<figure><img src="image_1.png" /></figure>

HAL
open science

# Application, understanding, and appropriation of the Montessori method for persons with dementia: A qualitative pilot study

Méryl Donadey, Guillaume Broc, Jérôme Erkes, Marie Lembach, Cameron Camp, Sophie Bayard

► To cite this version:

Méryl Donadey, Guillaume Broc, Jérôme Erkes, Marie Lembach, Cameron Camp, et al.. Application, understanding, and appropriation of the Montessori method for persons with dementia: A qualitative pilot study. Dementia, 2024, 23 (8), pp.1245-1262. 10.1177/14713012241264910. hal-04690015

HAL Id: hal-04690015

https://univ-montpellier3-paul-valery.hal.science/hal-04690015v1

Submitted on 4 Apr 2025

HAL is a multi-disciplinary open access
archive for the deposit and dissemination of sci-
entific research documents, whether they are pub-
lished or not. The documents may come from
teaching and research institutions in France or
abroad, or from public or private research centers.

L'archive ouverte pluridisciplinaire HAL, est
destinée au dépôt et à la diffusion de documents
scientifiques de niveau recherche, publiés ou non,
émanant des établissements d'enseignement et de
recherche français ou étrangers, des laboratoires
publics ou privés.

<figure><img src="image_2.png" /></figure>

Distributed under a Creative Commons Attribution 4.0 International License
This article has been accepted for publication in Dementia. The final published version is available at DOI: 10.1177/14713012241264910. Please cite the published version as follows: Donadey, M., Broc, G., Erkes, J., Lembach, M., Camp, C., & Bayard, S. (2024). Application, understanding, and appropriation of the Montessori method for persons with dementia : A qualitative pilot study. *Dementia* (*London, England*), *23*(8), 1245-1262.

https://doi.org/10.1177/14713012241264910
Application, understanding, and appropriation of the Montessori method for persons
with dementia: a qualitative pilot study.

Méryl Donadey¹, ², M.Sc., Guillaume Broc¹, Ph.D., Jérôme Erkes¹, ², Ph.D., Marie Lembach³,

Cameron Camp⁴, Ph.D. and Sophie Bayard¹, Ph.D.

¹EPSYLON EA 4556, Université Paul Valéry Montpellier 3

²AG&D Montessori Lifestyle

³Maison de Retraite Mathilde Laurent

⁴Center for Applied Research in Dementia

Méryl Donadey https://orcid.org/0009-0004-3984-0901

Guillaume Broc https://orcid.org/0000-0002-8684-9325

Jérôme Erkes https://orcid.org/0000-0002-5763-6486

Cameron Camp https://orcid.org/0000-0003-2986-3742

Sophie Bayard https://orcid.org/0000-0003-0767-4924

Correspondence concerning this article should be addressed to Méryl Donadey,
Laboratoire Epsylon, EA 4556, Université Montpellier 3, Rue du Pr. Henri Serre, 34000
Montpellier, France. Email : meryl.donadey@etu.univ-montp3.fr

Acknowledgements

We sincerely thank the AG&D's professionals for their valuable insights. Special
appreciation to Véronique Durand-Moleur, AG&D Director, for her unwavering support in
advancing Montessori research. Heartfelt thanks to the participants for engaging in
discussions about their practices. Our sincere appreciation to the psychologist and institution
director for their indispensable commitment, crucial for the project's success.

Research Ethics

Data were stored and processed confidentially and anonymously. Consent was
obtained before recording, and procedures for recording, transcription, analysis, and
presentation were explained in detail in advance to meet informed consent requirements.

This study was approved by the Research Ethical Committee of the University Paul-Valéry
Montpellier 3 (IRB ID: IRB00013307). To ensure the rights of all participants were protected,
the researchers strictly adhered to the Declaration of Helsinki (https://www.wma.net/wp-
content/uploads/2016/11/DoH-Oct2013-JAMA.pdf). Material has not been disclosed to
prevent compromise of participant confidentiality.
# Application, understanding, and appropriation of the Montessori method for persons with dementia: a qualitative pilot study.

## Abstract

**Objectives:** The Montessori method applied in nursing homes is a person-centered approach targeting the enhancement of autonomy, well-being, and quality of life for older adults with dementia. Despite its potential in the aging field, its operationalization remains unclear in the context of institutionalization. This study aims to outline the method's components and adoption factors using a behavior change intervention framework among professionals from a French institution demonstrating a high level of method application. **Methods:** We employed a qualitative descriptive approach based on thematic analysis. Nine professionals from the same institution underwent a semi-structured individual interview within the facility. The findings were modeled using the Behavior Change Intervention Ontology. **Results:** We obtained a final framework defining the intervention, mechanisms of action, exposure, contextual factors, and behavioral outcomes. The method is based on values, principles, and techniques such as facilitation, choice, meaningful activities, environmental adjustments, and specific tools. Applied continuously to residents, families, and professionals, its implementation is influenced by several contextual factors leading to practice changes at various levels. **Conclusion:** This study constitutes both a theoretical and practical contribution, providing a better definition of the method and the key factors influencing its appropriation.

**Keywords:** person-centered care, Montessori, dementia, nursing home, qualitative approach
Introduction

Global population aging is accompanied by a significant rise in dementia prevalence
and an increased demand for care and support needs for dependent older adults (OECD,
2021). The current approach to care provided to older adults living with dementia in long-
term care facilities struggles to meet their needs. This, in turn, contributes to increased social
isolation (Lapane et al., 2022), inactivity (den Ouden et al., 2015; Palacios-Ceña et al.,
2016), and mood disorders (Sury et al., 2013). These issues are recognized as precipitating
factors for cognitive decline (Yu et al., 2015). In this context, dementia emerges as a public
health priority, underscoring the need for the implementation of an international action plan
focused on enhancing quality of care for individuals affected by dementia to meet their
specific needs (World Health Organization, 2023). Person-centered care is considered as the
primary intervention for the older adults (Love & Pinkowitz, 2013). It constitutes a support
philosophy of care that recognizes the individual's needs, values, life experiences, and
abilities (Kitwood, 1993). The Montessori method, adapted for persons with dementia by
Camp, who saw its potential for people with dementia (Camp, 2010), serves as an example
of a person-centered approach to care. This method is based on the principles of Maria
Montessori's pedagogy for children. Its underlying principles include offering choices,
providing meaningful and adapted activities, as well emphasizing the valorization of the
individual and ensuring a social role within a community (Camp et al., 2018). It is based on
rehabilitation techniques imbedded in a global humanistic philosophy of care. This approach
focuses on the persons' existing abilities and aims to enhance their independence,
autonomy, well-being and quality of life (Camp, 2010).

The beneficial effects of the Montessori method, such as increased independence in
feeding, higher levels of engagement, improved mood during activities, and enhanced mental
health outcomes among residents, have been documented in three systematic reviews
(Mahendra et al., 2006; Sheppard et al., 2016; Yan et al., 2023) and two meta-analyses (Sun
et al., 2022; Xu et al., 2022). It also yields positive effects on professionals, including an
increase in job satisfaction (Booth et al., 2020; Brush et al., 2018; Sterns et al., 2011; Witt-
Hoblit et al., 2016) and a decrease in turnover rate (Roberts et al., 2015). Nevertheless, the level of evidence supporting its effectiveness remains insufficient, particularly concerning enhancements in cognitive abilities, quality of life and independence in activities of daily living (Sheppard et al., 2016; Yan et al., 2023). Several methodological limitations seem to contribute to the paucity of efficacy data (Sheppard et al., 2016). Among these limits, we note the lack of systematic evaluation of the method's application at the practical level. The proposed interventions raise the question of whether they adhere to the fundamental principles of person-centered care (Erkes & Bayard, 2023a). Most of the research does not document whether and how the intervention involves Montessori principles. Finally, the majority of these studies focus solely on the implementation of Montessori-based activity programs (Sheppard et al., 2016). However, research has demonstrated that the exclusive use of Montessori materials with children significantly limits the method's effectiveness to a comprehensive environmental intervention (Lillard, 2005). It is possible that the observed effects during activities may not endure beyond the activity period. Therefore, implementation of a comprehensive global model of care, based on Montessori principles, is recommended (Raghuraman & Tischler, 2021; Yan et al., 2023).

