Mary Conaghan, an 83-year-old nursing home resident, is petting Josie the cat and visiting with family in her room. She is showing her daughter the new blooms on her parsley plants while her great grandchildren are playing in the children 's activity room across the hall. The family is planning a picnic in the garden of the nursing home for that afternoon.
Sixth graders Bonnie, Aaron, Jimmy, and Claire finish school for the day and rush to the after-school program at the nursing home where their parents work. They are happily anticipating their assigned chore of cleaning the birdcages and helping to feed the parakeets.
Are these typical scenes in nursing homes? No? Why aren't they? Why aren't nursing homes places where family members of all ages would eagerly anticipate spending the day? Why aren't nursing homes places where families and community groups are anxious to visit and participate in activities? Why aren't nursing homes places where employees are happy to come to work because they feel valued and because they are pleasant places to work?
ANIMALS IN NURSING HOMES
The current reality is that frail older adults who live in nursing homes spend a good deal of their time alone, unable to care for themselves or their environments. They enjoy few stimulating activities. Even well cared for nursing home residents may be afflicted by loneliness, helplessness, and boredom. Nursing home residents are viewed by others as having a poor quality of life. They fulfill the stereotype of being depressed, in depressing surroundings. Caregivers in nursing homes are viewed the same way. They are seen as having low status among health care workers, low salaries, and high turnover rates (Cohen-Mansfield, 1997; Kettlitz, Zbib,&Motwani, 1998).
Nursing home residents suffer from loneliness, helplessness, and boredom more than from medical problems (Thomas, 1996). Most nursing homes operate from a medical model, yet most frail older adults do not enter nursing homes for medical care. The medical model focuses on treatment of physiological problems using medical interventions, failing to attend to psychological factors such as loneliness, helplessness, or boredom.
Dr. William Thomas, who proposed the Eden Alternative™, believes life can be fulfilling at any age. He says that nursing homes are primarily homes, not hospitals, and suggests nursing homes commit to a human habitat model. In this model, the residents' lives in nursing homes revolve around a decentralized team method of care delivery, resident animals, daily children's activities, and numerous plants.
PLANTS AND GARDENS IN NURSING HOMES
Frail older adults in nursing homes that have incorporated the Eden Alternative will likely have an improved quality of life and physical health (Thomas, 1996). Viewed as a good and innovative idea, this article will describe the elements, risks and benefits of the Eden Alternative model.
ELEMENTS OF THE EDEN ALTERNATIVE
Thomas (1996) conceived the Eden Alternative when he noted the isolation and inactivity of nursing home residents. He looked to nature for an "alternative" to the sterile environment in which many nursing home residents live. Thomas suggested creating a "human habitat," a home where the milieu is diverse, spontaneous, and natural. He saw residents having the opportunity to participate in caring for themselves, other residents, and their surroundings in an enhanced environment.
Elements of the enhanced environment included decentralization of management structure and team care delivery to empower the staff and place decision-making authority as close to the resident as possible. The introduction of many and varied plants, daily children's activities, and resident animals comprise the other components. These individual elements are not new in nursing homes, whereas the comprehensive approach is.
The Eden Alternative is based on the belief that caregivers in nursing homes will treat residents the way the caregivers themselves are treated. If caregivers feel nurtured and cared for, they will nurture and be caring toward the residents. If caregivers feel valued, they will value the residents. Toward those ends, decisionmaking in the Eden Alternative model is moved to the residents and to the employees closest to the residents - the nursing assistants. The traditional top-down bureaucracy in health care facilities is transformed to a team model, where staff members are empowered to accept responsibility for managing themselves and their assignments. Staff from the various departments form teams who cooperate in making decisions about everything in the work environment, resolve conflicts and share duties and responsibilities. Staff make their own schedules and their own assignments. Members of the team handle families, staffing problems, and all aspects of their units. Members of the various teams are identified by nametags.
Committees plan care for the elements of the environment, animals, plants, children, publicity, evaluation, and any other component the facility needs. All employees (e.g., administrators, nurses, housekeepers, maintenance, dietary workers) are included on these committees. Employees choose the committee group they wish to join according to their personal interests and abilities. Employees work with the part of the environment that most interests them. Higher level managers act as advisors on these committees, using their talents to develop leaders among the members of the groups.
The Eden Alternative is based on a naturalist perspective, incorporating a number of species in the environment. The philosophy is "biological diversity is as good for human habitats as it is for natural habitats" (Thomas, 1994, pp. 31-33). Therefore, the greater the number of species a habitat supports, the healthier the environment. Animal companions transform the lonely nursing home environment into a diverse, vibrant place to live. Dogs, cats, rabbits, birds, hamsters, and other species populate the facilities (Table 1). Selecting the animal companions is a group endeavor by the animal committees. These animals must be healthy, have appropriate temperaments, and fit in with the culture of the facility.
