by: Joanna Osborne, RD
On November 25, 2024 I attended the NHNSA Gala and had the distinct pleasure of being accidentally sat next to Deborah Bakti, creator of The Relational ApproachTM in Seniors’ Care.
For the majority of the evening, however, I knew her only as a very pleasant woman who had joined the Windsor Elms Village table in celebrating the LTC Awards of Excellence Finalists and Award Winners. It wasn’t until the evening was starting to wind down that she turned to me and, in a space in the conversation that serendipitously opened up, asked me what I did and whether it involved working with the families of residents. I recall that she asked with a level of genuine curiosity that made me pause and then provide her with a more robust response than what I might have otherwise given someone making small talk. This investment proved worthwhile as I walked away from the event with her business card in hand and the idea that there could be a podcast in my future.
It wasn’t long before I spoke with Deb again and began preparing to be interviewed for her podcast on The Relational Approach. It was through this preparation that I was forced to synthesize the approach I had been honing for the past decade without realizing.
I joined Windsor Elms Village as their Clinical Dietitian in 2011. When I think back to my initial years, I know my approach was informed by an acute care, medical model where I was making dietary recommendations for residents as the subject matter expert. I would speak with residents and families, but with the express purpose of letting them know about the change I was making. With my nutrition degree freshly framed on the wall, I was confident in my abilities to calculate nutritional requirements, advise on preferred meal patterns, and essentially dictate the dietary needs of the residents I served. This is what I had studied for four years, and I was thrilled to put my knowledge to good use.
The change in how I practiced was gradual. It took time working with residents and their families before I really began to understand the role of nutrition in meeting the needs of this specialized population. They were not at all what I had been taught. Then in 2015 the Elms undertook Homewide initiatives to create widespread culture change in its employees guided by the Eden Alternative philosophy of care. Being immersed in Eden accelerated my journey in understanding my role as a dietitian. Working in a culture that was resident directed (as in the resident literally directs their care) was in opposition to how I had been practicing. As I began to embrace this concept, I eventually realized that maximizing nutrition was not the end goal for a resident as I had always believed. It turned out maximizing a resident’s well-being was the end goal and food was only one of many ways to help them achieve this. Not only that, sometimes to achieve a higher quality of life, nutrition was decidedly un-nutritious!
This realization, that I in fact did NOT know what was best for someone else, was profound. As a clinician responsible for making recommendations, this left me in a conundrum. The answer to my problem turned out to be simple. I still needed all my experience, knowledge and expertise in nutrition, but instead of immediately making the decision, I needed to share this information with the resident or their Substitute Decision Maker (SDM) in order to find out what plan they would like to move forward with. Ultimately, they are their own subject matter expert – not me. Only they can blend the information I provide with their own goals and preferences to determine what will bring them the highest quality of life.
As with many processes that are influenced by Eden, it did take a bit longer. It required finding the time to catch a resident or the SDM to have the conversation about what seems to be changing, what might be causing the change, provide options of what we could do, and what the outcome might be. But ultimately, this approach paid off ten-fold in establishing trusting relationships. By involving families in discussions about the changes we are seeing with a resident and proactively checking in that the way we are responding is in line with the resident’s goals, we are able to foster and connect in a space where hard decisions can be made.
When preparing for the podcast with Deb, I searched for a way to explain my ‘relational approach’. I landed on the analogy of driving in a car which she later coined the ‘passenger seat approach’. It was the best way I could convey how I am an active participant in the discussion, but ultimately not the decision maker. The idea is this: I am sitting in the passenger seat alongside the resident or more often SDM who is in the driver’s seat. We are traveling together, both looking forward out the windshield, but we often see things slightly different. I see the landscape through a lens that has been shaped from years of working in long term care as well as the knowledge afforded me from a nutrition degree. I have likely travelled similar roads to this, which family may or may not have. I have a sense of what things might look like in the near or distant future. And if we reach a fork in the road I have an idea of how things may change depending on which path the driver chooses. I will share my perspective, and they will share theirs. But ultimately, their hands are on the wheel and they decide the road we take.
Another important difference between myself and the driver is I can’t see the rear-view mirror. I don’t know how the resident lived for the decades before they moved into our Home – in particular their meal preferences. I am grounded in the here and now. I see what is in front of me in this moment and can share my interpretation without the weight of knowing how they used to do it or how much has been lost. My focus is only on what they are doing now and how they are reacting.
This approach describes how partnering with families in their decision making, without trying to take over, is what builds trusting relationships that can withstand challenging conversations. Think changing food textures, thickening drinks, eating-at-risk, unintentional weight loss or weight gain, low appetite at end of life. These are discussions brimming with emotions, with limited time to process the information I am providing, and often with significant consequence. The key is it is not about convincing. I am not driving towards a pre-determined end goal. That is manipulation and people feel that right away. It is about truly being in it with them as they navigate the path so they are informed, feel supported but still in control.
I can’t tell them the road to take that is right for them. I know what best practice recommends, but ultimately the resident or their SDM is in the best position to decide which way to turn the wheel.
To see the full podcast with Deb Bakti and Joanna Osborne, please click HERE
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