This is a transcript from our podcast episode published March 14th, 2022. The podcast episode is offered for .1 ASHA CEU (introductory level, professional area). This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime.
A special thanks to our Contributing Editor, Caitlin Akier, for reviewing and editing drafts of our transcripts. Her work helps keep our material accessible.
[00:01:38] Kate Grandbois:
We're so excited for today. We get to welcome back a repeat guestthat we always have so much fun with.
Welcome Natalie Douglas.
[00:02:13] Natalie Douglas: Hello. I'm so excited to talk with you again.
[00:02:17] Kate Grandbois: Um, the last time that you were here, I think we had a moment where one of us screamed scurvy, which was like the most fun I think we have had on this podcast. Maybe not the most up there. It was great. So I can't wait to hear what you're going to teach us to say aside from scurvy.
[00:02:36] Amy Wonkka: I think, I think outside of scurvy, it's sounds like you're going to talk to us a bit about communication and life participation. We're super looking forward to, um, before we get started and for our listeners, um, who haven't met you before, can you tell us a little bit about yourself?
[00:02:56] Natalie Douglas: Sure. So I am Natalie Douglas.
I'm on the faculty at [00:03:00] Central Michigan University. I'm also an editor at the Informed SLP. And my biggest interest is in trying to merge the gap between research and practice through implementation science. Um, clinically, most of my work now is in quality of life and communication interventions for people with dementia in long-term care environments.
So sometimes that's assisted living, sometimes skilled nursing facility. Um, I do have a bit of a clinical background. I worked for about 10 years in between masters and PhD in hospital settings, outpatient, a little bit of home health. So. That's kind of me in a snapshot.
[00:03:46] Kate Grandbois: I love that you have that, um, that chunk of clinical experience prior to your doctorate.
I know in a previous episode you told us a lot of anecdotes about the real working conditions of a clinician, um, and how the [00:04:00] research to practice gap is so completely apparent when I believe your story was something. Why would you read an article when you can't even find a dry erase board, but marker for your patient.
And you're running around focus on that for 15 minutes, you know, the, the life of the real working clinician and the barriers that we all face. So your perspective is always so unique and we're really excited for you to teach us about this. Um, and as our listeners know, we know very little about this
[00:04:27] Amy Wonkka: and just a plug for our previous episodes on implementation science, uh, which is a fascinating area of the field that I knew nothing about, um, prior to having those conversations with you.
And it's, it's really interesting. And the idea of bridging that research to practice gap, uh, I think is such a huge, important thing for us to know about as a field.
[00:04:51] Kate Grandbois: You're here and we could get on a soapbox about that, but we won't, I'm going to redirect, redirect us over to our learning objectives.
[00:05:00] Um, so before we get into all the fun stuff and before, um, Natalie teaches us everything, I do need to read our learning objectives and disclosures and ask for me to skip this part. I can't ASHA make me read it. So please hang in there. I will get through it. Please describe elements of implementation, practice, that support training formal and informal carers and techniques to support quality of life and to make you bring it back.
Learning Objective Number two is that case studies highlighting evidence-based approaches to manage, communicate this patient for a person with dementia, Learning Objective number 3 summarize studies, summarize strategies to position LPs as key members of the healthcare team within the skilled nursing facility loaders. Dr. Natalie let's receive a salary from central Michigan university and informed SLP.
She also receives book royalties from plural publishing and has research funding from the American speech and hearing association. Douglas has no non-financial relationships to disclose consultancy and co-founder of SLP, nerd caps, nonfinancial disclosure, and the number 12 and serve on the AEC advisory group from Massachusetts advocates for children.
I'm also a member of the Berkshire association for behavior analysis and therapy, mass ABA association for behavior analysis, international intercourse on Expedia speech and [00:06:00] applied behavior analysis special interest group
[00:06:01] Amy Wonkka: Amy that's me. I am an employee about the system and my non-finance disclosures that a number of ASHA SIG 12, and I also serve on the AAC advisory and massachusets advocates for children
Right. We've made it through the dragons. How about you start us off by telling us a little about the first learning objective. And can you say a bit about care partners? I have to say, I'm not sure about the difference in care partners formal versus
[00:06:23] Natalie Douglas: informal, right? Right. So a couple of key points to that.
Thinking about somebody living with dementia. Along the same lines as a caregiver, but the idea was that you were parked at somebody who might just still have some level of dignity and autonomy and choice, as opposed to only the one to eight relationship of giving care. And so you can think of informal, and formal care partners as kind of like unpaid to a degree, right?
So the majority of dementia care in the United States, which costs billions of dollars annually is actually unpaid care, um, provided by [00:07:00] family members at home. And then we have your partners who are either through home health agencies, certified nursing assistants, um, direct caregivers who provide, you know, toileting feeding that type of care that they're paid for, um, activities either in a home health environment or skilled nursing assisted living those types of environments.
[00:07:18] Kate Grandbois: I know the term care partner also leads to me, interpreting it. Think of the, I guess, informal care partners. It implies that the caregiver is also experiencing components of dementia. At least when I think of it that way, because this is this disease has a really big impact on families, on quality of life force and those kinds of things.
It's not, uh, like you said, it's not a unilateral relationship where persons just giving care and the other, person's just receiving the care.