While the principles of the Montessori method are defined in the scientific literature (Camp et al., 2018), its application remains diverse in studies assessing its effectiveness (Yan et al., 2023). Among works focused on Montessori-based activity programs, implementation varies in terms of content, number of sessions, and personnel responsible for residents (Hitzig & Sheppard, 2017). Three studies propose interventions centered around a comprehensive, global reorganization of care facilities grounded in a person-centered approach based on Montessori principles (Brush et al., 2018; Roberts et al., 2015; Witt-Hoblit et al., 2016). These interventions differ significantly from Montessori activity programs. They involve reorganization and training of teams, environmental redesign, providing choices in many aspects of life, and family involvement, in addition to the administration of Montessori activities. Furthermore, Montessori principles are applied daily and continuously, while activity programs have a limited timeframe. Due to this diversity, it is essential to better
define the underlying principles and application mode of the Montessori method before
testing its effectiveness.

During the last two decades, the number of institutions receiving Montessori training
has significantly and constantly increased in many countries, including France (Camp et al.,
2017). This training process requires substantial financial resources and raises major
economic issues. However, there is a lack of data regarding the application of this method
within long-term care facilities after Montessori training programs. No controls are conducted
within the trained facilities to ensure that staff implement a model change for residents that
aligns with Montessori principles and values. Additionally, no study has documented the
factors influencing the implementation of the Montessori method in these facilities. Yet,
numerous field actors reporting that staff often struggle to change their practices, as it is
often the case for person-centered care implementation in general (American Geriatrics
Society Expert Panel on Person-Centered Care, 2016). Only two non-interventional
qualitative studies provide information on implementation factors and the understanding of
Montessori principles among professionals with training, knowledge, or experience related to
Montessori for the older adults (Ducak et al., 2018; Raghuraman & Tischler, 2021). However,
participants came from different facilities, and the level of Montessori method application
within these institutions was not controlled. Participants' method-specific experience and
proficiency levels were insufficiently documented. Moreover, the sample did not encompass
all professions essential for Montessori method implementation, even though it mostly relies
on implementation by all staff members (Raghuraman & Tischler, 2021).

Consequently, these observations lead to question the content of the Montessori
method, its components, and its mode of application. Nevertheless, the contours of an
intervention seem to go beyond the mere perimeter of its content, and rather extend to other,
more dynamic considerations such as its mechanisms of effect or its deployment (i.e.,
appropriation and implementation processes), i.e., consider the context of such an
intervention (Chaudhry et al., 2020; Madrigal et al., 2022). This is particularly true for a
comprehensive and integrative method such as the Montessori method, which aims at
modifying the behavior of multiple actors in nursing homes. As part of the Human Behavior
Project, Michie et al. (2017) thus developed an intervention theory modeling the process by
which a program leads to effects on the different outcomes, taking into account the
contributing effects of the deployment context. According to their Behavior Change
Intervention Ontology (BCIO) framework, the different components of a behavior change
intervention are:

Intervention – This refers to a set of activities designed to impact the target behavior.
It includes details about the content and delivery of these activities.

Exposure – These factors are related to how the intervention interacts with the target population.

Context – These factors are not directly linked to the intervention but can influence its effectiveness.

Mechanism of Action – This describes the processes through which interventions affect the target behavior.

Behavioral Outcome – This represents the specific behavior that the intervention aims to change.

The study by Ducak and al. (2018) is the only non-interventional qualitative study concerning the mode of application and adoption of the Montessori method that is grounded in a theoretical framework. These authors adopted an economic and political perspective to identify the variables that influence the establishment of a new care culture. Therefore, to date, there is no study on this topic grounded in a theoretical model derived from the field of behavioral sciences in this regard.

In this context, we present the results of an observational qualitative study. Given that we aim to understand what still qualifies the Montessori method as 'Montessori' in its synergy with the context, we interviewed participants from various professions in a single French long-term care facility, demonstrating a high level of method application. The aim of this study was to identify what are the different components of the method, what factors support
its overall coherence in its application and use by caregivers, and which factors conversely
undermine its integrity or limit its expression.

Method

Design overview

The study relies on a qualitative descriptive protocol grounded on thematic analysis, a qualitative approach designed to illuminate and understand experiences, perspectives, and contextual factors through the examination of textual data (Rohleder & Lyons, 2014). In contrast to quantitative methodologies, qualitative methods offer a broader scope of exploration of processes in context, facilitating a holistic comprehensive understanding of the Montessori method in its complexity.

This approach encompasses the unique characteristics of the institutions where the Montessori method is applied and captures the resulting diversity. This consideration is particularly pertinent since the implementation of the Montessori method must be customized to suit both the institutional setting (Madrigal et al., 2022) and its cultural context (Chaudhry et al., 2020). Moreover, qualitative methodologies facilitate the gathering of invaluable insights, perspectives, and emotions from professionals engaged in implementing the Montessori method within institutions (Rohleder & Lyons, 2014). Specifically, thematic analysis is the chosen method for this study, involving the identification, synthesis, and attribution of meaning to patterns discerned within qualitative textual data (Braun et al., 2014).

The COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist was applied to ensure the transparency and reproducibility of our Research findings (Tong et al., 2007) (Supplemental online material Table 1).

Research setting

The training organization (https://www.ag-d.fr/) and the third author, as a Montessori expert, had recommended the selected institution as a Montessori demonstration site for several years. All professionals underwent initial training in 2016 by an instructor who was immersed in the facility for one week. Multiple training sessions were conducted for new staff
members, practice follow-ups has been established and two Montessori trainers work in the institution. The Montessori principles are embedded in the institutional mission statement and in the job descriptions of the professionals. Finally, the institution is recognized as a reference center for elderly care by the French National Authority for Health.

This institution is a non-profit public long-term care facility in the Occitanie region of France. It accommodates a total of 64 residents, with 50 in open units and 14 in closed units.

## Recruitment

We employed a purposive sampling strategy to select participants based on their relevance to the research topic. We contacted the psychologist and the institution's director via email and postal mail. The psychologist was provided an exemplary list of targeted professions but any professional working within the institution was eligible for inclusion. Subsequently, she recruited professionals from the institution on a voluntary basis.

## Research Ethics

Data were stored and processed confidentially and anonymously. Consent was obtained before recording, and procedures for recording, transcription, analysis, and presentation were explained in detail in advance to meet informed consent requirements.

This study was approved by the Research Ethical Committee of the University Paul-Valéry Montpellier 3 (IRB ID: IRB00013307). To ensure the rights of all participants were protected, the researchers strictly adhered to the Declaration of Helsinki (https://www.wma.net/wp-content/uploads/2016/11/DoH-Oct2013-JAMA.pdf). Material has not been disclosed to prevent compromise of participant confidentiality.

## Participants

The final sample was comprised of one activity coordinator, one psychologist, one housekeeping staff member (who exclusively worked in the open unit), three nursing assistants (two from the closed unit and one from the open unit), the secretary, the coordinating nurse, and the institution's director. Participant demographics are available in table 1.

insert Table 1.
All participants received a minimum of three days of Montessori training, except for
the untrained director. Among them, five participants had their initial training within the
institution in 2016, while three received external initial training. Seven professionals attended
practice monitoring sessions in 2022. Four participants received multiple Montessori method
training sessions. Notably, both the activity coordinator and the psychologist are Montessori
trainers.

## Interviews

The authors (M.D.and G.B.) developed an interview guide for conducting semi-
structured individual interviews, as details in the Supplemental online material Table 2. To
ensure the guide's relevance and effectiveness, two peer debriefing sessions were
conducted, during which input was gathered and necessary adjustments were made. A
Montessori method expert (J.E.) participated in these sessions, providing valuable guidance
to align the interview guide with the goal of generating results that would be practical for end-
users, in accordance with the principles of authenticity logic (Hewlett et al., 2006; Lincoln et
al., 2011). Before being used to collect data, the interview guide underwent a pre-testing
phase.

The first author, who had no prior relationship with the professionals or any history
with the institution, conducted interviews within the institution between February 28 and
September 09, 2022. Durations ranged from 31 to 136 minutes. Each professional
contributed to a single interview. The session started with an overview, introducing the
interviewer, study context, interview process, and data handling. Subsequently, the interviews
were recorded using a voice recorder, alongside note-taking. All topics outlined in the
interview guide were thoroughly addressed using open-ended questions. Follow-up
questions were employed to explore points raised by the professionals. Recording ceased
once all intended topics had been explored. The latter part of the meeting was dedicated to
allowing participants to share any additional comments. Finally, a summary of the interview
was provided to the participants to ensure that their feelings were accurately understood by
the interviewer, with the goal of enhancing the study's both credibility and reliability level
(Lincoln & Guba, 1985). Summaries were only offered to seven participants due to participant availability. Demographic information was collected post-interview.

