The Eden Alternative™, created by Harvard-educated physician Dr. William Thomas, is a model for transforming skilled care facilities from institutions based on a medical model of care into human habitats that promote human growth. This change is accomplished through decentralizing the organizational structure of the facility to empower residents and front-line care-delivery staff, and through introduction of plants, animals, gardening, and children into the daily lives of residents (Thomas, 1996; 1998).
The Eden Alternative is the most comprehensive model existing for environmental transformation of skilled care facilities. Implemented as intended, it addresses the physical, psychosocial, administrative, and spiritual aspects of the facility; the quality of Ufe of both residents and employees; and the relationship of the facility to the surrounding community. The resultant environmental transformation dramatically changes both the physical environment and the cultural environment of the facility.
In 1998, Eden Alternative became a trademarked name, and only facilities recognized by the Eden Alternative registry are allowed to use the name. However, any facility may adopt the philosophies embodied by the Eden Alternative, and implement the principles for transforming their facility (Thomas, 1998; The Eden Alternative, 1999). Skilled care facilities and other long-term care institutions in North Carolina have shown a strong interest in environmental enhancement and the concepts of the Eden Alternative. In the year 2000, almost a third of skilled care facilities in North Carolina reported implementation of some form of environmental enhancement.
FUNCTIONS OF THE NORTH CAROLINA EDEN COALITION
North Carolina's goal is to improve quality of life in the people residing in the state's 367 skilled care facilities, 529 adult-care homes, and other institutional settings. In North Carolina, the Division of Facility Services (DFS) holds the contract with the Health Care Financing Administration (HCFA) to oversee regulation of the state's skilled care facilities. The North Carolina Eden Alternative Initiative was started with DFS's formation of the North Carolina Eden Alternative Coalition in the Fall of 1996. This was the first organization of its kind in the country. The success of the Coalition has led it to become a model for implementation in other states.
Currently, North Carolina has approximately 82 skilled care facilities implementing environmental transformations or enhancements, and leads the country in the number of registered Eden Alternative facilities (The Eden Alternative, 1999). One of those facilities, Broughton Hospital/Twin Oaks Nursing Facility, is the first psychiatric hospitalbased facility to embrace the Eden philosophies and has become a national role model. Two other North Carolina facilities, Silver Bluff and Whispering Pines Nursing Home, have been featured in the NBC nightly news (Prince, 1998). Other types of long-term care facilities in North Carolina have also shown interest in environmental enhancement.
The Coalition functions as a consumer-driven advisory and educational body rather than a formal regulatory standard body, and endorses implementation of the principles and philosophies embodied in the Eden Alternative. The mission statement and goals of the Coalition are shown in the Sidebar. The Coalition has proved to be a successful, cooperative effort among regulators, providers, advocates, and other experts to implement cultural and environmental transformation, including the philosophies of the Eden Alternative, without regulatory basis.
Because the Coalition was formed under the auspices of DFS and operates with its ongoing cooperation, it is in an excellent position to clarify and influence policies and regulatory issues concerning transformation of long-term care environments in North Carolina. For example, regulations followed by the state's sanitarians prohibit the animals in common dining areas. Many people were concerned that this would essentially ban animals in skilled care facilities, because residents eat in many areas throughout a facility.
The Coalition was able to work with the North Carolina Department of Environment and Natural Resources to clarify that "common dining areas" do not include residents' rooms, hallways, or activity rooms, even if residents eat in these areas. The Coalition was also able to define procedures under which preparation of food in crockpots and bread machines at nursing stations or nutrition stations was permissible. It was clarified that large potted plants were considered "furniture" and so could sit directly on the floor, without violating state safety regulations.
Recommendations have also been outlined for facilities building "kennel rooms," including handwashing sinks, floor drains and doors directly to the outside. Conversely, instances have been clarified when agencies were found deficient for reasons independent of their environmental transformations, despite the agencies' belief they were "cited for adopting Eden."
The Coalition's activities have been numerous. Through individual and group efforts of its members, the Coalition has served as a referral and educational resource for facilities and professional organizations, competed for awards, and served the public and other state agencies by researching and clarifying laws and regulations pertinent to longterm care facility transformation. Coalition members have conducted workshops for professional organizations, colleges and universities, and DFS staff have provided seminars on the philosophy of cultural and environmental transformation embodied in the Eden Alternative to staff, residents, and families at care facilities statewide. To disseminate information, the Coalition publishes a quarterly newsletter, and maintains a Web site (http://www.ncedencoalition.org).