[00:07:47] Natalie Douglas: Exactly, exactly it. Dementia, it affects everybody the entire, you could, you know, even at a systems level two, you've got one maybe adult son or daughter [00:08:00] and they're local, and then they make certain decisions.
But then an out of town, um, son or daughter might come in for a visit and kind of switch up those decisions. And you know, this is, it's just, there's a lot of complexity in terms of how dementia really impacts the whole family, friends, everyone.
[00:08:21] Kate Grandbois: Um, so now that you've sort of laid out this, this more preferred term is more dynamic term and explain difference between formal and informal care partners. How does this relate to implementation practice and science?
[00:08:33] Natalie Douglas: Right. So if you think of implementation science as the study of which strategies can support evidence-based practice uptake, right? So implementation science is really thinking about what do I need to do to really get a practice that I know works scientifically into the real world. And that has inquiry in [00:09:00] terms of scientific study.
The implementation practice. I've actually only learned about in the past couple of years. And so listeners that are really interested in this, I would bet you, they call he's essentially it’s saying if we will be able to teach in a best practice, we do have fights, but we also have to have the press. That's what we do all the time as speech, language pathologists, right?
We're constantly juggling that line between the science or the internal evidence and then the realities of clinical practice. And so one of the resources that they put out, these folks who are studying and really exploring implementation practice, they have six, um, principles that kind of underlie implementation practice.
So I don't know, or six domains, if you will. I don't know if we want to go over all of them or not, but I can [00:10:00] just preview it.
[00:10:02] Kate Grandbois: Yeah. Give us a snapshot because I'm not, I'm very unfamiliar with this term, so yeah. Very interested. Yeah.
[00:10:09] Natalie Douglas: Okay. So the first domain is being the first principle is being empathetic.
Hello. We already know about that. Being curious, being committed, advancing equity, using critical thinking and embracing cross-disciplinary approaches. And like, none of these things are new there.
Kate Grandbois: I love this.
Yeah. They're all things that we do as clinicians all the time. But I think to see it laid out with this implementation lens, you know, it is extremely helpful, but one of the main, um, aspects of this is you co-create and engage from the beginning [00:11:00] in order to sustain change.
Okay. So this is less of a top down. I have this information and I need to, from on high, put it down onto you. Right, but it's more of a, we're all in this situation, learning together. And we're kind of co-designing yes. Informed by evidence and the science, but we're also tailoring this to the context, if that makes sense.
And we're making those necessary modifications.
[00:11:37] Kate Grandbois: And can I say this back to you in case just as like a, to help digest that, because I think what you said was so obvious and, and something that we all do, but also it sounds like it's a little bit more complicated than that. And, and it, it sounds a little bit like a framework for how to go about implementing.
Science or [00:12:00] implementing your knowledge. And I know Amy and I, we both love a good framework, but it helps give a little bit of structure to what you might already be doing. And when something has structured, you have footholds to implement it better or implement additional components that you might have overlooked.
Is that the right sort of landscape?
[00:12:20] Natalie Douglas: It really is. It really is. So how they have it listed it's they, uh, Mets and colleagues it's called the implementation support practitioner profile.
[00:12:31] Kate Grandbois: And we'll link this in the show notes for anybody who's out there running, driving, or what have you all of this will be in there.
[00:12:36] Natalie Douglas: Awesome. And so if you're guided by these principles of empathy, curiosity, commitment, critical thinking equity and cross-disciplinary approaches, it suggests that we co-create and engage. That we participate in ongoing improvement. So it's not a situation where we're like, okay, here it is boom. We're done [00:13:00] sign off.
Right. But we're continuously monitoring either the client or the practice or whatever it is. And we're continually making these, these tweaks, knowing that we work with human beings within human systems. And so that's constantly going to require adaptation and change, and then it gives some suggestions for sustaining change.
Right? So it's like, now that we maybe have seen this change happen, how do we do it? And no shocker to the two of view. I'm sure the main way that you do that is through growing and sustaining relationships. Right? And so I think when it comes to dementia care, this I've found this. So. You know, illuminating because it's like nothing works in training, any care partner without the foundation of that relationship.
Right. And so, [00:14:00] yeah,
[00:14:00] Kate Grandbois: I also just want to highlight that the first thing, the first component here is empathy. I mean, that really just reframes your knowledge to be focused on person centered care, Crip, client centered care, considering client and family stakeholders and values and empathy and making that connection with them.
And that's, that's the first thing on this list, which is really wonderful. And just as a reminder to everybody listening, you know, client perspectives and values are part of our evidence-based practice model. We often get really hung up on evidence being a research article or this component of extra and evidence.
And yes, that's important, but considering clients and patients and values is also creating an, an evidence-based practice environment. So I love that. I love that that's listed first because I think we, as a field, tend to lose sight of that sometimes, and really get really hung up on our knowledge on our external knowledge.
[00:14:59] Amy Wonkka: [00:15:00]Yeah. I agree with your take on that completely. Um, and I think it also highlights, first of all, I'm like ready to go out and read these things. Cause this sounds like something,
[00:15:11] Kate Grandbois: um, that furiously taking notes over there
[00:15:13] Amy Wonkka: I know I'm like don't open the article in the middle of the report, but I do, you know, I think it is it's sometimes we get a little tricked and feeling that like we know the one best right answer for other people.