## Data analyses

Each interview was transcribed verbatim in its entirety and analyzed between April 2022 and March 2023. The data analysis was conducted by two investigators (M.D. and G.B.). A thematic analysis was applied to all transcriptions using QDA Miner Lite 2.0.9 software (Provalis research, 2021). No data exclusion was performed. Data analysis followed a six-phase method (Braun & Clarke, 2006), as detailed in Supplemental online material Table 3. In the terminology of William & Moser (2019), these steps aimed in summary to apply open coding to the data by segmenting the discourse into units of meaning (codes), and then to structure these elements thematically during an axial coding. A final coding step, also described by William & Moser, —i.e., selective coding— was added to Braun & Clarke's steps to refine the thematic tree and model the relevant information (Williams & Moser, 2019). In our study, such modeling was operated following Michie's BCIO framework (2017), the components of which were previously described, i.e., Intervention, Exposure, Context, Mechanisms of Action and Behavioral Outcomes.

To ensure methodological rigor, we adhered to the quality criteria outlined by Guba and Lincoln (Guba, 1981; Lincoln & Guba, 1985). To enhance the dependability of our results, a triangulation approach involving multiple researchers was employed. Furthermore, we actively sought input from experts in qualitative methodology and the Montessori method, which played a crucial role in shaping and refining the model's organization. These triangulation sessions also allowed us to discuss data saturation considering recurring themes addressed during the interviews. They resulted in a consensus among peers to stop data collection.

## Results

Thematic analysis enabled the production of a behavior change intervention model (Figure 1) that conforms to the criteria outlined in the BCIO scenario. The components and subcategories of the BCIO model are elaborated below, with descriptions of the themes and
sub-themes. A presentation of illustrative quotations from participants is provided in Supplemental online material Table 4. We will not present the thematic trees in the results. They represent merely an intermediate step in the analysis, with the ultimate goal being the logical model derived from the selective coding stage.

insert Figure 1.

# Intervention and mechanisms of action

## Content

In describing the method, participants referred to a set of values (Figure 1). Regarding its principles, they mentioned the principle of choice and control, which involves providing choices, fostering a sense of control, and preserving the individual's autonomy to the greatest extent possible. A second principle discussed was the one of community. It refers to the idea that participants perceive the institution as a place of life that promotes social roles, social connections, and operation according to the rules of democracy. Participants also mention the concept of meaningful support, as the proposed activities are oriented towards a goal and align with the resident's logic. Lastly, the Montessori method is defined as person-centered support rather than pathology-centered. Professionals take into account the individual's needs, life history, and abilities.

## Delivery

In terms of its administration procedures, professionals report that the Montessori method is applied continuously throughout the day in everything offered to the residents.

Among the described application techniques, the Montessori method involves adopting the role of a facilitator. This entails a change in posture, by allowing the persons to succeed in tasks on their own or working collaboratively rather than doing things for them; by prioritizing engagement in an activity over the outcome; by adopting a low-profile approach, which means being guided by the person, observing, and providing corrections. Another aspect of the facilitator's role is to offer support that does not create difficulties for the resident. This involves guiding and demonstrating actions; relying on the preserved abilities of the residents; allowing them to proceed at their own rhythm; progressing step by step.
The second application point involves providing choices by presenting various alternatives, seeking agreement, and respecting the individual's opinion. This may include using voting, involving residents in tasks and decisions governing the organization of the facility, and offering a model of support that is home-like. A third mentioned technique, emphasized by all professionals, is engagement in meaningful activities that align with the residents' interests and request. Professionals also underscored the importance of designing the environment to be pleasant, facilitative, and rich in sources of activities. Lastly, specific tools were described by the participants, such as resident committees, the observation of preserved abilities, the use of person-centered life plans, and Montessori based-activities.

## Exposure

### Reach and engagement

The target population and the population engaged in the application are described in the model (Figure 1).

The method is adapted at both inter-individual and intra-individual levels, considering individual abilities, habits, preferences, interests, and adjusting to the person's mood and needs.

The professional's engagement is characterized by variance in the extent to which the Montessori method is assimilated and embraced among professionals. The level of involvement and understanding of the method varies among the professionals interviewed. Although all professionals have a role to play, some professional domains such as care, recreation, and psychological support, seem more conductive to the application of the method than others. Modes of action also differ according to the professions. For example, managers are more actively applying the method to professionals, while those responsible for maintenance, leisure, and care focus the majority of their actions toward the residents.

Finally, the professional's engagement encompasses a set of facilitators and barriers (Figure 1). Among the facilitators, a key element is the fulfillment brought by the method. Participants present the method as a practice that gives them a sense of doing meaningful work, enhances the residents' quality of life, fosters enriching relationships with the residents,
and contributes to a fulfilling work environment. Moreover, professionals consider the method
to be deeply ingrained, describing it as a natural and automatic application as well as a
practice that should constitute a standard mode of support in every institution. Finally, the
interviews unveiled a strong attachment to the method, marked by a desire to promote it
outside the institution and its influence on the support provided to loved ones. Some barriers
are partially offset by the levers. For example, teams describe communication as an effective
solution to address misunderstandings among teams and families. Resistance stemming
from the perception of time constraints can be compensated by the time-saving aspect
offered by the method. In terms of safety, a gradual mode of action allows for the realization
that residents can gain autonomy without putting themselves in danger.

Residents' engagement involves mutual support among residents, adherence to the
method, and a high level of autonomy in carrying out daily tasks.

Implementation
---

Among the identified implementation factors, training and practice follow-ups were
described by participants as a means of continuing to communicate with each other and
maintaining the change momentum. Participants also mentioned the importance of following
a gradual progression from simpler to more complex tasks, working through trial and error,
taking steps, assessing progress, and accepting that it may take time. The support of
leadership, staff motivation, the presence of Montessori leaders and communication were
mentioned as key points to consider for the successful implementation of a model change.

Context
---

In terms of context, barriers and facilitators have been identified. Among the factors
specific to the institution, an inappropriate architectural structure for motor or cognitive
disabilities constitutes a hindrance while adapted structures or home-like environments are
facilitators. An institutional project aligned with the Montessori method and a non-profit,
human-scale municipal institution positively influenced implementation. Additionally, location
matters; being centrally located in a small town, near infrastructure, enhanced external
connections.
Factors impacting working conditions, like low income, inadequate staff-to-workload ratio, and misalignment between what is expected of professionals and their working conditions, contribute to team exhaustion and impede method application. Turnover is identified as a major obstacle, as new professionals are not adequately trained. Mitigating strategies include effective communication and integration of new professionals with residents. Concerning team exhaustion, the use of the Montessori method is presented as a means to compensate for the lack of professionals. Practice follow-ups are also identified as a facilitator to give meaning to the support method. Cultivating a values-based, pleasant work environment is suggested to reduce turnover.

The institutional framework posed challenges to the Montessori approach. Nursing homes, being communal, face challenges in honoring individual preferences. For instance, a resident wanting to stay in sleepwear may inconvenience others who prefer a more presentable appearance. Health and funding organizations, along with a hospital-like mode, may not prioritize residents' quality of life, conflicting with the method's principles. Notably, budget isn't a hindrance, as method implementation proves cost-effective.

Among the factors specific to the residents, the severity of motor and cognitive impairments can be a barrier. However, observing preserved abilities, proposing rigorously tailored support for each individual, establishing a strong alliance with the residents, and properly training teams can help mitigate these difficulties.

The type of service influences the method's application, with the dementia unit appearing to be associated with facilitating factors (small-scale, a small number of residents, residents with no motor impairments, etc.) compared to the other units.

Finally, the COVID-19 pandemic has been identified as a factor opposing the principles of the Montessori Method. Health protocols, including mask and plexiglass mandates, worsen cognitive impairments (e.g., communication, facial recognition). Residents were barred from social roles and activities, facing isolation, family separation, freedom infringements, and limited choice-making. Participants also identified that adhering to the health protocol was associated with a sense of loss of meaning in practice.
## Behavioral outcome

While the intervention targets residents, families, and professionals, here, we will focus exclusively on the behavior and practice changes of professionals. Given that the study is qualitative, we do not provide quantitative measures of behavior change, but we report several concrete examples of practice changes.