Caged birds are offered to each resident to be kept in resident rooms. Birds are inexpensive to purchase and keep, and require little space. They do need to be examined and quarantined before being placed on the units for health reasons. Residents enjoy the responsibility of ownership for this part of the animal populace. There are stories of residents who return to the nursing homes in record time after being hospitalized because they are worried about their birds. A 99-year-old blind resident described to the authors how delighted she was with the birds' movements and vocalizations. She commented she is never alone because she has the birds.
The benefits of animal companionship in long term care, with dogs and cats particularly, are well known. Animals have been shown to decrease stress, improve mood, increase communication skills and sociability, and decrease loneliness and depression. For caregivers, resident companion animals provide diversion and entertainment (Barba, 1995). The authors observed a cat, Dixie, who seemed to know where she was needed most. She stayed in the bed to be stroked by a resident with dementia for the last few days of the residents' life. One 94year-old woman was thrilled that a cat named Oscar "chose me to sleep with!" She said, "Do you know how long it has been since Tve had a warm body in the bed with me?"
Plants and Gardens
Large numbers and varieties of plants and gardens change the sterile environment into a softer, more pleasant and natural place (Table 2). Indoor plants improve air quality, increase humidity, and decrease the number of bacteria in the air (Thomas, 1996), The pleasant fragrances of some plants make a room more inviting and decrease unpleasant odors. Outdoor gardens supply vegetables, herbs, and materials for crafts. These gardens need to be accessible to wheelchairs and inviting and safe for wandering residents. Toxic plant materials should be avoided in deference to the animals and confused older adults who might ingest them. Lists of harmful species can be obtained from extension agents or poison control offices.
Residents are given the opportunity to provide care by starting seedlings or cuttings, nurturing plant growth, and planning productive decorative and vegetative gardens. Key elements to the introduction and maintenance of plants are to start small, indoors, and close to the residents. An activity director explained to the authors the process of initiating the plantings by spreading plastic covers on tables, dumping piles of potting soil out, and letting residents and staff "have at" the seeds and cuttings. The infection control nurse tried to convince residents to wear gloves, but residents refused, with one exclaiming, "It's been so long since IVe had my hands in dirt. I'm enjoying the feeling." Smiling and laughing together, residents and staff members with dirty hands and faces created tiny oases of life in little pots.
In the Eden model, children become fully integrated into the activities of the home, so residents and children come to know each other well (Table 3). Children visit, read, and play games with specific residents OD a regular basis. Small play areas on the grounds are a wonderful way for residents to watch children and make the facility less strange for the children. On-site childcare provides assistance for staff and allows residents to become familiar with their caregivers as parents. After-school activities and vacation daycare are other ideas for including children in the nursing home environment, while also helping integrate the home into the surrounding community.
Young volunteers help care for the elements of the environment such as feeding the birds, walking and training the dogs, and weeding gardens. If space allows, organized children's groups can meet at the nursing home. After watching a bus arrive with children in the after-school program, one nursing home administrator stated, "It's not often that you see 97 people making a mad dash into a nursing home" (Brack, 1997, p. 32).
Residents might help children with their schoolwork and with developing interests and hobbies. Residents have a wealth of knowledge waiting to be tapped by eager learners. When the nursing home facility cannot accommodate additional space for children's activities, some residents may be able to go to the local schools to contribute rime and offer individual attention to specific children who need it. However it is accomplished, the key to integrating children into the environment is the formation of ongoing relationships.
It is possible for nursing homes to meet community needs by welcoming community group meetings at the facility and inviting residents to participate as group members. The experience and expertise of the residents can enrich garden clubs, veterans' groups, political groups, and others. People of all ages can become an integral part of the nursing home environment, while the nursing facility becomes an integral part of the surrounding community.
Risk is a part of life that cannot be totally eliminated. These new risks must be understood, analyzed, and minimized (Thomas, 1996, p. 163).
There are risks to staff and residents involved with the elements of the Eden Alternative Model. Nursing home staff understand risks and ways to minimize them because the basic elements of the model are not new. The most common problems to be considered are allergies, injuries, and illnesses.
Allergies to animals and plants can occur, but seem to be rare. It has long been recognized that older adults do not respond to foreign antigens with the vigorous antibody production observed in younger individuals (Hampton, Craven, & Heitkemper, 1997). The risk of allergic reactions also depends on the amount of allergen present in the environment. In nursing homes, allergens are spread over a large area, the facility is cleaned often and the air filtering system tends to be efficient, so allergies are less of a problem. The rare allergy has been seen in nursing home staff members, but, in most institutions, allergies to latex probably pose a bigger problem than to animals and plants. If a problem arises, teamwork and cooperation can alter the environment to minimize the risk for the affected individual (Ransom, 1998).