And Natalie, I feel like you did a really nice job. Just talking about how that's, that's actually a conversation and the one best answer. Isn't something that you can just duplicate and apply. To all of your clients who present as XYZ because they're part of a human system and you call the human family system.
Um, and we all are, and, you know, having the empathy, like you were saying, Kate being curious about your client and their care partners [00:16:00] and what their values are, uh, is going to help us provide more meaningful and probably more effective therapy.
[00:16:06] Natalie Douglas:Yeah, absolutely. You know, and I think that I learned that as a practicing clinician, just feeling very burnt out and sad and like, I wasn't really helping anyone.
And part of the situation was I was working PRN and I think a lot of people work PRN in skilled nursing facilities because it works really well with the schedule. And, um, but I would come in, you know, I would pick my kids up from school. And then I would like get them situated and go in for a few hours and then be done.
And being there for those like three or four hours, I wasn't able to build the relationships that I needed to anything that I wanted to implement. It [00:17:00] was just extremely challenging to build that without that those relationships. And it was hard for me to provide a communication strategy, if you will, or a memory support, if I didn't know, okay. What's this person like during the day, what is the nursing assistants take on this? What is the most burdensome communication breakdown for them? Um, and those things were kind of absent. And I think sometimes that can be a really big challenge when we're thinking about people with dementia. If we don't have a picture of what's going on all day.
Um, and I imagine it's probably pretty similar with a school caseload too.
[00:17:47] Kate Grandbois: Yeah. I mean, I think no matter where we, as SLPs work, that, you know, workplace barriers and time restrictions are always a thing in terms of, you know, how we communicate with our colleagues, but also having access to [00:18:00] families, having access to home life, having access to and time built into our schedules for consulting with the families.
Um, for, I mean, I, I have to imagine that counseling is also a massive piece of, of, you know, working. I've never worked with an individual with dementia, but, um, You know, counseling families who are grieving, who are going through this incredibly complex, challenging time, arguing with their brother in Idaho, who made these decisions when they were here for Christmas or whatever.
I mean, there's a lot to unpack in these very complex situations. Um, and you know, we've said it on this podcast a thousand times before we don't necessarily get training in counseling, we don't necessarily have funding for indirect service. Most work settings don't have indirect service as a norm or even built in as an option.
So in everything that you're saying, in terms of the skilled nursing facilities and the PRN schedules, [00:19:00] those are massive barriers to be able to adequately support these families. If some of the first things we need to do are established relationships.
[00:19:09] Amy Wonkka: So to piggyback on, on that point, how, how do you integrate those elements of implementation practice and how might that change the way your training of the care partner looks?
So the difference kind of between training without integrating those components versus kind of a more informed approach to care partner training
[00:19:34] Natalie Douglas:. Right. And so I can answer the latter part in thinking about what I had to do, which was a lot of handouts. A lot of do this. A lot of, we need to, you know, do this type of strategy, kind of catching the nursing assistant, you know, wherever they were and trying to, you know, when they're obviously still so busy and overworked and [00:20:00] we're actually recruiting for a study right now.
Um, we're, we're trying to study if there's a way to do this. So we're, um, therapists who, speech paths who are working at Encore rehabs, or, um, have a partnership with them where we're looking at. Um, I have a kind of dementia care partner training, CNA certified nursing assistant program that we piloted, but it, but in this new iteration, we're trying to layer in some of these principles of implementation practice to see if that matters, if it makes a difference.
Um, so, and to see probably more importantly, is this an acceptable and feasible thing to do on the clock? You know, when you're working.
[00:20:54] Amy Wonkka: So, is that an example of implementation science right there.
[00:20:58] Natalie Douglas: Yeah, [00:21:00] it is. I mean, it's not done, we're trying to do it, you know, but, but I think the engage, you know, the partnership, right?
The is part of implementation science, the collecting the data in the real world and having the, so in some care partner training studies, what they'll do and you know, it's legitimate, um, is you have an interventionist come in, right? So you have like a special research employee of the grant, you know, that's funded by a grant and they deliver the intervention.
So in this scenario, it's the person that's already working. That's having to balance all of these situations and it's a mixed method study. So. You know, if the SLP is like, I can't do this, you know, the study isn't over. It's okay. Got it. Why, why can't you do this? Tell me what's going on. [00:22:00] Let's try to problem solve this.
And I'm hoping that we're going to learn, um, a lot.
[00:22:07] Kate Grandbois: That sounds incredibly interesting and also like a lot of work. So hats off to you for taking on such a robust project. Um, I'm thinking about our second learning objective and the and evidence-based practice approaches to managing communication. But before we get there to sort of set the stage, I wonder if you could just talk to us generally a little bit about components of supporting quality of life and communication for persons with dementia.
[00:22:37] Natalie Douglas: Right? So I think a person living with dementia, like. Every human being. They want a reason to get up in the morning. They want to have purpose and engagement, you know? Um, they don't necessarily, I mean, do you want to go play bingo every day? Right?
[00:22:57] Kate Grandbois: It's a rhetorical question and not very [00:23:00] helpful. I apologize.