To begin, the Montessori method influences care, services, and basic benefits. Professionals offer residents choices regarding wake-up, bedtime, and toileting schedules. They let residents choose the type of personal care they want and their level of autonomy in this task. Regarding household chores, maintenance staff allow residents to determine the extent to which they want to participate in cleaning their rooms. In terms of meals, chefs create a food preference list for each resident, and multiple meal alternatives are offered at each meal. Residents participate in mealtime scheduling and menu creation.

Concerning activities, professionals invite residents every day to participate in daily life activities, such as meal preparation, laundry management, facility administrative tasks, and pet care. A wide range of recreational activities is offered, including outings such as cultural outings, outings to market, beach excursions, and intergenerational activities at daycare centers and schools. Montessori activities are also conducted, such as category sorting with adapted materials and reading with adapted Montessori books. These activities are offered with the input and consent of each individual.

The Montessori method also impacts the overall organization of the facility. Managers apply the Montessori principles to professionals by seeking their input, especially regarding scheduling. Residents participate in job interviews and the selection of interns. Elections are held to appoint resident representatives to the social life council. The facility establishes committees, including welcome, farewell (intended to pay homage to the deceased), and communication committees, as well as various committees focused on specific interests such as gardening and sports. For each resident, individualized activities determined during the life project can be implemented, such as a Porsche ride, sea outing, or paragliding experience for instance.
Finally, regarding environmental design and materials, resident-created signage (labels, signs) is used. Most professionals wear large-print badges. Memory aids and adapted materials address resident needs. Activity spaces like a resident-managed chicken coop and shop are established.

## Discussion

This study was the first to survey staff in a French nursing home about their implementation of the Montessori method adapted to the older adults. Our aim was to describe the method's components, factors supporting its coherence in application, and its use by professionals, as well as factors influencing its integrity or limiting its expression. Results were structured into a framework based on the Behavior Change Intervention Ontology (BCIO) (Michie et al., 2017) (Figure 1). The components of the model will now be discussed and compared to existing scientific literature.

## Intervention and mechanisms of action

In terms of content, the general principles and values articulated by the participants align with the foundational tenets of the Montessori method as described by Camp and his colleagues (Camp et al., 2018; Erkes & Bayard, 2023b). This strong similarity can be partially explained by the fact that two participants are Montessori trainers. This homogeneity may also stem from the level of expertise within the teams and the implementation of practical follow-ups. It confirms a strong understanding of the method among professionals.

A qualitative study conducted in the United Kingdom involving eight professionals working in nursing homes also yields results that are broadly akin to our own findings (Raghuraman & Tischler, 2021). Similarly, the intervention aligns with studies implementing comprehensive Montessori-based care restructuring (Brush et al., 2018; Roberts et al., 2015; Witt-Hoblit et al., 2016). For instance, our results highlight the Montessori method as a holistic, continuous approach involving professionals, residents, and families. These observations support an application mode of the Montessori method that transcends isolated and time-constrained activity programs (Sheppard et al., 2016). Consequently, the effectiveness data from these programs may not accurately reflect the method's overall
efficacy in nursing homes when applied holistically. Furthermore, these comparative
elements suggest that the Montessori method is grounded in similar principles regardless of
the institution in which it is implemented.

Exposure

Despite this similarity, divergences are noted regarding the method's implementation
across studies. While the core principles of the interventions are similar, the intervention
programs and the steps of implementation remain heterogeneous (Brush et al., 2018;
Roberts et al., 2015; Witt-Hoblit et al., 2016). On one hand, this heterogeneity seems to be
inherent to the essence of the method, as its application mode relies on intra-individual and
inter-individual adaptation mechanisms. These adaptation mechanisms are closely tied to the
foundations of the Montessori method, as it is built on a person-centered approach (Kitwood,
1993). This adaptive process is highlighted by Madrigal and colleagues who made 36
modifications to a Montessori activity program to adapt it to a veteran population (Madrigal et
al., 2022). Similarly, Chaudhry and colleagues propose modifications to programs for
Pakistani participants (Chaudhry et al., 2020). On the other hand, it appears that the
implementation of the intervention depends on the necessary alignment of its content with
factors specific to the actors who apply it and the context.

In line with scientific literature, team training, along with effective communication with
families and among professionals, are described as key implementation factors (Ducak et al.,
2018; McArthur et al., 2021). According to Berwick, the perception of the balance between
benefits and risks influences the adoption of innovation. Increased knowledge about
innovation would enhance the perception of risk, benefits, and consequently, innovation
adoption (Berwick, 2003). Management support is another variable consistently identified as
influencing the Montessori method's implementation (Ducak et al., 2018; Raghuraman &
Tischler, 2021) and evidence-based recommendations (McArthur et al., 2021). These results
emphasize the importance of involving the leadership team in the training processes for the
method. Finally, our results indicate that the implementation of the method requires a gradual
rollout. Similar findings appear in Raghuraman's study, describing the implementation of the
method as "a marathon, not a sprint" (Raghuraman & Tischler, 2021). Given that the difficulty level of the innovation and his trialability affect the adoption of the innovation (Berwick, 2003), it is consistent that a step-by-step progression, from simpler to more complex, facilitates the implementation of the Montessori method.

Regarding factors specific to the actors involved, the method's implementation is influenced by both barriers and facilitators. Among the barriers, resistance from actors due to lack of knowledge, perceptions of dementia, lack of time and resources are mentioned by the professionals we interviewed and in scientific literature (Ducak et al., 2018; Raghuraman & Tischler, 2021). Among the facilitators that we identified, the observation of positive results generated by the method promotes engagement (McArthur et al., 2021; Raghuraman & Tischler, 2021). Participants also describe a natural and automated practice that relates to the concept of habit among the motivation processes for behavior change (Michie et al., 2011). Team cohesion is described as a facilitator for adopting the Montessori method (Ducak et al., 2018) and, in a broader sense, for new practices in long-term care units (McArthur et al., 2021). This consistency in scientific literature suggests that these factors are major variables influencing the intervention's mode of action.

## Context

In general, the contextual factors identified in our analysis, such as institution-specific factors, working conditions, institutional framework and residents, have already been documented in the scientific literature as variables that influence the implementation of practice changes in nursing homes (Ducak et al., 2018; McArthur et al., 2021; Zimmerman et al., 2014). However, some points of disagreement may arise. According to Ducak and colleagues, the lack of financial resources is described as a hindrance to the implementation of the Montessori method in nursing homes (Ducak et al., 2018). In our study, professionals indicate that the change in practice is not costly but is based on adopting a different approach to caregiving. Nevertheless, our results highlight that a deficiency of professionals can impact the quality of care provided due to reduced time allocated to residents and resulting staff burnout. According to the participants, the shortage of personnel may be
attributed to unattractive job positions due to low salaries. Furthermore, training and practice follow-ups require significant financial resources. Although professionals claim that the method is not costly, it appears that the financial resources of the institution indirectly affect the implementation of a cultural change.

## Behavioral outcome

To our knowledge, only Brush and colleagues provide a concrete description of professionals' practice changes in nursing homes within the context of culture change based on Montessori principles (Brush et al., 2018). The described changes appear very similar to the behavioral outcomes mentioned in our study, as they align with the same principles. Specific actions that differ are also identified. For instance, as an illustration of providing control in nutrition choices, participants in our study involved residents in menu creation, whereas Brush's study included the establishment of a refreshment station. Theses specificities are the result of contextual factors and actor-specific elements that modulate the exposure, the intervention's implementation and mechanisms of action. In this context, it is not reasonable to anticipate uniform results for each institution. On the contrary, it seems necessary for professionals to embrace the intervention in a way that adequately addresses contextual requirements, allowing it to endure over time and meet the needs of the target population.

## Limitations and prospects

Several limitations can be identified regarding our study. One primary limitation is the absence of validated tools for assessing the level of Montessori method implementation. Such tools need to be developed in the future. By providing a clearer definition of the principles and application of the method, this study can contribute to establishing guidelines for the development of these tools.

The qualitative approach, while valuable for our research topic, has drawbacks. The interview method relies on participants' introspective and analytical capabilities. Responses are inherently subjective and dependent on the cognitive abilities of the interviewees. In the context of our study, professionals faced challenges defining method principles, often
focusing on concrete applications within their institutions. This complicates identifying method
components and organizing them. Furthermore, the results may also be sensitive to
participants' intentions. For instance, discourse may be influenced by a tendency to highlight
the institution's practices.

Furthermore, we identified barriers and facilitators impacting method implementation.