Careful planning can minimize injuries to residents from the elements of the environment. Many fear the residents might trip over small animals or plant containers. Careful planning for placement of containers and bells on animal collars to indicate their whereabouts can decrease the risk of falling. Injuries from children's activities, such as toys left on the floor and running games, can be minimized by educating the children to be aware of the sensory and mobility changes of aging and the behaviors expected of them when interacting with residents in facilities.
The risk of illness in nursing homes is great, even without the introduction of plants, animals, and children. Employees have programs to minimize the risks of spreading infections from them to the residents. The same types of programs need to be in place for the visiting children. They should learn about the benefits of hand washing for other than the usual reasons.
Illness spread from plants can be controlled by careful choices of plants. Zoonotic illnesses, those spread from animals to humans, are numerous but rarely occur. Dogs and cats need to be free of parasites and have current immunizations. Birds need to be cleared by veterinarians and quarantined for a time before living in resident rooms. Aviaries are the best way to keep the bird population healthy and the risk low for spread of diseases.
Each committee is responsible for their particular environment. For example, immunization of animals is the responsibility of the animal committees of the agency using the Eden model. Donations may be sought to cover costs of animal care.
The risk of legal liability is a part of living in the United States. The best prevention against lawsuits is to communicate clearly and often, and to conduct oneself in a professional, caring, and thoughtful manner. Future research may show that the benefits of altering an environment that engenders alternatives to loneliness, helplessness, and boredom outweigh the possibility of litigation.
Residents, staff, families, and the community have noted benefits and rewards from transformation of nursing home environments to a human habitat model. Thomas' project (1996), research conducted in Texas (Ransom, 1998), and preliminary findings in North Carolina (Barba, Tesh, & Courts, 2002) suggest there are decreases in resident monthly prescriptions, psychotropic drug use, infections, pressure sores, behavioral incidents, and deaths; decreases in loneliness and depression; and increases in sociability and communication abilities of residents. Active involvement with children, plants, and animals helps residents feel and be useful. Spending time helping a child read or with children in daycare allows older adults to see they have much to contribute.
Effects of this nurturing environment have been documented for certified nursing assistants (CNAs). These are the health care workers who are most directly involved with the minute-to-minute care of the residents. Yet, in the traditional model, they are at the bottom of the chain of command. The CNAs are the most familiar faces to the residents, who depend on them to care for the their most personal needs. The CNAs generally know more about the residents* needs than the managers. However, traditionally they are not part of the decisionmaking related to resident care.
Empowering CNAs to make decisions and take responsibility for their work environment improved self-esteem and job satisfaction, thereby decreasing turnover rates and absenteeism (Anderson, Aird, & Haslam, 1991; Gaddy & Bechtel, 1995; Helmer, Oison, & Heim, 1993; Yeats & Seward, 2000). This is a tremendous direct savings to nursing homes, because orienting new employees is a costly budget item. Also, nursing assistants who feel valued and nurtured can be expected to treat residents in the same manner.
The CNAs are not the only employees who benefit from the environmental changes. All employees are offered an opportunity to display their talents on committees and to exercise leadership skills. Employees may be offered classes to help them handle money more efficiently. Additional classes provide formal educational opportunities from basic reading to studying for high school equivalency examinations, or provide preparation for advanced programs in health care careers. Employees conduct self-scheduling based on the belief that competent adults should have some control over their schedules. One of the goals of the Eden Alternative is to provide an environment that is nurturing to everyone populating it.
Placing a loved one in a nursing home can cause distress, concern about resident care, worry about inadequate staff and staff attitudes (Brody, Dempsey, & Pruchno, 1990), and guilt from feelings of having abandoned their loved ones (Matthiesen, 1989). Families might feel more comfortable and welcome in the congenial atmosphere of an Eden Alternative facility. Elements of the Eden Alternative establish a middle ground where families, residents, and staff can interact.
One administrator told the authors about Boots and the canary. A beautiful canary was put in a place of honor in the living room of the nursing home. One of the resident cats, Boots, decided this was not to be. He worked at knocking the birdcage from its hanger for weeks, finally swatting hard enough to topple the cage and allow the canary to escape. While Boots ran for cover from the tumbling cage, plants were knocked from the nearby shelf, the canary flew off in a panic, and the dogs chased the bird up the hall. The anticipation of the incident and its inevitable excitement were great topics of discussion in the nursing home community for weeks. Residents were anxious to report to visitors and laugh amongst themselves. Variety and spontaneity provided an experience residents, families, and staff could all share.