I see your point. I do not want to go play bingo every day
[00:23:03] Natalie Douglas: Right. But I mean like, yeah, if that's your own work to like listen to like a person with questionable talent sing in the hall, you know, um,
[00:23:17] Kate Grandbois: you know what I'm thinking of? I'm thinking of my in elementary school, we had to go sing at the nursing home a couple of times a year that's it's and it was our talent.
It was my questionable talent. Me you're talking about it. Isn't it. They don't want to come in here and me sing. Or my kids. But to your point, you're right. I mean, they're, they're still human beings and they have interests.
[00:23:37] Natalie Douglas: Right? Exactly. So I think one of the ways that we can best support, and this is supported in the literature as well, is to really get to know the person and to figure out what makes them tick.
And if it's not something that maybe is within their wheelhouse right now, what is it that they used to love to talk [00:24:00] about? What is it that they used to do and what can we do to modify that or to set up the environment in a way so that that can be supported. So one example I can give is, um, we had, I have a student and part of what they work on for their, these are undergraduates is they are communicating with someone with dementia, a couple of hours a week as part of a service learning course.
And so the student came and she was like, you know, I can't get this person to talk. It was a person, you know, in their eighties in a nursing home with Alzheimer's dementia. And she's like, he just kind of sat there and, um, just kind of awkward and, you know, so I'm like, well, what, what, you know, is there anything, is there anything about him that, you know, you know, and so sometimes that can be hard as you talked about access to family and access to interests, you know, but she happened to [00:25:00] see, um, something that had the Detroit tigers on it.
And so I'm like, what about making, you know, a memory book of just some famous Detroit tigers players and some photos. And I'm like, I have no idea who the Tigers players are, but, you know, so she went in, she just had some type of, um, external item that they could kind of go through and it's like, oh, look, it's the baseball, you know, it's, um, you know, having that communication support and you guys know all about this, this is your area, right.
Um, we can do that in a very low tech way. Um, but it has to be something that the person cares about. It can't be a random conversation topic, you know? So I think by cultivating interests, based on the person that can really support [00:26:00] quality of life and communication. And then the other thing is giving someone a meaningful role.
And so we even try to do this in skilled nursing environments. And a lot of this comes from the Montessori for aging and dementia approach. So you might've heard of Montessori for kids, but there's a whole, um, study of Montessori for people with dementia and aging, where it's, you know, maybe I used to love to maybe I was a home, you know, I worked at home.
So now we're going to have that person fold the towels, you know, in the, in the long-term care community. And that's going to be her role. Maybe I love to talk to people, but I can't remember anything. Well, I'm going to go pass the mail out to people, right. And that's going to be my role. So we can find ways to support engagement, really authentic and not[00:27:00] kind of a contrived activity. If that makes sense.
[00:27:03] Kate Grandbois: I love the word authentic. I love it. I think it nails exactly what it is you're trying to do because there are components of what we, I think sometimes feel we have to do in therapy that are so contrived and that we, we do our best to make them fun.
Right. We do our best to do, to be engaging, but it's sort of, it's exactly what Amy said before. It's not for us to decide it's for the person to decide. Um, and I know that can be tricky when you're working with someone who has a communication disorder, but that's, your job is to find something that's authentically enjoyable.
And I think that's the best, the best, the best adjective that you could use there. No question.
[00:27:45] Natalie Douglas: Yeah. Yeah, we got to keep it real. They know. I mean, you might lose your memory and you lose skills, but you know, when things feel yucky, right. And people [00:28:00] with dementia, they don't want to be quizzed or, you know, feel like they're taking a test, you know, or feel bad about themselves.
And sometimes these more impairment based activities can do just that with good intentions. But there are better things that we can do. I think
Amy Wonkka: so for the,
[00:28:19] Kate Grandbois: oh, go ahead.
[00:28:22] Amy Wonkka: I was just going to say that from a, from a quality of life standpoint, nobody wants to feel like they're failing a quiz all the time. So it makes sense that if your therapy activities are too deficit focused and it seems like you're making your client feel badly, you should probably pause and rethink how to, how to do things a little differently.
[00:28:42] Natalie Douglas: Yeah.
[00:28:43] Kate Grandbois: So as the implementation science expert, I'm going to, I'm going to give you the crown, you're the queen of implementation science here at nerd CastleVille nerdcast central for all of the PRN SLPs who are listening, [00:29:00] who have these realistic workplace barriers, who are there for only a small number of hours a week.
What are some practical, what are some practical things that they may be able to do within their workplace restrictions to make these connections to, um, I don't know, implement some of these evidence-based ways and overcome the hurdles that they, that the job just inherently has.
[00:29:26] Natalie Douglas: Right. I love that question so much.
And I think the first thing I would say, the first thing I would say is recognize that you are working in a broken system and you are doing the best that you can. And you're, this is not about a failure on your part. It's just not like the restrictions that you're experiencing in terms of time and productivity.
It's not your fault, [00:30:00] you know, and I think, I mean, I, it's, it's an impossible system to work in, in a lot of ways, you know? Um, so practically speaking, I would consider it skilled therapy, time to interview that person and get to know them because not everybody can do that. Right. That takes the skills of a speech language pathologist to dive in deeper and do.
And you can call it dynamic assessment. You can call it informal assessment. Um, but using your skills as an SLP, to really deep dive into who that person is. And I would also use your skilled billable time to make those memory aids and [00:31:00] supports in the presence of the person with the person.
