By Catarina Versaevel
National Director DCM Canada
The Butterfly Household Model of Care developed by Dr. David Sheard, Dementia Care Matters (DCM), a UK-based leading dementia care culture change organization, is currently transforming the culture of care in 5 supportive living and 2 long term homes in Canada. Over the past 20 years, this Model has grown across the UK, Ireland, and more recently has moved into Canada and Australia. As of July 2017, the first ever Butterfly Project started in the United States.
The Butterfly Household Model of Care rests on the belief that for people experiencing dementia, feelings matter most, that emotional intelligence is the core competency and that “people living with a dementia can thrive well in a nurturing environment where those living and working together know how to “be” person centred together” (Dr. David Sheard). Care home organizations who implement the Butterfly Household Model of Care are supported by Dementia Care Matters to undergo a one -year culture change program known as the Butterfly Project. The Butterfly Project incorporates several key components and guides and nurtures leadership, staff, families and care partners to be person-centred and relationship focused through established methodologies, tools, and staff Being a Butterfly training workshops.
Many articles have been written to describe the Butterfly Household Model of Care and the positive impacts on improving the quality of care for people experiencing different stages of dementia. (see website www.dementiacarematters.com). Based on the implementation of the Butterfly Household Model to date within the 7 Butterfly Projects/Homes in Canada, it is hoped that the lessons learned as described in this article will assist organizations in their implementation of the year-long Butterfly Project.
“Lifestyle Options Team… Reflecting back on our journey to make a difference for people living with dementia we were hopeful that DCM’s different training model would evolve into a more humanistic approach for staff, residents and their families. The start of our culture change was like comparing to “entering the world of the unknown”. We were fearful that things would be uncomfortable, that the journey could go wrong and that the success we wanted might not become a reality. It became more than we would ever have imagined. We saw our residents engaging in meaningful activities, feeling joy and happiness, connecting with others and coming back to living life their way. And by far, this culture change in dementia care has been the most rewarding in our lives, our staff and most of all, the lives of residents and their families” – Renate Sainsbury, General Manager, Lifestyle Options Retirement Communities, Edmonton Alberta
Key Lessons for Successful Implementation of Butterfly Projects
The implementation of the Butterfly Household Model of Care – Butterfly Project – as a culture change program relies on an appreciation and understanding of the organizational realities of each individual care home, the history, the existing culture, the governance and management of the organization and the family and external and community relationships. The key lessons described in this article link to these elements.
A Need to Understand the Organization’s Model of Care: To transform into a truly person-centred home where results can be seen in people’s daily lives, an organization will need to address the model of care in place and transition to a congruent model – a new emotion-led organization. A congruent model of care requires a Board who understands and supports the leadership and staff in the implementation of the Butterfly Household Model of Care.
Strong and Supportive Leadership: A leader who understands the Model, the implementation challenges and can provide the guidance, direction and modelling required for a change management program, as well as the strategy and tactics required to sustain the 12-month Project, is critical. Implementation success stands or falls on one charismatic, inspirational leader, a leader who can convey and model an emotional life journey and clearly grasp what “self” is about in an emotional led organization.
“Looking to and at the spirit of others, and in every move offering quiet appreciation is essential to good leadership. From this, then offering a picture of possibility that can inspire, ignite and involve.” – Nicole Gaudet, Vice President Choices in Community Living Inc and Site Leader Copper Sky Lodge, Spruce Grove, Alberta
“Significant support, direction and commitment from the management team at every level are critical for success. It allows managers to confidently follow the core ingredients of the model and, therefore, have a real chance of implementing lasting change. Passion and heartfelt leadership is key to driving the changes.” (Sally Knocker, Consultant Trainer Dementia Care Matters). A key learning is also to make the Butterfly Project and the Butterfly Household Model of Care implementation a standing agenda item and have all the Department Heads, such as Recreation, Housekeeping, Food Services, Maintenance and Administration, speak to their Department roles and how they, as leaders, are actively engaged with the Model ’s implementation.
Leadership and management team members’ presence and modelling for staff on a regular basis with people who are on the dementia journey is a real asset and support for staff especially if this modelling occurs following a Being a Butterfly workshop day so that staff know and can directly observe the leadership and management understanding and commitment to the culture change underway.
Positive, upbeat leadership and connections daily with people who live in the Butterfly Home and modelling warmth, caring and affection makes a huge impact and is a key ingredient to successful implementation.
