The Butterfly Approach in dementia care
Colourful environments, no uniforms, and shared mealtimes, are just some of the new ways of working advocated by the Butterfly Approach to caring for people with dementia, reports Kathy Oxtoby
Sally Knocker tells a tale of two care home visits. At her first visit, staff are stressed and rushed – not unkind – but don’t know another way to be. A woman in a wheelchair by the nursing station, with her head in her hands, tells her: “We do an awful lot of waiting here.”
People sit in lines of chairs in lounges with the television on loudly and nobody seems to be watching it. Staff occasionally come in and out, and there is little conversation.
On a second visit to the same care home one year later, a woman living with dementia greets her with a big smile. They walk arm in arm down a colourful hallway decorated with pictures of farm animals and fields as she learns about the woman’s life as a farmer’s wife.
The kitchen smells of fresh bread and three people are sitting at the table chatting and laughing as they eat – it’s not clear (and doesn’t matter) whether they are living or working there.
In a corner of the room a woman in the much later experiences of dementia sits looking out of the window at the birds, with a team member sitting beside her holding her hand.
What is the Butterfly Approach?
Knocker is a consultant at Meaningful Care Matters, a care and organisational development group that specialises in helping health and social care providers to access a variety of support services. She uses this story to illustrate how people with dementia living in care homes and those who support their care can benefit from the ‘Butterfly Approach’ after a year of practical and creative transformation.
This care model focuses on creating “a truly person-centred approach where people are free to be themselves. It values emotional intelligence, domestic household living, and the core belief that everyone living with a dementia has a unique story which has meaning and matters,” she says.
The Butterfly philosophy was developed in the early 1990s by Dr David Sheard who founded the culture change training organisation Dementia Care Matters. Sheard believed the institutional approach to care was inadequate for meeting the needs of people living with dementia. Instead, the focus should be on “creating a real family house where everybody, whether they live or work in the home, is sharing the day together”, says Knocker.
Dementia Care Matters was eventually dissolved by its Salvation Army owners. In 2019, Peter Bewert, a former employee and registered nurse, established Meaningful Care Matters to continue implementing and developing the approach to support people with dementia, their families and carers. The business, run by managing director Bewert and his wife, also helps care homes to access a variety of services designed to encourage the effective and sustainable implementation of person-centred care models for health, social/aged, and disability care settings. It works in partnership, not only with individual care home groups, but also organisations with similar visions such as NAPA, My Care Matters, and the Royal British Legion.
Although, the Butterfly Approach is typically associated with people living with dementia in care homes, Bewert says the core principles are transferable to services that support people with disabilities, people who receive day services, or those in hospital settings.
Now, ‘The Butterfly Approach ®’ – so-called because like the transformation from caterpillar to butterfly it seeks to enable care organisations to change the way they work – is transforming care homes, day services and even some hospitals across the UK, and globally, including Ireland, Australia, Canada and the US. Some homes are accredited with the Butterfly Approach, while many hundreds are following it in practice.
These transformations are tailormade to suit the individual needs of those living and working there because “You can’t take a ‘one size fits all’ approach to dementia care,” says Bewert.
Butterfly Approach in practice
While every Butterfly Home is likely to look and feel a little different, there are some core ‘essentials’ which they share. These include a sense of home versus a place of work. “We need to remember the quote: “We are working in people’s homes – they are not living in our workplace,” says Knocker.
Uniforms, staff notices, and nursing stations are removed so that the space feels like a real family home. Words and actions which emphasise a divide between people living and people working in a home are removed. The jargon of ‘work talk’ is avoided in the home areas such as ‘shifts’, ‘breaks’, ‘units’, and ‘feeds’.
Team members are recruited with a focus on emotional intelligence and can be seen to be sharing the day like friends of those who live there. “Team members are comfortable with ‘being with’ people rather than ‘doing for’ people. They focus on the feelings behind words and actions moment by moment,” says Bewert.
This philosophy is not just confined to those providing care. “All members of the team, including housekeepers, kitchen, maintenance and gardening staff are part of the Butterfly Approach.
“Our philosophy is whatever your role you need to know how to connect with people. That’s everybody’s job,” Knocker says.
Those working in the home share meals with those living in the home. Mealtimes are regarded as social events in the day, not scheduled routine tasks. “Sharing meals is one of the key parts of our culture change as that’s what you do at home,” says Knocker.
People live in small groups or households, often linked to where they are in their experience of dementia, so that those with different needs aren’t all muddled up together. “It’s important that those people in the later stages of dementia don’t get forgotten. These houses are very sensory, with lots to look at on the ceiling, and lots to touch,” says Knocker.
The environments are colourful and have lots of pictures, including people’s family photos, sensory objects and everyday items to prompt conversations and memories. “They connect with people’s life stories and interests and offer invitations for people to be meaningfully occupied,” says Bewert. Such is the attention to detail to making people feel at home that photos can be taken of their own front doors, which are blown up to life size and attached to their rooms in the care home.
People living in the home can be involved in domestic activities and there is a kitchen area which is accessible for people to use. “The focus on the kitchen is that it is the heart of the home,” says Knocker.
Activities are integrated into all parts of the day, not just predetermined and structured groups at set times, and all team members play a role, including housekeeping, food services and maintenance. Children and animals are “welcome informal and regular visitors, not just for an arranged ‘therapy’ or special occasions like Christmas”, says Bewert.
