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... therapy (2nd ed.). Philadelphia, PA: Churchill Livingstone Elsevier. ... The Princess Margaret Hospital. PO Box 800, Cashmere, Christchurch, New Zealand.

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PRE-PUBLICATION COPY Published World Federation of Occupational Therapists Bulletin 01/2014; 70:15-17

Walking in Another’s Shoes: Encouraging Person-Centred Care for People Living with Dementia in New Zealand Susan B. Gee and Maria E. Scott-Multani Canterbury District Health Board, New Zealand

Abstract If you walk in another person’s shoes you can understand their journey. This is the person-centred philosophy behind “Walking in Another’s Shoes” programme, a New Zealand developed initiative to provide education and support for paid carers working with people living with dementia. The Walking in Another’s Shoes programme is a small group experiential training program combining workshop sessions with one-onone work-place facilitation to promote a person-centred approach to dementia care. Key-words: Dementia; Experiential education; Person-centred Walking in Another’s Shoes: Encouraging Person-Centred Care for People Living with Dementia in New Zealand

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Introduction The philosophy of occupational therapy is based on a holistic recognition of people as unique individuals. It takes a personalized or client-centred approach, consistent with the principles and practice of person-centred care (SCIE & COT, 2010; Sumsion, 2006;). The skills and the philosophy of care of occupational therapists can thus offer a rich resource for helping shape a wider person-centred culture of care. One way that occupational therapists can have a wider impact on the culture of care is through involvement in educational initiatives. Staff education is one of the keys to ensuring high standards of person-centred care (Ballard, O’Brien, James, & Swann, 2001). Education and support for care-givers can make a difference in the rate of use of medication and restraint, and in the quality of life and behaviour (“symptoms”) of residents (Fossey et al., 2006; Loveday,1998; Mason & Adeshina, 2011). Training that is interactive and experiential with reinforcement of skills in the workplace is particularly effective in enabling staff to develop qualities that lead to person-centred care (Loveday,1998; Mason & Adeshina, 2011).

Walking in Another’s Shoes Walking in Another’s Shoes is a New Zealand education programme for carers developed by occupational therapist Maria Scott-Multani. It is a small group experiential training programme combining workshop sessions with one-on-one work-place facilitation to promote a person-centred approach to dementia care. The eight-month programme aims to strengthen the knowledge and skills, and especially

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to enhance insight into understanding and responding in a positive and person-centred way to people living with dementia (Gee, Scott, & Croucher, 2012). Throughout eight months the participants attend monthly intensive and interactive workshops, as well as monthly one-on-one sessions with the facilitator to talk through and plan improved approaches with specific clients. Care givers are encouraged to think differently about how they go about their interactions with the people they work with. The focus is on putting the person with dementia at the centre of care, rather than the disease. The Walking in Another’s Shoes programme is about changing attitudes. The programme turns the traditional emphasis in training upside down. There is an enormous growth in skills and knowledge in the programme but the focus is on how these can be tools for a more person-centred approach. A person-centred approach is the underlying theme throughout Walking in Another’s Shoes rather than it just being a one-off topic. Tom Kitwood’s work provided a clarion call to value the agency and individuality of people with dementia, and to provide person-centred care rather than task-driven or disease-driven care that may treat the person as a passive object (Kitwood, 1997). Person-centred care offers a different paradigm of dementia care in which the person comes first. There are four cornerstones of person-centred care: 

Valuing people living with dementia and those who care for them

Treating people living with dementia as individuals and taking an individualised approach to assessing and meeting their needs,

Looking at the world from the perspective of the person living with dementia, and

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Recognising the importance of relationships and interactions with other people and their potential to promote well-being (Brooker, 2004; Kitwood, 1997).

One of the key things the students take away from the course is that a cornerstone of person-centred care is getting to know the individual and seeing the world from their perspective. Having a student say “I stopped seeing the problem and started seeing the person and my whole attitude changed” is always a good news story for the facilitators. The programme helps the students to understand and respond positively to situations where they may find the behaviour of the person with dementia challenging. Consider an example of a client who does not want the carer to help with their shower and becomes upset. The students learn to ‘put on their detective hats’ and recognise that the person’s dementia is just one small part of the picture. By being aware of the person’s unique likes and dislikes, their life history, and their needs, they can respond in a person-centred way to each unique individual – for one person turning the shower into a pamper session, for another a singing session, for yet another taking gradual reassuring steps to acknowledge a fear of water. Part of the Walking in Another’s Shoes approach is that both the classroom work and the one-on-one work take an appreciative inquiry approach. This is an approach that holds that at its best, change is a process of inquiry (a process of asking questions) that is based on affirmation (Whitney & Trosten-Bloom, 2010). The facilitators don’t come into the discussions as experts to hand out answers, but rather