Figure 1. The Eden Coalition meets.
One of the earliest activities sponsored by the Coalition was a 2day educational conference, "It's Not Just Fur and Feathers," held in the Fall of 1997. The conference was coordinated and staffed by DFS personnel. A minimal registration fee was charged to offset the costs incurred.
Figure 2. Nadine Hamilton, North Carolina Division of Facility Services, meets with Coalition President Alice L. Carroll
The 450 participants represented more than 100 nursing and adult care homes, assisted living facilities, hospitals, mental health agencies, government agencies, academia personnel, and the general public. The conference was successful at disseminating information on environmental transformation, and the philosophy and principles of the Eden Alternative, with the state agency receiving nothing but positive response from the participants.
That same year, the Coalition, in conjunction with DFS, took the bold step of developing a grant program to encourage the use of environmental transformation and the Eden Alternative principles by developing demonstration projects in Medicaid-certified nursing homes across the state. Federal funds supplied the entire budget for the grant program. These public funds constitute a collection of federal fines from skilled care facilities that are out of compliance with federal regulations. The HCFA gave approval for the use of these funds for the grant program, and DFS coordinated administration and provides oversight of the grants.
During this first round of grants, 13 of the 33 skilled care facilities that applied were awarded $15,000 each. Grant recipients are expected to demonstrate to the rest of the state how quality of care can be improved through empowerment of staff and the introduction of animals, plants, and children to the long-term care setting. The costs of implementing these principles might have deterred some facilities from embarking on environmental transformation. The grant monies have enabled these facilities to implement the process, evidenced by the submission of quarterly reports.
To better serve as role models for other facilities in the state, the facilities awarded grants are also participating in an ongoing outcome evaluation study conducted by one of the authors (A.T.) at the University of North Carolina at Greensboro. A second round of competitive grants was awarded to another seven facilities in January 2001.
The Coalition has aided in the education of several state regulatory agencies, such as the Department of Environment and Natural Resources, the Group Care Licensure Section of DFS, and the Division of Medical Assistance on environmental transformation and the principles and philosophies embodied in the Eden Alternative. In addition, all newly employed skilled care surveyors or inspectors are introduced to the concepts during their classroom orientation period. This ensures that facilities implementing environmental transformations are not impeded by misunderstandings or misperceptions on the part of surveyors.
Figure 3. A subcommittee of the Eden Coalition. (From left: Patsy Rudolph, Barbara Hearne, and Nancy Easterling.
This strategy has been very effective. Some members of state agencies and surveyors had initial misconceptions or misgivings about environmental transformation, but after education, they have been able to work with homes in cooperative problem-solving rather than obstructing change.
Figure 4. The North Carolina Eden Coalition. (From left: Cathy G. Frye, Leslie Jarema, Yvette Porterfield, Patsy Rudolph, Anita S. Tesh, Alice L. Carrol, Nadine Hamilton, Nancy Easterling, Barbara Heame, and Dianne Holcombe.)
Two state agency members of the Coalition are currently involved in a work group to draft proposed revisions to the regulations used by the Division of Environmental Health sanitarians in the state. The current sanitation regulations ban all animals from common dining areas and prohibit animals in food preparation areas. With the advent of the Eden Alternative and other environmental transformations, there is a need to address the established rules with respect to making skilled care facilities more homelike, while also ensuring resident well-being.
HISTORY AND STRUCTURE OF THE NORTH CAROLINA EDEN COALITION
In 1993, Emily Swearingen, then Licensure Branch Manager at DFS, began reading about a new idea that seemed to hold promise for improving life in North Carolina's skilled care facilities. Steve White, Section Chief for North Carolina Division of Facility Services Licensure and Certification, heard Dr. Thomas speak at a conference in 1996. The Eden Alternative philosophies inspired White and Swearingen to transform North Carolina's skilled care facilities into human habitats. Thus, the idea for the North Carolina Eden Alternative Coalition was born. The group's name was subsequently changed to the North Carolina Eden Coalition, to clarify that the Coalition supports all positive change in care facilities, not just the trademarked Eden Alternative.