Participants were recruited from a single institution where the method has been correctly applied and embedded in practices for several years. Certain significant barriers to implementing the method in nursing homes may not have been addressed. On the one hand, to achieve such practice changes, it is likely that our participants encountered fewer obstacles compared to teams struggling to implement the method. On the other hand, professionals' assimilation and time since implementation could influence discourse.

Responses may be subject to cognitive biases emphasizing facilitative elements rather than barriers. Memory reconstruction may lead to forgetting barriers over time (Schacter, 2022).

This has implications for identifying implementation challenges crucial for supporting institutional care model changes. Future analyses with institutions facing implementation struggles could offer a more comprehensive description of factors.

More comprehensively, the model we used does not describe the interaction between
the different factors of implementation. In practical terms, it would be useful to associate
recommendations with the obstacles by identifying which facilitative factors can counteract
specific barriers. Such an analysis would allow us to formulate clear recommendations for
stakeholders to develop the method in institutional settings.

Finally, we chose to only interview professionals. However, in our study, we found that
the method involves not only professionals but also residents and families. It is possible for
families and residents to exhibit behaviors that contribute to the effects of the method. In the
future, surveying families and residents would provide a more comprehensive understanding
of the method's lived experience and facilitate a detailed description of its effects.
## Conclusion

This exploratory study has enabled the proposal of a descriptive model of the processes through which professionals have modified their approach to caring for older adults in nursing homes using the Montessori method. It addresses the need to accurately define new person-centered approaches aimed at providing alternatives to medication-based treatments (Zimmerman et al., 2014). Our results contribute theoretically by outlining the Montessori method's principles. Implementation insights can guide protocol development for assessing effectiveness, offering practical implications for professionals. Additionally, they have practical implications considering key factors during method implementation, potentially shaping training programs and advancing care models in nursing homes. Improving practical recommendations for implementing a change in care models is a significant challenge that qualitative research is well-suited to address, ultimately enhancing the care provided to our elderly population.

## Declaration of conflicting interests

Dr. Cameron Camp is a consultant and trainer for the French organization AG&D involved in diffusing training, research and documentation about Montessori method and person-centered approaches in dementia care. Dr. Jérôme Erkes is Director of Research for AG&D. Marie Lembach is a trainer employed by AG&D. Méryl Donadey is a Ph.D. student employed by AG&D in the research department. Dr. Sophie Bayard and Dr. Guillaume Broc report no disclosure. The ideas and data appearing in the manuscript have not been disseminated before.

## Funding statements

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article. This work was supported by the organization AG&D under Grant CIFRE 2022/0688.
References

American Geriatrics Society Expert Panel on Person-Centered Care. (2016). Person-Centered Care: A Definition and Essential Elements. *Journal of the American Geriatrics Society*, 64(1), 15-18. https://doi.org/10.1111/jgs.13866

Berwick, D. M. (2003). Disseminating innovations in health care. *JAMA*, 289(15), 1969-1975.
https://doi.org/10.1001/jama.289.15.1969

Booth, S., Zizzo, G., Robertson, J., & Goodwin Smith, I. (2020). Positive Interactive Engagement (PIE): A pilot qualitative case study evaluation of a person-centred dementia care programme based on Montessori principles. *Dementia (London, England)*, 19(4), 975-991. https://doi.org/10.1177/1471301218792144

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. *Qualitative Research in Psychology*, 3, 77-101. https://doi.org/10.1191/1478088706qp063oa

Braun, V., Clarke, V., & Terry, G. (2014). Thematic Analysis. In *Qualitative research in clinical and health psychology* (p. 95-113). Palgrave Macmillan.

Brush, J., Douglas, N., & Bourgeois, M. (2018). *Implementation of the montessori program in assisted living: Positive outcomes and challenges*. 42-48.

Camp, C., Antenucci, V., Roberts, A., Fickenscher, T., Erkes, J., & Neal, T. (2017). *The Montessori Method Applied to Dementia: An International Perspective*. https://amshq.org/About-Montessori/Montessori-Articles/All-Articles/The-Montessori-Method-Applied-to-Dementia

Camp, C. J. (2010). Origins of Montessori Programming for Dementia. *Non-Pharmacological Therapies in Dementia*, 1(2), 163-174.

Camp, C. J., Bourgeois, M. S., & Erkes, J. (2018). Person-centered care as treatment for dementia. In *APA handbook of dementia* (p. 615-629). American Psychological Association. https://doi.org/10.1037/0000076-033

Chaudhry, N., Tofique, S., Husain, N., Couture, D., Glasgow, P., Husain, M., Kiran, T., Memon, R., Minhas, S., Qureshi, A., Shuber, F., & Leroi, I. (2020). Montessori intervention for individuals with dementia: Feasibility study of a culturally adapted
psychosocial intervention in Pakistan (MIRACLE). *BJPsych Open*, 6(4), e69.

https://doi.org/10.1192/bjo.2020.49

den Ouden, M., Bleijlevens, M. H. C., Meijers, J. M. M., Zwakhalen, S. M. G., Braun, S. M.,
Tan, F. E. S., & Hamers, J. P. H. (2015). Daily (In)Activities of Nursing Home

Residents in Their Wards: An Observation Study. *Journal of the American Medical
Directors Association*, 16(11), 963-968. https://doi.org/10.1016/j.jamda.2015.05.016

Ducak, K., Denton, M., & Elliot, G. (2018). Implementing Montessori Methods for Dementia™
in Ontario long-term care homes : Recreation staff and multidisciplinary consultants'
perceptions of policy and practice issues. *Dementia (London, England)*, *17*(1), 5-33.

https://doi.org/10.1177/1471301215625342

Erkes, J., & Bayard, S. (2023a). La méthode Montessori adaptée aux personnes âgées présentant des troubles cognitifs, une approche globale centrée sur la personne Partie 2. Données de la littérature scientifique, effets et perspectives. *Gériatrie et Psychologie Neuropsychiatrie du Vieillissement, 21*(2), 223-232.

https://doi.org/10.1684/pnv.2023.1095

Erkes, J., & Bayard, S. (2023b). [Montessori Method applied to dementia, a person-centered global approach Part 1 : Origins and principles]. *Geriatrie Et Psychologie Neuropsychiatrie Du Vieillissement, 21*(1), 97-106.

https://doi.org/10.1684/pnv.2023.1079

Guba, E. G. (1981). Criteria for assessing trustworthiness of naturalistic enquiries.

*Educational Communication and Technology Journal*, 29(2), 75-91.

Hewlett, S., Wit, M., Richards, P., Quest, E., Hughes, R., Heiberg, T., & Kirwan, J. (2006).

Patients and professionals as research partners : Challenges, practicalities, and
benefits. *Arthritis and rheumatism*, 55, 676-680. https://doi.org/10.1002/art.22091

Hitzig, S. L., & Sheppard, C. L. (2017). Implementing Montessori Methods for Dementia : A
Scoping Review. *The Gerontologist*, 57(5), e94-e114.

https://doi.org/10.1093/geront/gnw147

Kitwood, T. (1993). *Dementia reconsidered : The person comes first*. Open University Press.
Lapane, K. L., Lim, E., McPhillips, E., Barooah, A., Yuan, Y., & Dube, C. E. (2022). Health effects of loneliness and social isolation in older adults living in congregate long term care settings: A systematic review of quantitative and qualitative evidence. *Archives of Gerontology and Geriatrics, 102*, 104728.

https://doi.org/10.1016/j.archger.2022.104728

Lillard, A. (2005). *Montessori : The science behind the genius*. Oxford University Press.

Lincoln, Y. S., & Guba, E. G. (1985). *Naturalistic Enquiry*. Sage.

Lincoln, Y. S., Lynham, S. A., & Guba, E. G. (2011). Paradigmatic controversies, contradictions, and emerging confluences, revisited. In *The Sage Handbook of Qualitative Research* (4th éd., p. 97-128). CA: Sage.