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they ask lots of questions. In this way the students are learning to ask the questions in their own work that they need to enable a person-centred approach. The programme has developed a well-received and effective model based on principles identified in related adult education contexts as providing a high-quality effective teaching-learning style, format, and philosophy. This includes a strengthbased approach, valuing learners and their own experience, using a range of interactive learning modes, creating a learning environment that is positive and supportive, inclusive and cohesive, safe and enjoyable, providing flexible individualised support and helping students set their own learning goals, having a small number of students who undertake the programme together, fostering a sense of belonging and cohesion, and providing ongoing support for putting theory into practice in the workplace (e.g., Arini et al., 2007; Curtis et al., 2012; Kuske et al., 2007; Marshall et al., 2008; Mason & Adeshina, 2011; Ministry of Education, 2005; Zepke et al., 2005). The Role of Occupational Therapy Drawing on the Model of Human Occupation (Kielhofner, 1995) and Tom Kitwood’s model of person-centred care (1997) as underlying philosophies, the Walking in Another’s Shoes programme provides students with the opportunity to take a holistic approach when meeting the needs of people living with dementia. Concepts covered within the eight month programme include activity analysis; consideration of culture and diversity; environmental modification; grading and adaption of activities of daily living; interpersonal communication; meeting of unmet emotional needs; optimising and maintaining function; promotion of choice; utilisation of a restorative approach and sensory modulation.

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The programme uses a strengths-based approach and focuses on developing student’s sense of autonomy; self-efficacy; and conscious use of self. Using principles of occupation and volition, students are encouraged to see themselves as positive points of influence within the workforce and are taken through a group process that results in attitudinal change, greater sense of value and the development of strong support networks. This results in the students being able to respond in a positive and person-centred way to people living with dementia. While remaining consistent with an Occupational Therapy approach, the programme is able to be facilitated by other health professionals as the programme expands. Impact The Walking in Another’s Shoes programme began in the Canterbury District Health Board in 2008. There is now a Walking in Another’s Shoes Educator in every District Health Board in the South Island. The Hawkes Bay DHB was the first District Health Board in the North Island to adopt the programme, followed by Midland DHB this year. The programme is offered without a fee to carers working with people with dementia in residential facilities. In some regions versions of the programme are also offered to home-based support workers and to registered health professionals. In this last financial year over 300 staff enrolled in Walking in Another’s Shoes, and three quarters of all the eligible aged care facilities in the South Island were engaged in the carers’ programme. The Walking in Another’s Shoes programme is copyrighted to the Canterbury District Health Board . District Health Boards who are using the programme agree to maintain a consistent standard of delivery in keeping with the philosophy of the Walking in Another’s Shoes programme. Trainers receive full

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training; training manuals; relevant resources and ongoing support to enable consistent high quality delivery of the programme.

The progamme has been extremely well-received by students, with high evaluation ratings of perceived impact. For graduate Sue Allen, a carer in a dementia unit in the Hawkes Bay, the programme gave her new insights into what it might be like for the residents she works with after 16 years as a care giver. “I was asked if I would like to participate in the Walking in Another’s Shoes course so I jumped at the opportunity to learn more, which I have done in bucket loads” she told us. “It has given me an affirmation that things I am doing make a difference and how I may do them differently or better, it has given me a whole new toolbox of techniques and strategies, and a different line of thought that I can use to further improve the quality of our residents’ lives, and the improved tools to cope with behaviours that challenge. It has given me improved self-esteem and courage to not only apply what I have learnt but to share it with others.” A suite of outcome measures are collected at the beginning and again at the end of the programme. These show a significant improvement in the students’ personcentred attitudes (Approaches to Dementia Questionnaire, Lintern 1996), personcentred behaviour (manager’s rating using part of the Person Centred Dementia Care Assessment Tool, State of Wisconsin, 2006) and work experience (Using items drawn from the Career Stress Scale, Pearlin et al., 1990 and COPE index, McKee et al., 2003). Ensuring that effectiveness can be carried over to new generations of the programme is integral to the expansion process, and analyses confirm that the new

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generations of the programme do not differ significantly in their effectiveness compared to the original.


