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In Search of Eden: Deinstitutionalizing Long-Term Living Environments

By: Sandy Ransom, RN, MSHP

The practice of providing long-term care for individuals with traumatic brain injury and other cognitive impairments is undergoing a significant change. The institutional model predominant in most nursing homes, assisted living facilities, psychiatric, and long-term living programs is being challenged by a holistic philosophy of care that views these environments as habitats for human beings rather than facilities for the frail or disabled. At the forefront of this Culture Change movement is Eden Alternative®, which emphasizes person-directed supports and individual autonomy to the greatest extent possible, personal relationships and connectedness between individuals, the inclusion of naturalistic elements such as plants, animals and children in the living environment, and collaborative organizational decision-making and responsibility (Fox 2007). Seeking to create a more humanistic paradigm, Eden Alternative offers a tangible set of values and practices to help organizations move away from the medical/treatment system of supports towards a more sustainable model of healthy long-term living.

The Eden Alternative is the brainchild of Dr. William Thomas, a Harvard educated geriatrician, who realized that the bulk of suffering in nursing homes occurred as a result of loneliness, helplessness, and boredom—social not medical plagues. In 1991, he received a grant from the New York Department of Health to conduct a 3-year pilot to study the effects of creating an environment that incorporated plants, animals, and children into the daily lives of those living in a rural New York nursing home. Additionally, he altered the management hierarchy by empowering those workers closest to the clients, the hands-on caregivers. Outcomes of that initial study included fewer medications given, lower staff turnover, decreased infection rates, and a lower mortality rate.

The newly formed Texas Long Term Care Institute then performed a larger study to determine if Dr. Thomas’s results were replicable. The results of the “Texas Study” revealed additional significant outcomes including a 60% decrease in behavioral incidents, a 57% decrease in decubitus ulcer formation, a 48% decrease in staff absenteeism, and an 11% decrease in employee injuries.

Dr. Thomas’ Eden philosophy is based on ten Principles. These principles rest on the premise that, given the proper environmental stimuli, the client is capable of continued personal growth and development, despite specific medical, cognitive or emotional limitations.

Eden Alternative Principles:

1. The three plagues of loneliness, helplessness and boredom account for the bulk of suffering among people in care.

2. A Person-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 a pathway to a life worth living.

3. Loving companionship is the antidote to loneliness. People deserve easy access to human and animal companionship.

4. A Person-centered community creates opportunity to give as well as receive care. This is the antidote to helplessness.

5. A Person-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. A Person-centered community honors its People by deemphasizing top-down bureaucratic authority, seeking instead to place the maximum possible decision-making authority into the hands of the People or into the hands of those closest to them.

9. Creating a Person-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.

While recognizing that persons requiring care have medical needs and may have physical and cognitive limitations, the overarching thrust of the Eden Alternative and other culture change philosophies is to enhance the total well-being of persons entrusted to care. Eden advocates believe one means to this end is to motivate and empower Direct Support staff in such a way that it positively impacts those whom they serve. Ultimately, at the heart of the Eden Alternative mission is the desire to create an environment and introduce a broad range of experiences that will give meaning to the life of each and every individual.

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