Kate Grandbois: Love that idea.
Natalie Douglas:Yeah, that's not my I, so this is Becky Khayum’s idea. With memory core and cognitive concierge. And she's one of our, um, she's a colleague and a friend of mine. And, um, she's like, you know, cause the productivity is a major issue, especially in skilled nursing facilities. And so it's a skilled service, right? Because maybe you're, you're, you're getting personal information and you're using that to tweak your external memory aid or your communication to support.
Right. And so you're, you're trying it out. You're and you know, one of the things that she recommends, if you don't have, um, a huge budget, which not many people in snfs do is to ask your rehab manager to get one of those portable laminators, um, they're only like 50 bucks. And then. You know, with [00:32:00] all the other equipment that PT and OT have, it's a pretty reasonable request.
And then you can, um, print and make some memory aids and trial them out, you know, as part of your session. Um, so that might be some practical tips that I hope, you know, might facilitate that.
[00:32:19] Amy Wonkka: So in talking about these memory aids, I feel like you're leading us right into our second learning objective, talking about some case studies that highlight evidence-based practice approaches to manage communication in life participation.
So I don't know if there are there other, there are other evidence-based approaches that we should be aware of?
[00:32:39] Natalie Douglas: Right. So I think that, you know, external memory aids and supports, we have the most evidence for that, you know, in terms of dementia, I think another really high impact, high evidence practice is environmental modifications.[00:33:00]
So what can I do to make the environment more conducive to communication? So this might look like simplifying the environment in terms of not making it too cluttery. Um, if you have an external memory aid, a lot of what we do in some of the buildings where we're implementing Montessori is we'll put the external memory aid in a frame.
So it'll say like, please enjoy, um, the music, right? And like, it'll be like a memory that says that right next to some type of music player. Right. So they might be, oh, oh, look at this. I can. And it might be new every time and we don't expect the person to remember that. Um, but if it's a designed memory aid that is clear, you know, they're going to get that cue, you know, getting rid of clutter, labeling things like labeling the toothpaste, [00:34:00] labeling the soap, um, not having a bunch of like, you know, different chotchkies in various places.
Um, so that things are nice and, um, clean, you know, one of the things that, um, we did in a community that we were working in was, um, there was this beautiful bay window and one of the, um, people with dementia, she loved to look outside. There was like a bird house and it was so nice. And wouldn't, you know, if somebody went and brought in this like nasty, fake plant and it like took up the whole window. Right, right. I don't know, but I took it and I put it in my car.
[00:34:55] Kate Grandbois: The plant thief! It was the brother from Idaho wasn't it. That's who it was. It was [00:35:00] right. But it's like, sorry to all of you in the Idaho.
[00:35:03] Natalie Douglas: Sorry, Idaho. Um, yeah, but it's like, when you think about setting the environment up for communication, her looking at the birds and looking at the flowers outside, that's an opportunity for communication.
Right. And so having that blocked, you know, and then we would even put a cue there that says, please enjoy looking outside. Oh, that's right. I love to look outside. You know, I love to watch these birds. Um, so I think external memory aids, the environment, training, communication partners, and care partners, and also.
Instructional techniques such as errorless learning and spaced retrieval training can really support outcomes related to safety related to even swallowing strategies that a person with dementia might have. Um, and [00:36:00] other kind of key pieces to support engagement.
[00:36:05] Kate Grandbois: What's a spaced retrieval strategy?
[00:36:08] Natalie Douglas: Oh good.
I was hoping you would ask that. So if you, um, if you Google health professions press spaced retrieval training, there's a little four-minute video that, um, Jennifer Brush and Jeanette Benigas and Gail Elliott made as a companion to the resource spaced retrieval training. Step-by-step it's essentially you capitalize on the preserved procedural memory of a person with dementia.
And this means I might not be able to tell you with my words, how to make a cup of coffee, but if you put the coffee filters, the [00:37:00] coffee in the pot and coffee was something that I made every morning. There's a very good chance. I can just walk up to the coffee and start doing it right now. What spaced retrieval will do is it targets one specific area of interest. So I'll give the example of, if you wanted to train someone to use a call button before they got up out of their bed, if you wanted them to call the nurse with the button, instead of just getting up, because maybe they're at risk for falling. Okay. So if I were to do spaced retrieval, I'd say, Hey, Kate, what do you want to do?
What do you do when you get out of bed? And I, and then I would say you hit the call button. Okay. And then I would maybe take your hand and I would show you the call button and you would hit the call button. Right. And then [00:38:00] like one second later, I would say, Hey Kate, what do you do when you want to get out of bed?
You hit the call button. Right? And so then you would say, I hit the call button while you're hitting the call button. Okay. If you didn't, if you weren't able to answer me. Right away then after a few times, I might say, okay, Kate's not really a candidate for spaced retrieval training. It's almost like a built-in screen, but if you were successful and you repeated me and you were able to do the action right away, I would wait two seconds.
And then I would ask you again, and then if you were successful, I would wait four seconds. And then I would ask you again, and you can kind of go all the way up to like 15, 18 minutes to where ideally I might say, I might go and see some other clients and then come [00:39:00] back a few hours later and say, Hey, Kate, what are you doing when you want to get out of bed?
