

57.

Stolee

Esbaugh

Aylward

Cathers

Harvey

D. P.

Hillier

L. M.

Feightner

J. W.

(2005) Factors associated with the effectiveness of continuing education in long-term care. The Gerontologist 45: 399–405.

58.

Stolee

McCainey

Hillier

L. M.

Harris

Hamilton

Kessler

Le Clair

J. K.

(2009) Sustained transfer of knowledge to practice in long-term care: Facilitators and barriers of a mental health learning initiative. Gerontology & Geriatrics Education 30: 1–20.

59.

Volicer

Simard

Heartquist Pupa

Medrek

Riordan

M. E.

(2006) Effects of continuous activity programming on behavioural symptoms of dementia. Journal of the American Medical Directors Association 7: 426–431.

60.

Wiersma

Dupuis

S. L.

(2010) Becoming institutional bodies: Socialization into a long-term care home. Journal of Aging Studies 24: 278–291.