Thomas (1996) reports more frequent and longer visits from family members, which include decidedly more children. This probably indicates an improved attitude about spending time in this enriched environment where there is spontaneity and variety. On Sundays, the parking lots of Eden Alternative facilities are full. There are also reports of increased volunteerism, with waiting lists of individuals wanting to participate in the enriched milieu.
Effects of the Eden Alternative on residents can be conceptualized within the "Theory of Thriving" proposed by Haight, Barba, Tesn, and Courts (2002) on pages 14 to 22 in this special issue. Based on this model, frail older adults living in human habitats would live life to the fullest, growing and developing because of positive interactions with their human and nonhuman environment. They are provided companionship, diversity, variety, spontaneity, and mutual interactions with their environment.
Elements of the human environment in an Eden Alternative nursing home (e.g., caregivers, family and friends, children, other residents) encourage the development of social connectedness and attachments that give meaning to the residents' lives. The nonhuman environment (e.g., physical facilities, plants, animals, decentralized care delivery system) facilitates adaptation to changing physical patterns and positive affective and cognitive function. The Thriving Theory proposes that consequences of the human habitat would be physical, social, and psychological resilience.
IMPEDIMENTS TO EDENIZING
Nursing homes that attempt to make environmental changes meet many impediments. Change is difficult, even in the best of circumstances, which is why the Eden Alternative process is recommended for facilities with minimal problems and only with the full support of administration. An initial period of education should include residents, employees, and families. Change can be facilitated by following the Eden Alternative suggested process, including sending key people to Eden Associate training sessions, coordinating efforts with the Eden Alternative regional coordinator, and starting on the road to Eden certification of the facility. The Eden Alternative Web site provides information to help facilities start the program and may answer some questions (www.edenalt.com).
Providing opportunities for all opinions and comments to be heard is the best way to handle negative attitudes about the process. Field trips to other facilities that are successfully implementing similar changes often ease fears and correct misunderstandings. Housekeepers may not believe that this process does not require extra cleaning time until they talk with housekeepers in an Eden mode! facility. Mistaken images of hoards of dogs and cats wandering the halls can be corrected by experiencing the environment personally.
The total transformation of the Eden model requires a complete attitudinal shift of everyone involved. Preliminary work takes more than a year at an estimated cost of $15, 000 (Hamilton & Tesh, 2002).
Administrators who are not committed to the Eden Alternative; who are dealing with other major problems within the facility, such as financial or staffing problems; or who are not secure and open to innovation, make implementation of any environmental change in a nursing home impossible. The facility must be fairly well staffed, in decent financial condition, and free of significant deficiencies to consider serious changes. Administrators need to feel safe altering the organizational structure to a committee and team model, rather than the traditional hierarchical model. They must provide mentoring for budding committee chairs and team leaders to develop leadership qualities throughout the process.
There are logistical problems, such as placement of dog crates, bird cages, and fish tanks. Federal and state sanitary and fire regulations are of primary importance, and facilities can feel mired in overregulation and underreimbursement. Unless the staff is creative and enthusiastic, regulations and codes can provide serious impediments. Rather than a reactive approach, adopting a proactive approach can be the most effective with regulators.
Giggles of children, chirping of birds, purring of cats, and wagging of dogs' tails can go a long way toward convincing regulators of the efficacy of environmental change. With persistence, resistance becomes tolerance and tolerance becomes acceptance. The vision will become reality. Empirical evidence of success would help, too.
A transformation of nursing home environments in the United States is long overdue. The combination of decentralized teams, resident animals, plants, and daily children's activities is the best idea the authors have seen to date. Beneficial outcomes for residents, staff, and facility environments have been impressive, but not too well documented. Further research is necessary to support the outcomes seen so far. Research needs to involve the residents, staff, and family caregivers directly.
Education of nurses and other health professionals who work with frail nursing home residents on the Eden Alternative is key to the transformation. The Theory of Thriving (Haight, Barba, Tesh, & Courts, 2002) provides a framework for research and application of the Eden Alternative. After all, the primary goal of nursing home care is to improve the quality of life for the frail older adults who live there.
The effect of the transformation may be best summarized by Florence, a cognitively intact, highly functional nursing home resident. Florence lived in an efficient traditional facility. Shortly after the home began the Eden Alternative process, she was holding a sleeping baby in her lap and petting a dog reclining near her chair. Standing nearby, the lead author (B.E.B.) overheard the resident say to herself, "Lord, I feel like a human being again."
Health care providers must provide a resonant, vigorous habitat where residents live and grow, feel useful and needed, and thrive, not a sterile, rigid place where they go to wait to die or fail to thrive. With vision and persistence, the changes will happen, one facility at a time.
The names used in this article are fictitious.
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ANIMALS IN NURSING HOMES
PLANTS AND GARDENS IN NURSING HOMES