I hit the call button. Right? And so it's one of those things where it's the opposite of what we think. With our typical speech therapy services in that we shouldn't expect it to generalize to other topics. Okay. So it's very situation specific. So if you want to train something using space retrieval, you only do it one at a time until that information is learned.
[00:39:38] Amy Wonkka: And in this example that you gave us, it involves a motor movement. Does it always involve a motor movement or could it be something else?
[00:39:46] Natalie Douglas: Yes. So there have been studies where it's used for other things like, you know, important names, um, you know, names of loved ones, things of that nature. In my experience, I [00:40:00] find that it's, it is much more effective when you have a motor movement.
The other way that we use spaced retrieval is as an instructional technique to attend to an external memory aid. So a lot of times people will say, you know, I put up signs, I put up cues and they don't look at them. Well, that's part of our skill set as well. Right. We have to train them how to use it. So it's like, what do you do when you want to know the schedule for the day?
I look at my calendar. What do you do when you want to know the schedule for the day? I look at my calendar, right? So you can use it. I think it's more effective, especially in people with dementia when you're pairing it with a motor movement or when you're referring to some other type of support, like a memory aid.
[00:40:52] Kate Grandbois: That makes a lot of sense. Just that interaction between the environment, the movement. Making it a multi-sensory multifaceted learning [00:41:00] experience. I mean, we know from so many components of literature that that's a critical component of learning is making it more dynamic, engaging all of those things. So that, that makes a lot of sense.
Are there any other evidence-based practice approaches that you want to go over before we start talking about, um, SLPs as key members of teams?
[00:41:22] Natalie Douglas: You know, I think if you think about, if you, if we come at this from a person centered lens, and then we're thinking about creating, you know, from our instructional perspective, like the instructional techniques that we use in people with dementia, they, it really should be errorless learning.
And like, if we don't, if the person is making a mistake at all, even once we got a backup and do something else, like it has to be totally successful because people with dementia are going to continue to lose [00:42:00] cognitive function. And so it's not a situation where it's like, okay, my goal is to stop this person from using cues, right?
Like you want them to use every possible cue. And so if a person is making mistakes or not getting it, then we need to switch what we're doing or add more supports or something like that. So I think thinking about person centered, this external supports, an environment that supports communication and meaningful engagement.
I think those, you know, that will go a long way.
[00:42:37] Kate Grandbois: And my mind, you just painted a Venn diagram with these three circles and sort of like living somewhere in the middle of those, depending on patient specific variables and idiosyncratic changes that need to happen and stuff that was very eloquent.
[00:42:53] Natalie Douglas: Yay.
You're, you're just very kind, you know, eloquent coming out. [00:43:00]
[00:43:01] Kate Grandbois: Well, considering I started this episode talking about how I wasn't going to scream scurvy in your face. I'm glad I've upped my game since the last time you were here. Um, so let's think about, and want to sort of paint a broader, broader strokes picture really quickly.
So we're thinking about SLPs, who might be listening, working as, uh, in a PRN capacity with numerous hurdles to implementing some of these things, needing to have a focus on person centered care, considering these components of implementation practice. I think that the workplace setting, as we have said multiple times is such a real barrier.
And I think your third learning objective really starts to get at that in terms of workplace settings and the team that you work on and how the SLP can, knowing this information that we've gone over really advocate to become a key member of the healthcare team and how that might impact some of [00:44:00] this work you're talking about.
I wonder if you could tell us a little bit more about that.
[00:44:03] Natalie Douglas: Right. Right. I think that by finding out, you know, what are the pain points of other people who are working within the community? So for example, what is the physical therapist trying to get the person with dementia to do, right? And so maybe we can do a memory support for hip precautions or fall precautions.
Maybe we can use spaced retrieval to train the person to lock their wheelchair breaks before they get up. If that's a goal that the physical therapist has, or, you know, what is occupational therapy doing? What activities are they wheeling them down to? You know, what are the, um, activities assistant, what are they taking them to and how engaged are they?
[00:45:00] So is there something that we can do that's kind of within the routine or the program of events of that person that we can help support? Right. So it's, we're kind of showing our value by saying, okay, look, they were just coming to activities and they were just sleeping the whole time. But yet we could say that they were in the activities room when really.
There's a way that we could support that. What is a pain point for the nursing assistant? Is it getting dressed every day? Is it eating? Is it something that happens at night? Right. So I think by inquiring about what's hard from other staff members can really show our value, um, because we can make it easier for [00:46:00] everybody, because I think with people with dementia, the fundamental problem is the lack of ability to communicate.
Right. And so when we have these things that people call behaviors. Right. Um, they're really responses, right. They're attempts to communicate, right. So when Mrs. Smith starts screaming in the hallway and crying, um, how can we attend to the emotion that's underneath that and validate where she's at and support.
Right? So I think that a lot of times we're tempted in that setting to kind of just go in and get our minutes and get out. I mean, that's what I did. And a lot of cases, there's absolutely no judgment there. Um, but I think if there's any way that we can get the [00:47:00] bigger picture and make our plan of care somehow related to other aspects of the person's care, It can really show the value, like when we can open up communication for someone who's really struggling,
[00:47:18] Kate Grandbois: you know, what, something that you just said reminded me of, um, we had Dr. David Luterman on as a guest, uh, what a ways back and for anybody who's listening, who hasn't listened to that episode, um, it's on counseling and he talked about responding to the subtle, the subtle knocking, so what is the underlying emotion? What's the underlying feeling and responding to that instead of the screaming, instead of the crying and trying to lead with empathy and respond to that subtle knocking.