The “roots” of the Butterfly Approach are ensuring that “the whole organisation believes, nurtures and demonstrates every day that each individual needs to be supported to be free to be themselves and that emotional care is as important as physical care”, says Bewert.
And people working at the home won’t be rushing around focusing on tasks. “Our approach is not about approaching people with a task mentality but about making meaningful connections with them,” he says.
Changing the culture
Care homes looking to implement the Butterfly Approach will typically begin the process with a one-day observation of the home by Meaningful Care Matters consultants “to see the whole live experienced of a day living there, and get a real understanding of what people’s needs are”, says Knocker.
The consultants then produce a comprehensive report, including suggestions for what needs to happen next to change the home’s culture. A 12-month plan is developed to support teams in developing a culture change. Psychometric profiling is used so that there’s a good personality ‘fit’ between the consultants overseeing the change and the care home leadership team.
During those 12 months of culture change, consultants involve not only those working in the home, but also those living there, their families, friends, and local community, says Bewert.
Month by month, consultants meet with the care home’s leadership team to work through the essential elements of implementing the approach. Simple steps include changing the environment to become more vibrant and colourful.
More complex steps include changing behaviours and attitudes. ‘Behaviours’ in both people living and working in a home are understood as expressions of emotion – a need to be met, not problems to be managed or controlled. ‘Controlling behaviours’ could be moving people in their wheel chairs “without asking, as if they’re not there”, or reducing people to labels, “such as asking “have you cleaned room five?” Knocker explains.
At the end of the process consultants conduct another observation, similar to day one, to see how the Butterfly philosophy has worked in action, and how it has been improving the quality of people’s care experiences, before the care home receives accreditation.
Care home team members also have the option of attending one of Meaningful Care Matters’ courses, which provide the key elements of the Butterfly philosophy, “so you don’t necessarily need a MCM consultant to be passionate about this approach”, says Knocker.
There are numerous examples of how the Butterfly philosophy is changing lives and giving people with dementia a renewed sense of purpose. Bewert recalls a “lady who every Sunday demonstrated a degree of distress and tried to pull out all the furniture”.
“We discovered she was a nurse in the late 1940s and that Sunday was the day that the wards were cleaned. We gave her cleaning cloths and a bucket so she could clean on Sundays. This removed some of her agitation, and shows the importance of understanding people’s lived experiences,” he says.
Benefits and challenges
The change the Butterfly Approach can bring is “both simple and miraculous” says Bewert. Meaningful Care Matters is increasingly gathering evidence with its partners of significant outcomes of the approach, including people eating better and increased healthy weight gain, reduced staff turnover and less staff absenteeism, and improved team morale.
Becoming an accredited Butterfly Home with Meaningful Care Matters requires “driven commitment over the year of initial change and the ongoing need to sustain the approach,” says Bewert.
Of course, not everyone is comfortable with this approach to care. Some may miss the routine of a task focused model. Some miss wearing a uniform. And others simply prefer their traditional way of working.
Another challenge, says Knocker, is that “the Covid-19 pandemic has understandably increased the more clinical and controlling features of care so that a return to a renewed focus on quality of life will be both more challenging and even more important”.
Looking ahead, the Butterfly model will “continue to develop and adapt to people’s changing needs” says Bewert.
Knocker hopes “many more care homes will want to follow this approach”. “I want people to feel it’s possible to actually live really well in a care home or day service, that they can still enjoy life, and that dementia doesn’t have to be a sentence of misery.
“I hope people will feel inspired to find out more about our work.Those that do really get the Butterfly Approach always say: ‘Of course – this is how life at our care home really should be’.”
“Creating a loving environment where everyone matters”
A West Sussex day service has become the first of its kind in the UK and internationally to be accredited with The Butterfly Approach.
Bradbury Wellbeing Centre, in Worthing, recently received the accreditation from care and culture consultancy, Meaningful Care Matters, for the successful implementation of its person?centred care model.
The day care centre achieved an ‘excellent’ rating from Meaningful Care Matters, who describe the service’s team as having a “meaningful rapport with the people in attendance at the day centre”.
Opened in 2015, the day service is operated by Guild Care, a Worthing?based charity that provides a wide range of community services to support older people and children and adults with learning disabilities. Adjacent to Guild Care’s Haviland House dementia care home, Bradbury Wellbeing Centre offers an extensive programme of events, supporting hundreds of people living with dementia each year, whilst at the same time offering respite for their carers.
On receiving the accreditation, Claire Howell, Guild Care’s director of community services, says: “We couldn’t be more thrilled that the Bradbury Wellbeing Centre has received an ‘Excellent’ accreditation from Meaningful Care Matters as a result of their recent audit.
“Person-centred care is an essential component of every Guild Care service, from our community services right through to our nursing homes, but no more so than when we are supporting those living with dementia and their carers. We pride ourselves on creating a loving environment where everyone matters and each person is free to be themselves, whether they are a service user, a relative, a volunteer, or a member of staff.”
Peter Bewert, managing director of Meaningful Care Matters, says: “It has been testing time for the social care sector, so we applaud their determination to offer an environment where people using their services can thrive and enjoy the highest quality of life possible. We look forward to assisting more day centres in facilitating the creation, reinvigoration and sustainable implementation of person?centred care cultures. It’s coming back to the art and heart of care, where people, and moments, matter.”
Meaningful Care Matters: https://meaningfulcarematters.com/
Bradbury Wellbeing Centre and Guild Care: https://www.guildcare.org/