Love, K., & Pinkowitz, J. (2013). Person-Centered Care for People with Dementia : A Theoretical and Conceptual Framework. *Generations: Journal of the American Society on Aging*, 37(3), 23-29. https://www.jstor.org/stable/26591677

Madrigal, C., Mills, W. L., Keleher, V. C., Pimentel, C. B., Hartmann, C. W., Snow, A. L., Camp, C., & Hilgeman, M. M. (2022). A Spotlight on Adaptation : Pre-Implementation of Montessori-Based Activity Programming in Long-Term Care Using the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME). *The Gerontologist*, gnac133. https://doi.org/10.1093/geront/gnac133

Mahendra, N., Hopper, T., Bayles, K. A., Azuma, T., Cleary, S., & Kim, E. (2006). Evidence-based practice recommendations for working with individuals with dementia : Montessori-based interventions. In *Database of Abstracts of Reviews of Effects (DARE) : Quality-assessed Reviews [Internet]*. Centre for Reviews and Dissemination (UK). https://www.ncbi.nlm.nih.gov/books/NBK72281/

McArthur, C., Bai, Y., Hewston, P., Giangregorio, L., Straus, S., & Papaioannou, A. (2021). Barriers and facilitators to implementing evidence-based guidelines in long-term care : A qualitative evidence synthesis. *Implementation Science: IS*, 16(1), 70.

https://doi.org/10.1186/s13012-021-01140-0
Michie, S., van Stralen, M. M., & West, R. (2011). The behaviour change wheel : A new method for characterising and designing behaviour change interventions.

*Implementation Science: IS*, 6, 42. https://doi.org/10.1186/1748-5908-6-42

OECD. (2021). *Health at a Glance 2021: OECD Indicators*. OECD.

https://doi.org/10.1787/ae3016b9-en

Palacios-Ceña, D., Gómez-Calero, C., Cachón-Pérez, J. M., Velarde-García, J. F., Martínez-Piedrola, R., & Pérez-De-Heredia, M. (2016). Is the experience of meaningful activities understood in nursing homes? A qualitative study. *Geriatric Nursing (New York, N.Y.)*, 37(2), 110-115. https://doi.org/10.1016/j.gerinurse.2015.10.015

Provalis research. (2021). *QDA MINER LITE (2.0.9)* [Logiciel].

https://provalisresearch.com/fr/produits/logiciel-d-analyse-qualitative/gratuit/

Raghuraman, S., & Tischler, V. (2021). 'The Jigsaw Culture of Care' : A qualitative analysis of Montessori-Based programming for dementia care in the United Kingdom. *Dementia (London, England)*, 14713012211020143.

https://doi.org/10.1177/14713012211020143

Roberts, G., Morley, C., Walters, W., Malta, S., & Doyle, C. (2015). Caring for people with dementia in residential aged care : Successes with a composite person-centered care model featuring Montessori-based activities. *Geriatric Nursing (New York, N.Y.)*,

36(2), 106-110. https://doi.org/10.1016/j.gerinurse.2014.11.003

Rohleder, P., & Lyons, A. (2014). Introduction : Qualitative Research in Clinical and Health Psychology. In *Qualitative research in clinical and health psychology* (p. 1-6).

Palgrave Macmillan.

Schacter, D. L. (2022). The Seven Sins of Memory : An Update. *Memory (Hove, England)*, 30(1), 37-42. https://doi.org/10.1080/09658211.2021.1873391

Sheppard, C. L., McArthur, C., & Hitzig, S. L. (2016). A Systematic Review of Montessori-Based Activities for Persons With Dementia. *Journal of the American Medical Directors Association*, 17(2), 117-122. https://doi.org/10.1016/j.jamda.2015.10.006
Sterns, A., Sterns, H., Sterns, R., & Lax, G. (2011). Bridging the Intergenerational Gap in Therapeutic Activity Delivery Between Younger Professional Caregivers and Older Adults Living With Dementia. *Journal of Intergenerational Relationships, 9*, 161-175.
https://doi.org/10.1080/15350770.2011.568340

Sun, X.-C., Sun, Z.-R., & Ma, H.-M. (2022). Effect of Montessori method on the cognitive and behavioral intervention of senile dementia patients: A meta-analysis. *Aging Communications, 4*. https://doi.org/10.53388/AGING202204007

Sury, L., Burns, K., & Brodaty, H. (2013). Moving in: Adjustment of people living with dementia going into a nursing home and their families. *International Psychogeriatrics, 25*(6), 867-876. https://doi.org/10.1017/S1041610213000057

Tandan, M., Kaup, M., Cornelison, L., & Zimmerman, S. (2023). The relationship between person-centered care in nursing homes and COVID-19 infection, hospitalization, and mortality rates. *Geriatric Nursing (New York, N.Y.)*, 51.
https://doi.org/10.1016/j.gerinurse.2023.03.012

Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. *International Journal for Quality in Health Care: Journal of the International Society for Quality in Health Care, 19*(6), 349-357. https://doi.org/10.1093/intqhc/mzm042

Williams, M., & Moser, T. (2019). The Art of Coding and Thematic Exploration in Qualitative Research. *International Management Review*.
https://www.semanticscholar.org/paper/The-Art-of-Coding-and-Thematic-Exploration-in-Williams-Moser/c0a0c26ac41cb8beb337834e6c1e2f35b91d071d

Witt-Hoblit, I., Miller, M., & Camp, C. (2016). Effects of Sustained, Coordinated Activities Programming in Long-Term Care: The Memory in Rhythm® Program. *Advances in Aging Research, 05*, 1-8. https://doi.org/10.4236/aar.2016.51001

World Health Organization. (2023). *Dementia*. https://www.who.int/news-room/fact-sheets/detail/dementia
Xu, L., Zhang, Z., & Xu, X. (2022). Effectiveness of Montessori-based activities on agitation among Asian patients with dementia: A systematic review and meta-analysis.

*Medicine*, **101**(32), e29847. https://doi.org/10.1097/MD.00000000000029847

Yan, Z., Traynor, V., Alananzeh, I., Drury, P., & Chang, H. (2023). The impact of montessori-based programmes on individuals with dementia living in residential aged care: A systematic review. *Dementia (London, England)*, **22**(6).

https://doi.org/10.1177/14713012231173817

Yu, L., Boyle, P. A., Segawa, E., Leurgans, S., Schneider, J. A., Wilson, R. S., & Bennett, D.

A. (2015). Residual decline in cognition after adjustment for common neuropathologic conditions. *Neuropsychology*, **29**(3), 335-343. https://doi.org/10.1037/neu0000159

Zimmerman, S., Dumond-Stryker, C., Tandan, M., Preisser, J. S., Wretman, C. J., Howell, A., & Ryan, S. (2021). Nontraditional Small House Nursing Homes Have Fewer COVID-19 Cases and Deaths. *Journal of the American Medical Directors Association*, **22**(3),

489-493. https://doi.org/10.1016/j.jamda.2021.01.069

Zimmerman, S., Shier, V., & Saliba, D. (2014). Transforming nursing home culture: Evidence for practice and policy. *The Gerontologist*, **54** *Suppl 1*, S1-5.

https://doi.org/10.1093/geront/gnt161
**Table 1**

*Demographic Characteristics of Participants*

<table><thead><tr><th></th><th colspan="2">Sample (n = 9)</th></tr></thead><tbody><tr><td>Age, (y)</td><td>44.1 ± 10,7</td><td>[31 - 59] <sup>a</sup></td></tr><tr><td>Female, % (N)</td><td>100% (9)</td><td></td></tr><tr><td>Professional experience<sup>b</sup> (y)</td><td>10.7 ± 8,1</td><td>[1 - 21]</td></tr><tr><td>Average tenure within the institution<sup>c</sup> (y)</td><td>11.7 ± 9,4</td><td>[0.25 - 21]</td></tr></tbody></table>

y = years

<footnote>a [minimum – maximum]</footnote>

<footnote>b number of years practicing the profession</footnote>

<footnote>c seniority within the institution</footnote>
<caption>Figure 1</caption>

Framework of the Montessori Method for persons with Dementia that adheres to the criteria of the BCIO scenario

<figure><img src="image_3.png" /></figure>
Supplemental online material

<caption>Table 1</caption>

The COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist (Tong et al., 2007)

