Renee Kinder

Sunday morning in Kentucky, front row of the Presbyterian church, five children, first row because we were late … again.

Everyone is behaving remarkably well until Joseph decides to respond to a rhetorical question posed by the pastor.

“No!” Joseph shouts out.

Gasps, then silence, and a few chuckles.

My heart races. I have never heard someone speak out in church. What is everything thinking?

I know what they are thinking: “They have five children and obviously have their hands full.” And, “All those kids, don’t they know HOW that happens?”

All eyes on the pastor. “Thank you,” he says and then again, “Seriously, thank you.”

Thank you?

Apparently in a sanctuary full of children who have been thoroughly schooled in Presbyterian obedience, one having an opinion was refreshing.

Speaking “out of turn” is an expression that I have also heard in my professional career.

Often, speaking out of turn is problematic.

“There is a difference in thinking and knowing, if you don’t know, don’t speak out of turn”

“I know the answer, however I wanted to check with you so that I don’t speak out of turn.”

Similar context is present in our communications with residents who have impaired abilities to communicate, or have opinions that are challenging, “difficult,” or worst case, involve refusal of care.

Mr. Jones said, “No,” he doesn’t want a shower this morning.

Ms. Smith said, “I am not eating that puree crap.”

Mrs. Adams refuses to use her walker to outside of her room.

Caregivers in the skilled nursing setting know that speaking out of turn is an oxymoron when a resident we serve voices an opinion. It is, however, up to caregivers to determine what individuals are attempting to express in these events, and how they should adjust care to meet their needs.

Such was the case in a SNF I recently had the pleasure to visit which had decided to implement the Kawa Model to increase their ability as an interdisciplinary team to understand the needs of residents with significant mental health diagnoses.

Speaking out and self-expression were common place in this facility. Determining the “what” and “why” associated with speaking out was the challenging piece.

The Kawa Model was created by a team of Japanese occupational therapists and uses the natural metaphor of a river to depict one’s life journey. The model provides guidance on how to approach individual care and investigate a patient’s past history, current wishes and future intents by investigating the areas below:

•  Their River Flow, which indicates life flow and priorities

•  River banks, which are metaphors for the environments and contexts, social and physical

•  Rocks, which indicate obstacles and challenges

•  Driftwood, which depicts influencing factors

•  Spaces, which indicate opportunities for enhancing flow

Watching a team of nurses and therapists engage patients in conversations using the Kawa model was very eye-opening.

Mr. Jones, for example, says no to his shower. This is a rock or obstacle.

When the nurses engaged Mr. Jones with the probing questions provided in the Kawa framework, they were able to drill down to the root of why he is refusing his shower. Changing his “speaking out” or refusal, per se, and allowing him to “speak up” and express what about the experience was causing him increased levels of anxiety.

They learned that changes in the environmental set up including a different shower bench and a different kind of soap reduced his apprehension and made him more agreeable to bathing.

Small changes, a world of difference, all because the care team changed their terms for speaking and engagement.

Renee Kinder, MS, CCC-SLP, RAC-CT currently serves as Director of Clinical Education for Encore Rehabilitation (insert:  and acts as Gerontology Professional Development Manager for the American Speech Language Hearing Association (ASHA).