Whilst the Walking in Another’s Shoes programme has been tailored for a New Zealand audience. The need for a person-centred approach is internationally recognized. The Walking in Another’s Shoes programme provides a successful model which could easily be adapted in other cultural contexts. With an increasing aging population, the challenge is how to meet the needs of many by using health resources and secondary services differently. The Walking in Another’s Shoes programme is an example of the benefits that can occur when we embrace a changing health climate and focus on developing a service or programme that recognizes the importance of valuing, celebrating and supporting all those who contribute to the care journey. Focus on one person with dementia; identify one area of the person’s well being that you think could be improved . . .And when you succeed in improving the wellbeing of one person with dementia, know that you have achieved something profoundly important (Loveday, 2013, p.150).


Ballard, C.G., O’Brien, J., James, I., & Swann, A. (2001). Dementia: Management of behavioural and psychological symptoms. New York, NY: Oxford University Press.

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Brooker, D. (2004). What is person-centred care in dementia? Reviews in Clinical Dementia, 13, 215-222. Fossey, J., Ballard, C., Juszczak, E., James, I., Alder, N., Jacoby, R., & Howard, R. (2006). Effects of enhanced psychosocial care on antipsychotic use in residents with severe dementia: cluster randomised trial. British Medical Journal, 332, 756761. Gee, S., Scott, M., & Croucher, M., (2012). Walking in Another’s Shoes: Encouraging person-centred care through an experiential education programme. Good Practice Publications. Wellington, NZ: Ako Aotearoa Kielhofner, G. (1995). A model of human occupation (2nd ed.). Baltimore: Williams & Wilkins. Kitwood, T. (1997). Dementia reconsidered. Buckingham, UK: Open University Press. Kuske, B., Hanns, S., Luck, T., Angermeyer, M.C., Behrens, J., & Riedel-Heller, S.G. (2007). Nursing home staff training in dementia care: a systematic review of evaluated programs. International Psychogeriatrics, 19(5), 818-841. Lintern T, Woods B, Phair. L. (2000). Before and after training: a case study of intervention. Journal of Dementia Care, 8, 15–17. Loveday, B. (1998). Training to promote person centred care. Journal of Dementia Care, 8(4), 20-22.

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Loveday, B. (2013). Leadership for person-centred dementia care. London, UK: Jessica Kingsley. Marshall, J., Baldwin, K., Peach, R., (2008). Te Rau Awhina: The guiding leaf. Wellington, NZ: New Zealand Qualifications Authority. Mason, J., & Adeshina, A. (2011). The role of psychiatrists in developing the skills of dementia care workers. Advances in Psychiatric Treatment, 17, 372-380. McKee, K.J., Philp, I., Lamura, G., Prouskas, C., Oberg, B. et al., (2003). The COPE index - a first stage assessment of negative impact, positive value and quality of support of caregiving in informal carers of older people. Ageing and Mental Health, 7(1), 39-52. Pearlin, L.I., Mullan, J.T., Semple, S.J., Skaff, M.M. (1990). Caregiving and the stress process: An overview of concepts and their measures. The Gerontologist, 30(5), 583-594. State of Wisconsin (2006). Person-directed Dementia Care Assessment Tool: A Guide for Creating Quality of Life and Successfully Refocusing Behavior for People with Alzheimer's Disease and Related Dementia in Long Term Care Settings. Madison, WI : State of Wisconsin Department of Health and Family Services. SCIE & COT (Social Care Institute for Excellence and College of Occupational Therapists) (2010). Personalisation briefing: Implications for occupational therapists. London, UK: SCIE. Sumsion, T. (Ed.) (2006).

Client-centred practice in occupational therapy (2nd ed.).

Philadelphia, PA: Churchill Livingstone Elsevier.

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Whitney, D., & Trosten-Bloom, A. (2010). The Power of Appreciative Inquiry (2nd ed). San Fancisco, CA: Berrett-Koehler Publshers.

Susan Gee (left) and Maria Scott-Multani (right)

Corresponding author: Maria Scott-Multani Psychiatry of Old Age Academic Unit Level 2 Heathcote Building, The Princess Margaret Hospital PO Box 800, Cashmere, Christchurch, New Zealand [email protected]