<table><thead><tr><th>No Item</th><th>Guide questions / description</th><th>Reported on</th></tr></thead><tbody><tr><td colspan="3"><strong>Domain 1: Research team and reflexivity</strong></td></tr><tr><td colspan="3"><strong>Personal Characteristics</strong></td></tr><tr><td>1. Interviewer/facilitator</td><td>Which author/s conducted the interview or focus group?</td><td>7</td></tr><tr><td>2. Credentials</td><td>What were the researcher's credentials? E.g. PhD, MD</td><td>Title page</td></tr><tr><td>3. Occupation</td><td>What was their occupation at the time of the study?</td><td>N/A</td></tr><tr><td>4. Gender</td><td>Was the researcher male or female?</td><td>N/A (female)</td></tr><tr><td>5. Experience and training</td><td>What experience or training did the researcher have?</td><td>N/A</td></tr><tr><td colspan="3"><strong>Relationship with participants</strong></td></tr><tr><td>6. Relationship established</td><td>Was a relationship established prior to study commencement?</td><td>7</td></tr><tr><td>7. Participant knowledge of the interviewer</td><td>What did the participants know about the researcher? e.g. personal goals, reasons for doing the research</td><td>7</td></tr><tr><td>8. Interviewer characteristics</td><td>What characteristics were reported about the interviewer/facilitator? e.g. Bias, assumptions, reasons and interests in the research topic</td><td>19</td></tr><tr><td colspan="3"><strong>Domain 2: Study design</strong></td></tr><tr><td colspan="3"><strong>Theoretical framework</strong></td></tr><tr><td>9. Methodological orientation and Theory</td><td>What methodological orientation was stated to underpin the study? e.g. grounded theory, discourse analysis, ethnography, phenomenology, content analysis</td><td>5</td></tr><tr><td colspan="3"><strong>Participant selection</strong></td></tr><tr><td>10. Sampling</td><td>How were participants selected? e.g. purposive, convenience, consecutive, snowball</td><td>6</td></tr></tbody></table>
<table><tbody><tr><td>11. Method of approach</td><td>How were participants approached? e.g. face-to-face, telephone, mail, email</td><td>6</td></tr><tr><td>12. Sample size</td><td>How many participants were in the study?</td><td>6</td></tr><tr><td>13. Non-participation</td><td>How many people refused to participate or dropped out? Reasons?</td><td>N/A (no one refused to participate)</td></tr><tr><td>Setting</td><td></td><td></td></tr><tr><td>14. Setting of data collection</td><td>Where was the data collected? e.g. home, clinic, workplace</td><td>7</td></tr><tr><td>15. Presence of non-participants</td><td>Was anyone else present besides the participants and researchers?</td><td>N/A (four interviews were interrupted by other staff members or residents passing through the room. Additionally, one interview was also briefly interrupted by a professional intervening in the conversation)</td></tr><tr><td>16. Description of sample</td><td>What are the important characteristics of the sample? e.g. demographic data, date</td><td>6</td></tr><tr><td>Data collection</td><td></td><td></td></tr><tr><td>17. Interview guide</td><td>Were questions, prompts, guides provided by the authors? Was it pilot tested?</td><td>7</td></tr><tr><td>18. Repeat interviews</td><td>Were repeat interviews carried out? If yes, how many?</td><td>7</td></tr><tr><td>19. Audio/visual recording</td><td>Did the research use audio or visual recording to collect the data?</td><td>7</td></tr><tr><td>20. Field notes</td><td>Were field notes made during and/or after the interview or focus group?</td><td>7</td></tr><tr><td>21. Duration</td><td>What was the duration of the interviews or focus group?</td><td>7</td></tr><tr><td>22. Data saturation</td><td>Was data saturation discussed?</td><td>8</td></tr><tr><td>23. Transcripts returned</td><td>Were transcripts returned to participants for comment and/or correction?</td><td>N/A (no transcripts were returned to participants)</td></tr><tr><td>Domain 3: analysis and findings</td><td></td><td></td></tr><tr><td>Data analysis</td><td></td><td></td></tr><tr><td>24. Number of data coders</td><td>How many data coders coded the data?</td><td>8</td></tr><tr><td>25. Description of the coding tree</td><td>Did authors provide a description of the coding tree?</td><td>9</td></tr></tbody></table>
<table><caption>Table 2</caption><tr><td>26. Derivation of themes</td><td>Were themes identified in advance or derived from the data?</td><td>8</td></tr><tr><td>27. Software</td><td>What software, if applicable, was used to manage the data?</td><td>8</td></tr><tr><td>28. Participant checking</td><td>Did participants provide feedback on the findings?</td><td>8</td></tr><tr><td>Reporting</td><td></td><td></td></tr><tr><td>29. Quotations presented</td><td>Were participant quotations presented to illustrate the themes / findings? Was each quotation identified? e.g. participant number</td><td>9</td></tr><tr><td>30. Data and findings consistent</td><td>Was there consistency between the data presented and the findings?</td><td>N/A</td></tr><tr><td>31. Clarity of major themes</td><td>Were major themes clearly presented in the findings?</td><td>9 - 14</td></tr><tr><td>32. Clarity of minor themes</td><td>Is there a description of diverse cases or discussion of minor themes?</td><td>9 - 14</td></tr></table>

Interview grid

<table><thead><tr><th>Thèmes</th><th>Questions</th></tr></thead><tbody><tr><td>Understanding, meaning and representation of the Montessori Method</td><td><ol><li>What are the three to five words that come to mind when I mention the Montessori method?<ol type="a"><li>You mentioned (...), could you tell me more about it?</li></ol></li><li>For you, what does the Montessori method consist of?<ol type="a"><li>How would you define the method?</li><li>Explain to me what are the main principles of the Montessori method?</li><li>In your opinion, how is the accompaniment based on the Montessori method different from a classic accompaniment?</li></ol></li><li>What does applying the Montessori method mean to you?<ol type="a"><li>What motivates you to get involved in this type of support?</li></ol></li></ol></td></tr><tr><td>Application of the Montessori Method</td><td><ol><li>In concrete terms, describe how the Montessori method is applied in your establishment on a daily basis?<ol type="a"><li>Is the method applied in the same way for everyone?<ul><li>Explain</li></ul></li><li>Is the method applied in the same way in different sectors?<ul><li>Explain</li></ul></li></ol></li></ol></td></tr></tbody></table>
Appropriation of
the Montessori
method

5. What facilitates the application of the Montessori method in your institution?

6. What difficulties do you encounter in implementing the Montessori Method in your institution?

7. What advice would you give to professionals who wish to apply the Montessori method in nursing homes?

Effects of the
coronavirus
epidemic on the
application of the
Montessori
method

8. How has the health crisis affected the application of the Montessori Method?

a. Has the health crisis had a positive impact on the application of the Montessori Method?

<caption>**Table 3**</caption>

Data analysis following the six-phase method (Braun & Clarke, 2006)

<table><thead><tr><td>Phase</td><td>Description</td></tr></thead><tbody><tr><td>(1) Familiarization with the data</td><td>The investigator familiarized herself with the interviews by reviewing the Familiarization transcriptions and making notes about different coding hypotheses. In the interviews, the investigator made notes about different coding hypotheses.</td></tr><tr><td>(2) Coding the data</td><td>Data coding occurred in two phases. First, a deductive analysis of the data was conducted using a thematic map based on the interview guide. In a second phase, an inductive analysis was performed to identify sub-themes. Memos were used during the coding phase for points of inquiry.</td></tr><tr><td>(3) Searching for themes</td><td>The codes were grouped into themes based on their similarities. A thematic tree was created using the XMind software (XMind, 2021).</td></tr><tr><td>(4) Reviewing themes</td><td>The review of themes was conducted by revisiting the codes grouped within each theme and was guided by the following questions:<ul><li>Does the theme address the study's objectives?</li><li>Does it include a sufficient number of codes to form a theme?</li><li>Are the codes within the theme sufficiently similar?</li></ul>Modifications were made as necessary.</td></tr><tr><td>(5) Defining and naming themes</td><td>The themes were defined and illustrated using notable and representative quotations from the transcripts.</td></tr><tr><td>(6) Producing the report</td><td>The themes and sub-themes were described in a final report along with the creation of a table summarizing the various themes, sub-themes, and associated illustrative quotations.</td></tr></tbody></table>
Table 4

Tables of themes, sub-themes, and representative quotations associated with the various components of the framework

Table 4.1.