Vision and Stakeholder Relationships: A collaborative and trusting relationship with government, regulators, policy makers built on a shared appreciation, understanding of and commitment to the Butterfly Model is key to addressing the cultural barriers that will inevitably arise throughout the implementation of the Model. For example, to create the look and environment of a Butterfly Home relies on collaborative and proactive work with external partners to manage risk, the cultural barriers and to sustain / refresh the environment and stuff throughout the year-long Project. The understanding and buy-in of the Model is also important for Fire Marshall, infection prevention and control and government officials who conduct compliance audits and monitoring of the home.
Project Management Methodology and Expertise: Implementing the Butterfly Household Model of Care at its core is changing the care culture and a change management program with many components. The degree and pace of change has been called by some as ‘brutal’ in the sense that it requires absolute focus and determination as well as the ability to cut through all the obstacles and sometimes make difficult or unpopular decisions. “The Butterfly Household culture change model is certainly well defined, with an array of piloted and rigorous practice tools, and it proceeds at a vigorous pace of change”. (Dr. David Sheard). Project management expertise and leadership within the organization to ensure due diligence, effective structures and follow-up and focus on the 12-month deliverables is critical to implementation success.
“Project management is the secret sauce in any project; it’s the difference between project success and failure. In the hands of an experienced leader, project management best practices and methodology offers a strategic and forward-thinking way of getting the project over the finishing line without limiting creativity and an individualized end state. At Malton Village, Region of Peel, we rely on the Butterfly Project methodology and tools and find these resources and the DCM consultancy key to our success.” – Mary Connell, Project Manager, Butterfly project, Region of Peel, Ontario
Dementia Care Matters Consultancy and Access to Dementia Care Matters Tools/Methodologies: The consultancy support from DCM through regular Skype sessions, through on-site visits, e-mails etc. with the proven expertise, experience in implementing the Model many times over, and guidance, is critical. Access to the DCM tools, resources, methodologies and taking the time to review and incorporate these resources into the staff practices and procedures is key. Using the tools, methodologies with consistency and rigour is also important. DCM has a very coherent and proven project structure, with monthly set deliverables describing the sequence of the planned culture change within the organization required to implement the Butterfly Household Model of Care. A key lesson is to adhere to the structure and the set deliverables and not significantly deviate from the flow and sequence.
Matched Households: One of the key elements in the implementation of the Butterfly Household Model person centred approach to dementia care is the creation of matched households. This concept is based on the belief that “matching” people at a similar point in their dementia in a household provides more focused and individualized care. This gives the opportunity to bring out the very best in people and avoids the potential distress and muddle of people with very different needs all being together in a large group. It also means staff have the chance of focusing their own skills to meet individual needs and to provide more specialist care and support. This concept is introduced fairly early on in the implementation, and a lesson learned toward successful implementation is to introduce the concept and approach to staff and families early in the Project, and to not transition to matched households late in the 12-month project.
Licensed Practical Nurse (LPN) Leadership and Knowledge: The LPN embodies a critical role in the implementation of the Butterfly Project. The daily and consistent LPN modelling and support for staff of what relational care means and what it means to be a staff in a Butterfly Home is critical. The LPN’s daily presence to address issues and concerns as they arise is also key. Another lesson is the importance of organizational support for LPNs in the development of the LPN leadership skills as well as the skills to mentor, support and nurture staff.
“As an LPN and leader of the Butterfly Project at Villa Marie, I’m proud of the culture change we’ve been able to implement . It has truly made a world of difference to the people that live and work here.” – Michelle Hansen, Resident Care Supervisor, Covenant Care, Alberta
Engaged Home Action Team: The Home Action Team is the organization’s link to the staff within the care home during the Butterfly year-long Project. The Home Action Team consists of 6-8 people from different departments/areas within the home. Their role is to communicate to their colleagues on what is happening, how it is going, and to convey to the home leadership any issues or concerns from a staff perspective. In other words, the Team members are the ambassadors for the Project and a key asset for problem solving and helping the leadership understand the barriers, challenges and implementation opportunities from the staff perspective.
Ongoing Staff Engagement: Throughout the year-long period, it is most helpful to provide ongoing opportunities for staff to engage with the leadership, to present ideas and to problem solve. Staff know the people with dementia and their families the best and are a valuable, essential resource to the implementation as the Project progresses throughout the year.
Strong Family Participation: Throughout the year-long project, it is important to hold regular meetings with families to describe the Butterfly Household Model of Care. This includes explaining the steps and progression of the Project, to identify the changes that are anticipated and to provide opportunities for families to network and have fellowship with each other on the dementia journey. This can really make the difference in enabling implementation and is worth the time and follow-up it takes. Authentic engagement of families is key.