And I think he credited that to maybe Carl Rogers. I can't remember off the top of my head, but references there. And I think it's such great, great advice. [00:48:00]
[00:48:00] Natalie Douglas: Yeah, I was going to tell you that I had my, um, counseling students this summer. That's how we started. The first day of counseling class was listening to that podcast
[00:48:11] Kate Grandbois: So good to hear! He's amazing.
[00:48:15] Natalie Douglas: It was awesome.
[00:48:17] Kate Grandbois: I, you guys there for that, I was there for that interview and I've listened to it like three or four times. I made my husband listen to it. Really. He was really he's just so influential.
[00:48:29] Natalie Douglas: Gosh, he's so dang wise,
[00:48:32] Kate Grandbois: anyway, this is the first time we've gushed about a previous episode on the current episode.
So that's a first, it's always, always exciting with you, Natalie, but I mean, but responding to that, that pain
[00:48:44] Natalie Douglas: what's underneath? Exactly.
[00:48:47] Kate Grandbois: It's that subtle knocking. Um, and for anyone who doesn't feel like they have it in their skillset or wants to learn more about counseling, I definitely, we all encourage you to do it.
It's a key component of what we do as SLPs and we just don't get enough [00:49:00] training on it, unfortunately.
[00:49:01] Amy Wonkka: And I feel like just to cycle back to the first learning objective, that's also got to make a difference in our client's quality of life.
[00:49:10] Natalie Douglas: Absolutely, absolutely. You know, and I think one of the things that implementation practice has really challenged me on is trying to engage with direct care providers, you know, so in this case it would be certified nursing assistants. How do I engage with them in a way that is authentic and meaningful and real? So we already have a huge pay gap between what an SLP is making and what a certified nursing assistant is making. They're there, you know, cleaning up puke and blood and wiping butts.
Um, and we're seeing the person for maybe 30 minutes, right? There's already [00:50:00] some perceived imbalance there. And so how do we kind of enter into what the nursing assistant has to do and engage in a way that would be meaningful? To the nursing assistant and the person with dementia and to us, because then we can see that we're really making a measurable difference.
[00:50:27] Kate Grandbois: I also, I feel like this is related to another topic that's come up recently here related to something totally unrelated to snfs, but that's bringing humanity back into therapy. So, so being a person showing up at work as a person, trying to make those connections with your colleagues, trying to make those connections with your patients when you can.
And I mean, to your point, we've all just shown up at work just to get the hell out of there. I mean, that's part of being a human and there's no judgment there at all. But I think when, when you're a clinician working [00:51:00] in environments that where there is grief and there is pain and there is vomit or blood or something that is, you know, evokes an emotional reaction, it's impossible to just clock in and clock out every day.
There is some component of humanity. That we need to embrace in our clinical work to improve the lives of our coworkers, our patients, and establish, I love how you've wrapped this up in establishing us as team members of the team, because there are workplace politics involved in humanity too, which is crazy.
We don't think of it that way, but it's true.
[00:51:35] Natalie Douglas: It really is true. And I will never forget. One of the biggest learning experiences for me was I was working with a nursing assistant and it was hard to connect and sometimes it's hard. Sometimes it's hard to connect with other humans. And, you know, I was asking her, you know, if she could use this communication strategy and I think the person had [00:52:00] swallowing strategies and she was just kinda like, yeah, yeah.
Um, and I don't know how the topic came up, but there was a lice outbreak. Okay. And like, My kid had lice. Her kid had lice. Somehow that came up and I'm telling you, the moment of connection was so real. And it just was able to dissolve all the barriers between us. And I know that all three of us, the person with dementia, her, me, we all had a better day.
We had a better outcome over this horrific thing that I hope never comes in my house again, it was a human, it was that humanity moment that you speak of.
[00:52:54] Amy Wonkka: But hopefully folks will find something a little less intense than lice
[00:52:59] Natalie Douglas: a little less [00:53:00] invasive you guys can't see my hair. Yeah. I have a lot of hair curly and it's just like a lice field day in there. Yeah.
[00:53:11] Kate Grandbois: I mean, but, but really, I mean, we talk about this as part of, um, in your professional collaboration that ASHA has really embraced.
So, you know, having a focus on interprofessional education and interprofessional partnerships, um, it's something that's defined by the world health organization. It's something that's very real. It's not just making buddy buddy with, with your, with your coworkers. I had a mentee say to me one time, but I don't want to be friends with them.
And I want to be friends with this person. And I had to sort of back up the train and, and highlight that this isn't about friendship. This is about positive working relationships and being, you know, showing up with professional maturity, showing up with humility and being a person, being a person and not a jerk.
And everybody's allowed to be a jerk sometimes I definitely am [00:54:00] sometimes. Um, you know, it's, it's, it's, it's a thing. Um, and I, I, again, just bring this back to your learning objective. And I love that you did this. I think this is so brilliant, is that when you do that, when you embrace these qualities, your work environment, it will improve.