Themes, sub-themes and representative quotations associated with the intervention / mechanisms of action

<table><thead><tr><th>Subcategories (from BCIO)</th><th>Themes (deductively generated)</th><th>Sub-themes (inductively generated)</th><th>Representative quotations</th></tr></thead><tbody><tr><td rowspan="5">Content</td><td rowspan="5">Values</td><td>Equality</td><td>For me, equality isn't "I am a professional and, therefore, I am the one who knows and they are the residents, and therefore, I get to decide because I know what's best".</td></tr><tr><td>Trust</td><td>These are tasks they have been doing at home forever, that's how it starts, and then they are used to it. We trust them, we let them, you have to let them do it.</td></tr><tr><td>Patience</td><td>Patience. Because ultimately, one of the issues we often have in institutions, at least as reported, is the lack of time, and I am convinced that this lack of time is not necessarily... it is more subjective than objective. We have the time, it's more about how we use it.</td></tr><tr><td>Kindness</td><td>It's about doing good for them, providing them comfort... showing kindness... and making them see that it's not a place, as one might say, where they are going to die, but it's still a place of life, the nursing home.</td></tr><tr><td>Respect</td><td>Respect for these elderly individuals, of advanced age, and all their knowledge, all their richness. In</td></tr></tbody></table>
<table><tr><td></td><td></td><td>fact, what I feel is that we don't give it the value it deserves.</td></tr><tr><td></td><td>Freedom</td><td>The resident leaves his room when he wants, he leaves the facility... If they want to go outside the facility, as they wish, they come back whenever they want...</td></tr><tr><td rowspan="4">Principles</td><td>Choice and control</td><td>By giving them choices, empowering them, involving them in the life of their home, and being closer to their needs and desires, we allow them to be alive.</td></tr><tr><td>Community</td><td>It's a place of life, always showing them that they can do things like at home</td></tr><tr><td>Meaningful support</td><td>I think there is a lot of common sense in the Montessori method, it's a great deal of common sense and respect for the human being</td></tr><tr><td>Person-centered support</td><td>To listen to his needs, his desires, and also what he doesn't want. That's it, really respecting his way of life, his lifestyle habits.</td></tr><tr><td rowspan="3">Delivery</td><td>Duration of application</td><td>Continuous application</td><td>It is applied... to all our behavior. We always think about how to apply it, I don't know how to explain it. In everything, it starts in the morning with waking up, getting ready, mealtime, finding something meaningful for them in the afternoons, activities that make sense to them... That's it. It's throughout the day.</td></tr><tr><td>Techniques</td><td>To adopt the role of a facilitator</td><td>After that, I lay out the tablecloths. I'll place the glasses, and that serves as a guideline for them to continue setting the table.</td></tr><tr><td></td><td>Giving choices</td><td>On important themes within the facility where there are choices that can be significant, within the</td></tr></table>
<table><caption>Table 4.2.</caption><tr><td></td><td>communication committee, I'm quite involved. Within the projects committee, I'm quite involved, in co-constructing with them. (Quote from the facility director)</td></tr><tr><td>To offer meaningful activities</td><td>The activity must make sense for the individual(...) Sometimes there are professionals who want to implement activities because it makes sense to them, for their work, but it may not necessarily make sense for the person in question.</td></tr><tr><td>To design the environment</td><td>To have an environment that serves as a kind of cognitive prosthesis, but also provides a rich environment.</td></tr><tr><td>To use specific tools</td><td>To have an environment that serves as a kind of cognitive prosthesis, but also provides a rich environment</td></tr></table>

Sub-themes and representative quotations associated with the exposure

<table><thead><tr><td>Subcategories (from BCIO)</td><td>Sub-themes (inductively generated)</td><td>Representative quotations</td></tr></thead><tbody><tr><td rowspan="3">Reach</td><td>All the residents</td><td>I believe the Montessori method is truly applied to everyone, but we adapt to each individual.</td></tr><tr><td>All the professionals</td><td>The Montessori method is with the inhabitants, it's for the inhabitants, but it's not just that... It's with colleagues, it's really about seeking the potential in each person and trying to highlight that and build upon it.<br>We practice Montessori among ourselves, you know.</td></tr><tr><td>The families of residents</td><td>Because here, families also have a real place (...) They come, they connect with each other, they create bonds among</td></tr></tbody></table>
<table><tr><td></td><td></td><td>themselves, for us, it's really... we work with the families</td></tr><tr><td rowspan="2">Engagement</td><td>Professional engagement</td><td>We work for them because it's their home, and our goal is for them to feel their best, in fact, there is no other goal than that, but yeah, I really like it!<br/>(Q) : What drives you to apply this method, then? (A) : Because it works !</td></tr><tr><td>Resident engagement</td><td>Some residents listened to what I said and helped me during the dishwashing workshop. They came, and we all participated. They understood what I told them. I repeated this sentence to them two or three times, 'we need you, and you need me,' and everything went well in a calm manner.</td></tr><tr><td rowspan="5">Implementation</td><td>Training and practice follow-ups</td><td>It's true, we had a training recently, a refresher, and it really boosted me! (...) I think we should have one every year.</td></tr><tr><td>Gradual implementation</td><td>It's about setting achievable goals. And if it works, congratulate ourselves on that success. And if it didn't work, evaluate it, try to understand why it didn't work, try to readjust, and only then set a new goal. That's really about taking it step by step.</td></tr><tr><td>Identification of staff motivation</td><td>Perceiving the motivation of the facility's staff to want to give a different perspective and meaning to their practice. Because if we don't have that fundamental motivation from the outset, I don't see how it can hold.</td></tr><tr><td>Support of leadership</td><td>(Q) "Did you encounter difficulties in applying the method?" (A) "Maybe at the beginning. But... not really. Because afterward, we've always been supported by the management, whether it's the former director or the current director, so difficulties at that level, no".</td></tr><tr><td>Montessori leaders</td><td>Having trainers on-site is great, I think, because sometimes they tell me, "so you could do this, you could do that."</td></tr></table>
<table><caption>Table 4.3.</caption><tr><td>Communication (with families, with professionals)</td><td>Communicating with professionals who haven't been trained, communicating with families. That's really... it's about making allies, in fact.</td></tr></table>

Sub-themes and representative quotations associated with the context

<table><thead><tr><td>Sub-themes (inductively generated)</td><td>Representative quotations</td></tr></thead><tbody><tr><td>Factors specific to the institution</td><td>I have the impression that overall, in facilities that are located in smaller towns or even villages, with already familial and warm atmospheres, the implementation of Montessori principles and values is a bit simpler</td></tr><tr><td>Factors specific to working conditions</td><td>And us, within this establishment, there isn't much turnover because the personnel are civil servants, and we have a public establishment. So when you're a civil servant, typically, you've built a career. In this career, it's better to feel good rather than, in parentheses, endure routine. It's better to invest in it, so finding renewal that also makes you feel good in your work. You feel good in your work, you have secondary benefits, you feel good in your personal life, you live with less frustration, you make proposals, you create projects.</td></tr><tr><td>Factors specific to the institutional framework</td><td>Our goal is to maintain the person as independent and autonomous as possible, but at the same time, we know that the more we keep them independent and autonomous, the less we will receive in terms of subsidies, support, and funding.</td></tr><tr><td>Factors specific to the residents</td><td>We have a lot of people in wheelchairs who communicate very little, who are lifted using verticalizers, so it's a huge workload for us.</td></tr><tr><td>Factors specific to the services</td><td>The real difference with the closed sector is that, first of all, they have more staff for care. They have residents who can walk even if they have cognitive problems. We have many of those as well, but there, it's a stimulation they have all day because they are with them, really close to them. We go back and forth between the two floors, we have a large dining room where all the residents eat together, it's not the same. So, it's true, I call the closed sector the little cocoon.</td></tr><tr><td>Factors specific to the health crisis</td><td>They took away our freedom, so how do you expect us to make choices if they take away our freedom? It's not consistent.</td></tr></tbody></table>
<caption>Table 4.4.</caption>

Sub-themes and representative quotations associated with the behavioral outcome

<table><thead><tr><td>Sub-themes (inductively generated)</td><td>Representative quotations</td></tr></thead><tbody><tr><td>A change in practices at the level of care, service provision, and offerings.</td><td>It's the same for this, we asked if they preferred to eat at 12:00. They prefer to eat at 12:30. For the evening, it's the same, it's 6:15 PM. We had suggested eating at 7:00 PM because 6:15 PM seemed a bit early. They didn't agree.</td></tr><tr><td>A change in practices regarding activities</td><td>She entered the nursing home because she had a stroke, and while talking to the activity coordinators, pretty much everyone, and talking to her, she said, "I would like to ride a Harley!" So we contacted some bikers, and they came here.</td></tr><tr><td>A change in practices regarding the overall organization of the facility</td><td>There is also something else that is different is that residents conduct tours of the house.</td></tr><tr><td>A change in practices regarding the layout of the environment and equipment</td><td>We had a residents' committee that worked on the upcoming signage that would be implemented, about choice of the themes for each floor. So, we're going to put street names, and they will craft enameled ceramic plaques with the street names.</td></tr></tbody></table>