The Eden Alternative: Culture Change in Eldercare

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Bill Thomas was working as a geriatrician in a nursing home in the early 1990s, examining an elderly resident there and treating her for a recurrent skin rash when she changed his thinking and his life by grasping the sleeve of his white coat and telling him what really ailed her: “Doctor, I am so lonely,” she said. “Can you help me?”

Her plaintive plea plagued him — and spurred Thomas and his wife, Judith Meyers-Thomas, on a crusade to change the culture in long-term care facilities by seeking to eliminate the “three plagues” of loneliness, helplessness, and boredom prevalent in most of them.

Their approach, dubbed the Eden Alternative, sought to create care communities for elders that helps foster companionship among people of all ages and abilities as well as continuing contact with plants and animals.

“We thought nursing homes should be much more like gardens than hospitals,” says Thomas, who now pridefully labels himself a Nursing Home Abolitionist. “We brought plants, animals, children, and life into areas elders were living and celebrating it.”

The 10 Eden Alternative Principles

Initially, they refined The Eden Alternative to include 10 basic principles envisioned in “elder-centered communities” aimed to overcome the common senior plagues, none of which have medical roots.

In brief, the principles are that:

  1. Loneliness, helplessness, and boredom account for most of the suffering among seniors.
  2. Close and continuing contact between elders and plants, animals, and children helps create relationships that improve the quality of life for all.
  3. The antidote to loneliness is human and animal companionship.
  4. The antidote to helplessness is the opportunity to give as well as receive care
  5. The antidote to boredom is an environment filled with unexpected and unpredictable interactions.
  6. The opportunity to do things considered meaningful is essential to human health.
  7. Medical treatment should be the “servant” of genuine human caring, as opposed to its “master.”
  8. Decision-making authority should rest with the elders and those closest to them rather than being in the hands of a bureaucratic hierarchy.
  9. The process of creating an elder-centered community is ongoing and never-ending.
  10. Wise leadership is the lifeblood of the struggle against loneliness, helplessness, and boredom.

Changing an Entrenched Culture

The Eden Alternative stoked the drumbeat that began a couple decades ago recognizing that approaches to long-term care are in drastic need of reform.

Geriatric experts and consumer advocates agreed that what was needed is nothing short of a revolution creating a culture change in long-term care. They urged a move away from the traditional, institutional “medical model” centered on medical providers who concentrate on curing physical symptoms to a “comfort model” that included considerations of the body, mind, and spirit of the person in need of care.

While the Eden Alternative approach originated as a way of changing the look and feel of nursing homes, it soon stood out, and does still, by setting its sights on transforming the living environments for seniors in short-term care, as well as home and community-based settings. It envisions “habitats for human beings” that improve the quality of life for elders and their caregivers. A basic premise is that culture change must evolve “one relationship at a time” and must involve not only the seniors in need of care, but the medical professionals, family members, friends, and volunteers who help care for them.

Putting the Alternative to the Test

It’s a messier matter to pay attention to the holistic needs of seniors in long-term care rather than to routinely mind the clock and calendar of events scheduled in care facilities. Somewhat surprisingly, many of the reforms that developed and endure focused first on dementia care.

And that was the initial test for the Eden Alternative. In the early 1990s, founder Thomas received a grant from the state of New York to fund “The Dementia Project,” which fostered fine-tuning the Eden Alternative philosophy in Chase Memorial Nursing Home in upstate New York.

In an upheaval of the usual look and feel of a traditional nursing home, the project proposed introducing indoor plants, vegetable gardens, and pets (including parakeets, dogs, and cats) to share life with residents. Children were also encouraged to engage with residents through a daycare center, after-school programs, and a summer camp on the premises.

Thomas then published a handbook for “Edenizing” nursing homes with the long but hope-inspiring title: Life Worth Living: How Someone You Love Can Still Enjoy Life in a Nursing Home — The Eden Alternative in Action.

The book also addresses one of the most ticklish problems in instituting culture change in nursing homes: getting understanding and buy-in from management and staff.

In a short time, a number of facilities put the philosophy to the empirical test by instituting the Eden Alternative. Research on the impact revealed some promising results in the health of residents, satisfaction and effectiveness of staff — and well-being of the facilities themselves.

For example, a two-year study of six nursing homes by the Texas Long Term Care Institute revealed that the Eden Alternative was responsible for a:

  • 60{d0e74b8a3596e4326b45924d39792f257a1f9983beed4201831d386befd3d18e} decrease in behavioral incidents
  • 57{d0e74b8a3596e4326b45924d39792f257a1f9983beed4201831d386befd3d18e} decrease in pressure sores
  • 48{d0e74b8a3596e4326b45924d39792f257a1f9983beed4201831d386befd3d18e} decrease in staff absenteeism
  • 25{d0e74b8a3596e4326b45924d39792f257a1f9983beed4201831d386befd3d18e} decrease in bedfast residents, and
  • 18{d0e74b8a3596e4326b45924d39792f257a1f9983beed4201831d386befd3d18e} decrease in the use of restraints.

And another comparative study by Elmhurst Extended Care in Rhode Island showed that:

  • Staff turnover decreased from 46{d0e74b8a3596e4326b45924d39792f257a1f9983beed4201831d386befd3d18e} to 4{d0e74b8a3596e4326b45924d39792f257a1f9983beed4201831d386befd3d18e}
  • Agency nursing hours were reduced to 0
  • Overtime decreased by more than 50{d0e74b8a3596e4326b45924d39792f257a1f9983beed4201831d386befd3d18e}
  • Employee injuries were reduced by 63{d0e74b8a3596e4326b45924d39792f257a1f9983beed4201831d386befd3d18e}, and
  • Fundraising increased by more than 50{d0e74b8a3596e4326b45924d39792f257a1f9983beed4201831d386befd3d18e}.

The Eden Alternative is now an international nonprofit that trains others in its philosophy. There are currently 30,000 Certified Eden Associates and Certified Eden at Home Associates worldwide — all organizations professing to transform traditional models of care into person-directed approaches — searchable in the Eden Registry.

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