There will be a ripple effect there. It's not just to be, you know, hokey pokey with everybody and sit around and give each other hugs all day long. There are actual realistic and logistical positive outcomes that will come from embracing this, this kind of team environment and person centered and humanity centered care.
[00:54:38] Natalie Douglas: I think so. I really think so.
[00:54:43] Kate Grandbois: I think so too.
[00:54:48] Amy Wonkka: Are there any other strategies beyond being a human, being a friendly person, trying to actually identify the barriers for your colleagues and coworkers and work to support your client through [00:55:00] navigating those barriers? I'm thinking, you know, as someone who does partner training type tasks, you know, is, is there also this piece of be cognizant of how much work you're asking other people to do or any other.
[00:55:15] Natalie Douglas: Gosh yes. So much, so much yes Amy. Yes. Like so one example, um, that we use a lot in training, our students and other, you know, clinical fellows is I, I personally, I have learned that I, I don't want to give a nursing assistant something else to do, unless I'm willing to take something off of their plate. So sometimes I will say, you know, sometimes, I mean, sometimes, I mean, I'm a big advocate for cross training of everybody in the building when we're talking about a skilled nursing facility so that everybody can take [00:56:00] people to the bathroom.
Everybody can take, you know, the transfer with, you know, with supports and of course there's training that's required to do that. But if I can, maybe I can go take this trash out. Maybe I can help make the bed, even if I'm not trained so that you can do this. Right. So it is more reciprocal. So not putting on the burden of more work, unless we can take something back because it's just not, it's just not feasible to add more to someone's workload.
[00:56:36] Amy Wonkka: And I almost wonder if that helps with the relationship piece, because it breaks down some of those kinds of hierarchical pieces too, of like, well, I don't, I don't do, I don't do transfers that, uh, I don't know.
[00:56:45] Natalie Douglas: That’s right that’s right. Exactly. And I know some people are constrained because like they're not chained and they're truly not allowed to do transfers or, you know, bathroom, different pieces, [00:57:00] different rules.
Yes.
Amy Wonkka: Safety first, for sure.
Natalie Douglas: But if you can, you know, even if it's not a transfer bathroom, if it's a little thing like passing a tray, you know, or something that doesn't require training to kind of show
Kate Grandbois: comradery.
Natalie Douglas: Yes, exactly. Yeah.
[00:57:18] Amy Wonkka: You could ask about training perhaps, you know, it, depending upon the management, like, it's, it doesn't there that requires training doesn't mean you couldn't ask about the training because we're sort of asking everybody else
[00:57:31] Natalie Douglas: that's right.
Amy Wonkka:To want our training
Natalie Douglas:that's right,
[00:57:38] Kate Grandbois: exactly right. How completely condescending of us to expect other people to be, to get our training. If we're not going to help you make the. That's not very nice.
So in our last, in our last minute, I'm just thinking of people who might be listening in these positions, who are, have like listened to [00:58:00] all of this information over the last hour. Do you have any advice, any parting words of wisdom or advice for clinicians who either want to learn more about implementation practice or want to acquire more knowledge in this area, um, or, or anything?
[00:58:19] Natalie Douglas: You know, I would, I would only, my biggest piece of advice is probably to continue to care for yourself if you can. Um, this is such a high need high, you know, it just, it takes so much, it, it requires so much. And if you can, um, care for your, for yourself. And, you know, it's just so critical and I am so happy to, you know, there's a community of people that are really passionate about improving dementia care in these settings.
And if there's anything that any of [00:59:00] us can do, I mean, I hope that you really will reach out. Um, of course there's books and articles and blah, blah, blah. Um, but not that those are bad, but, um, if you want to brainstorm something, you know, we're here, this is, this is what, this is what we do. But, you know, recognizing the work that you're doing in caring for yourself,
[00:59:21] Kate Grandbois: that was really good parting words. I don't think I can follow anything up. I don't think I can follow that, Am?
[00:59:27] Amy Wonkka: no was good. If, if, if we don't take care of ourselves, we burn out and there's no one, there's no one to do any of that helping.
[00:59:36] Kate Grandbois: Thank you so much for being here today. You're just so full of wisdom and we learned so much from you every time you're here.
So thank you so much for, for being here and for your time and all that stuff.
[00:59:47] Natalie Douglas: Well, I'm so grateful to be here with all of you. There's only two of you but,
[00:59:53] Kate Grandbois: there's so many people listening though, right? I mean, yeah, we hope we hope for all of the [01:00:00] things that we talked about today, there will be links in the show notes.
So if you're driving, running, um, everything will be written down. There are references resources and links. There's also a link in your podcast player to earn ASHA CEUs if you so choose. Thanks everybody for being here. And we hope everybody learned something.
[01:00:19] Natalie Douglas: Thank you.
[01:00:20] Kate Grandbois: Thank you so much for joining us in today's episode.
As always, you can use this episode for ASHA CEUs. You can also potentially use this episode for other credits, depending on the regulations of your governing body. To determine if this episode will count for professional development in your area. Please check in with your governing bodies or you can go to our website, www.SLPnerdcast.com.
All the references and information listed throughout the course of the episode will be listed in the show notes. And as always, if you have any questions, please email us at info@slpnerdcast.com. Thank you so much for joining us and we hope to welcome you back here again soon.
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