The Eden Alternative: Re-Imagining The Nursing Home

Richard E. Gamache, Vice President/Administrator at Elmhurst Extended Care in Providence, Rhode Island, and certified Eden Alternative educator, spoke at the December Community Resource Center Information Session. He spoke about a revolutionary and inspiring long-term care model, the Eden Alternative, that seeks to dramatically change the experience of life in a nursing home for all involved.

The phrase the “Eden Alternative” was coined in 1991 by William Thomas, MD. He credits the genesis of this model to an experience he had as a nursing home physician. Shortly after taking a job at the local nursing home, Dr. Thomas was making his rounds one day. He went to see a woman who had a rash on her arm. In his best doctor voice, he leaned down and screamed in her ear, "Hello, I'm Dr. Thomas, what can I do for you today?" He will never forget the beautiful blue eyes that stared up at him as she reached up to draw him closer. And he will never forget the words she whispered, "Doctor, I am so lonely." Those words haunted him for weeks as he searched his medical texts and found nothing. And so he began to think about a different kind of world. He began to think about a true human habitat - a place where humans could live, not just wait to die.

Dr. Thomas identifies three main deadening forces at work in a typical traditional nursing home, the three “plagues”: loneliness, helplessness and boredom. These are plagues of the human spirit, not the human body, but they can be just as debilitating and just as deadly as any disease of the body. Some common resident behaviors viewed in this light suddenly are understandable; behaviors such as slumping, excessive sleeping, repeated calling out, disengaging and profound sadness. The Eden alternative seeks to counter these symptoms at the source, by providing meaningful engagement and human connection for residents and staff alike, illustrated by the saying “Everyone needs a minimum daily allowance of meaning.” Another key belief that impacts care delivery is that everyone, regardless of medical or mental status has the ability to grow and teach. For example, even those with very significant needs can teach caregivers the importance of being gentle and having patience.

The most visible and simple changes one might see in a conversion to the Eden Alternative principles, are the presence of plants, animals and children in the facility. Elders are encouraged and enabled to care for plants and animals and to form meaningful relationships with children. Some facilities provide on-site childcare with ongoing interaction between the children and elders. Others, like Elmhurst, with space constraints have to be more creative. Elmhurst has an agreement with local schools to have ongoing visits to the facility from a consistent group of children to allow the formation of relationships over time.

These changes alone, however, would be simply cosmetic. The Eden alternative encourages a deeper culture change. One key component of this culture change is shifting decision-making power to the elders and those closest to them. Elders and resident-councils in facilities are empowered to make key choices about daily life. When an individual elder cannot make decisions on his/her own, line staff the closest to the individual are empowered to do so. Another key component is in changing the assembly-line/medical model/staff convenience priority of providing care and instead placing the focus on allowing the elder autonomy and a responsive environment. So for instance, instead of waking all residents at the same time and providing morning medications, breakfast and morning care on the same schedule, elders determine their morning routine. Instead of rotating staff every few weeks, staff are given permanent assignments to encourage the development of stable and deeper personal relationships between residents and caregivers.

Another aspect of this pervasive culture change is in adopting the management credo that ‘the way managers treat staff, so shall staff treat elders’. Respect, empowerment and sincere caring between management and staff will encourage the same positive changes in the parallel relationship between staff and residents.

Some further examples include the way that Elmhurst recognizes the need of residents, families and staff to grieve after a resident dies. Often in the typical traditional facility there is little attention to these issues. The resident is gone, the family picks up their belongings, and then the bed is filled again. Rick Gamache told of receiving his mother’s belongings in a trash bag and the message of lack of respect and dignity this conveyed to the family. At Elmhurst they hold remembrance services, they put together photos and scrapbooks of those they’ve lost, and find other ways to acknowledge the presence of the resident and the impact she or he had on the other members of the community. Oh, and they have a special bag for the elders belongings, so families don’t have to receive them in a trash bag.

Other examples of what is different in an Eden facility include attention to the learning and career growth needs of staff. Elmhurst has instituted a career ladder for CNAs and a gerontology nursing course and management course for nursing staff. Staff and elders now eat together instead of separately. And an open buffet is open expanded hours so those that want a snack can have choices beyond a packet of crackers. They’ve opened a real pub, that actually serves alcohol. Elders still are adults who may chose to have a drink with friends rather than having that choice removed for institutional convenience.

Studies show that implementation of The Eden Alternative is a powerful tool for improving quality of life and quality of care for those living in nursing homes. Also, in homes that have adopted Eden as an organizational-wide philosophy, there is often improved staff satisfaction and retention and significant decreases in the overuse of medications and restraints. Most importantly, Elders, supported by their caregivers, can once again direct their own daily lives.

Elmhurst, as other facilities, is finding impressive hoped-for results from their efforts. Their discharge rate to hospitals dropped by 38% and their patient death-rate declined by 40%. Depression levels fell significantly. Resident performance on mini-mental status exams also improved. Their use of restraints is now 0, while maintaining a percentage of falls that is about equal to the state average. Staff satisfaction improved as well. Staff injuries declined by 63%, and turnover, a huge problem in the industry, declined by 20%.

Current Eden facilities in Massachusetts include The Bostonian in Dorchester, St. Joseph’s in Brockton, Briarwood in Needham and Heritage Woods in Agawam.

The Eden Alternative 10 Principles

  1. The three plagues of loneliness, helplessness and boredom account for the bulk of suffering among our Elders.
  2. An Elder-centered community commits to creating a Human Habitat where life revolves around close and continuing contact with plants, animals and children. It is these relationships that provide the young and old alike with a pathway to a life worth living.
  3. Loving companionship is the antidote to loneliness. Elders deserve easy access to human and animal companionship.
  4. An Elder-centered community creates opportunity to give as well as receive care. This is the antidote to helplessness.
  5. An Elder-centered community imbues daily life with variety and spontaneity by creating an environment in which unexpected and unpredictable interactions and happenings can take place. This is the antidote to boredom.
  6. Meaningless activity corrodes the human spirit. The opportunity to do things that we find meaningful is essential to human health.
  7. Medical treatment should be the servant of genuine human caring, never its master.
  8. An Elder-centered community honors its Elders by de-emphasizing top-down bureaucratic authority, seeking instead to place the maximum possible decision-making authority into the hands of the Elders or into the hands of those closest to them.
  9. Creating an Elder-centered community is a never-ending process. Human growth must never be separated from human life.
  10. Wise leadership is the lifeblood of any struggle against the three plagues. For it, there can be no substitute.

For more information:


-Thanks to Rick Gamache for his presentation and help with this article. Parts of this article are excerpted from the above two websites.

12/07