The Coalition recognizes not all facilities will choose to implement all aspects of the Eden Alternative or to apply for the Eden Alternative registry, and so it supports use of the philosophies and principles embodied in the Eden Alternative rather than the trademarked name. The Coalition is composed of volunteers representing provider facilities, provider associations, several government agencies involved with older adults or with children, advocates, and other related Eden organizations. The Coalition members also represent areas such as plant horticulture, child day care, sanitation, and the state's veterinary school.
With the support of DFS, the Coalition began on October 6, 1996 with Miriam Stermer, administrator of Asbury Care Center (The Methodist Home), as chairman. Miriam served in this capacity for just more than 2 years. Carolyn Hill, administrator of Nash Grove Manor, was elected to succeed her. The Coalition started with 12 members. The structure of the Coalition has formalized as the organization has evolved. Membership was offered to the 93 North Carolina certified Eden Alternative Associates in the Spring of 1999. Fourteen committed to serve on the Coalition. The current membership is comprised of 34 members, with an elected president who serves a 2-year term.
Meetings are held monthly on the campus of the DFS main office. The lead author (N-H.) is a nurse consultant with the Nursing Home Branch of DFS. She provides secretarial support, meeting rooms, and membership mailings. She is a certified Eden Associate and a member of the Coalition. For information about the Coalition activities or Eden regulatory issues, the author can be contacted at (919) 733-7461 or firstname.lastname@example.org.
North Carolina has been recognized nationally for the Coalition's achievements. The state received the 1998 Best Practice Award for Quality Improvement from the Association of Health Facility Survey Agencies (Cindy DePorter, MSW, personal communication, February 11, 2002). In addition, it was recognized as one of the better entries in the 1999 American Public Health Association's Archstone Foundation Award and encouraged to reapply for the award (Gerald Eggert, personal communication, June, 1999).
An entry was also submitted in the 1999 Innovations in American Government award program. In addition, Broughton Hospital/Twin Oaks Nursing Facility received the 1998 North Carolina Governor's Award for excellence for pioneering the Eden Alternative in a psychiatric setting (Governor Jim Hunt, personal communication, October, 1998).
The Coalition plans to continue its focus on education. To date, Coalition activities have been funded by donations, volunteer labor, and support (e.g., for printing and meeting space) from DFS. The Coalition is currently pursuing designation as a nonprofit institution for it to be eligible for grant funds to expand its activities. With the use of additional federal penalty monies, more grants to facilities may be awarded in the future.
It is North Carolina's goal that environmental transformation and the Eden Alternative concepts improve quality of life by providing human habitats in major institutional settings. Also, these concepts will provide opportunities for public-private partnerships, community involvement, strengthening of family ties, and opportunities for several government agencies to work together in a cooperative and creative venture. For these reasons, the state has supported the Coalition and is enthusiastic about long-term care facilities implementing environmental transformation and the philosophies and principles of the Eden Alternative.
IMPLICATIONS FOR NURSING
Nurses have played key roles the Coalition. Many of the representatives of both state agencies and long term care facilities are nurses. The project evaluator is a nurse. And nurses have been essential to the movement of environmental transformation in North Carolina.
The success of the Coalition demonstrates the advantages to the nursing profession of collaborating with other disciplines to work toward a common goal - the improvement in quality of life in long-term care facilities. Despite having only modest funding, the Coalition has had a major impact on skilled care facilities statewide. No individual working alone could accomplish this, and it would be difficult for a discipline working alone.
Nurses in other states, and those who wish to address other goals, should carefully consider the advantages to be gained by strategic multidisciplinary alliances. Collaboration is one of the things nurses do best, and in collaboration there is strength.
- Eden Alternative, The [On-Line]. (2002, February 6). Available: http://www.edenalt.com.
- Prince, G. (Executive Producer). (1998, August 2). NB C nightly news. New York, NY: National Broadcasting Company.
- Thomas, W.H. (1996). Life worth living: How someone you love can still enjoy life in a nursing home: The Eden Alternative in action. Acton, Mass: Vanderwyk fit Burnham.
- Thomas, W.H. (1998). Open hearts, open minds: The journey of a lifetime. New York: Summer Hill.