Being a Butterfly Workshops: A key component of the year-long Butterfly Project is the 8- day learning program for staff. This learning program demonstrates to staff how to apply all the ideas and skills into one coherent learning and development approach. The course is very different from traditional ‘dementia awareness’ and starts with team members sharing ‘self’ and what matters to them in their own lives, emphasizing that the very best support is not about looking at people living with dementia as ‘them’ and different, but that it is really about all of us as people sharing life day-to-day, as friends and family might. This approach emphasizes that: improving self-awareness is the route to being person-centred; guaranteeing people’s quality of life is the central focus of learning; and, transferring skills into team-based action is the only real evidence that matters. Another key part of the learning is all team members being given an opportunity to observe the lived experience of people using the DCM ‘QUIS’ observational tool. Facing the reality or the truth of what life is really like for people can have a transformative effect in motivating the team. The implementation lesson learned is also that the investment in ensuring staff from all areas in the home participate is critical to truly change the culture of care, to grow action-based teams, and to ensure the daily lived experience of people is as positive as it can be. An important challenge for the home is also to think through how best to enable the casual staff to benefit and learn from the Being a Butterfly learning and development program.
“Being a Butterfly workshops allow for staff to be fully immersed in this significant culture change; focusing on our own life story, and how it impacts the way we view and care for others. Being a Butterfly workshops give staff permission see themselves as being a detached professional and creates an opportunity to be an attached professional through examining the emotional needs of not only our residents, but themselves. Exploring how we impact our residents is a key component of the Butterfly education and understanding the truth of what our care really looks like. Once you allow staff to pull back the layers of who they are, you see the lightbulb moments, and the motivation to learn and do better shines through. These workshops equip staff on how to change each moment for our residents so the daily lived experience is one of joy, purpose and fullness” – Amy McDonough, Former Butterfly Trainer, Southwood Care Centre, Intercare Corporate Group, Calgary, Alberta
Occupation/Activities: The Being a Butterfly learning program and the DCM tools and resources provide staff with creative ideas to engage and assist to occupy people experiencing the dementia journey in a person-centred way, recognizing the interests, hobbies and past work lives of people. Staff transition from task oriented care to putting relationships at the heart of interactions, and to meaningful occupation being built into the whole day rather than recreation or “activities” being seen as something separated and not everyone’s job as it should be. The team will also benefit greatly from ongoing ideas, modelling and encouragement from the home’s leadership, recreation staff and LPNs. For example, the staff team needs to know that even when individuals provide no verbal or immediate feedback, they may be experiencing or enjoying an activity, that people are still connecting, and so it is important for staff to persevere.
Part of the leadership in implementing the Butterfly Project is understanding each of the staff roles and working toward re-configuring roles (health care aides, recreation/activity workers, food services, housekeeping, maintenance etc.) to achieve an overall 1:5 staff ratio. This ratio is required for a vibrant, sustainable Butterfly Home and one focused on ensuring a positive, engaged day for all the people who live in the home.
Communications: In advance of the commencement of the Butterfly Project, the thinking through of the communications approach and plan to inform and engage families, staff, the community, external and professional partners regarding the Butterfly Project and the new culture of care is a key part of successful implementation.
Focus on Human Resources: The Butterfly Household Model of Care and achieving real culture change in dementia care homes is based on a model of emotional intelligence as the primary competency. This Model demonstrates how emotional intelligence, authenticity, being genuine and being real is the true basis for a new culture of care. Therefore, the role of Human Resources within the organization is critical to ensure that current systems do not disadvantage people who are possibly ‘naturals’ at being with people living with dementia, but don’t have the pieces of paper or years of experience to prove it. A focus on human resources including recruitment, true understanding of emotional labour and rigorous use of the DCM tools, such as, the Person Centred Appraisal and Leadership Appraisal tools as well as addressing staffing issues as they arise is essential to success. In some cases, a ‘success’ might actually be some staff members leaving their jobs, as they are in reality never going to ‘get’ the new approach to being with people or leading a team.
Celebrate and Mark Successes: Successful implementation flows from celebration and marking the successes of the team in nurturing and achieving positive days for the individuals who make their home in the Butterfly Home! It is important to look after each other and to enjoy the day!
Hopefully, the implementation lessons learned to date from our Canadian experience will assist other organizations as they transition to a new culture of dementia care and implement the Butterfly Household Model of Care. Dementia Care Matters looks forward to disseminating future learnings, as more Butterfly Projects are implemented in various provinces in Canada. A future DCM article to be released will address the sustainability challenges and learnings after a year-long Project concludes on how best to sustain the new culture of care and the Butterfly Household Model of Care.