The Promise, Practice, and Problems of the Eden Alternative

The Promise, Practice, and Problems of the Eden Alternative
One facility’s learning experience


It is estimated that 76 million baby boomers are getting ready to enter long-term care (LTC) facilities over the next 25 years. Many were privileged to grow up in a health-conscious environment that promoted various forms of social and recreational diversity. These future LTC residents will demand independence and physical activities, and will exhibit intellectual curiosity, spirituality, caring, tolerance for others, and self-forgiveness.
Clearly these baby boomers will not be satisfied with the current LTC routine of being cared for with standard medical treatments only, a focus that promotes a healthy body, but does nothing to foster a healthy mind and spirit1. In view of this, the traditional LTC facility is in desperate need of reform. In the traditional LTC environment, the residents relinquish control of their lives and become isolated from the community2. Staff controls personal activities such as bathing, dressing, and toileting. Life becomes a burdensome, scheduled daily routine.

Long-term care is becoming an increasingly competitive market, forcing facilities to adopt nontraditional principles to attract new residents. The Eden AlternativeÖ (EA) is one such option that may hold the answers to many of the issues faced by these facilities and their residents. Its implementation, though, presents challenges.

The following discussion describes the process of “Edenization,” as applied in one large facility, and the resulting successes and problems of that process. The facility in question has all levels of care, but the main focus of Eden implemen-tation has been in the 450-bed LTC setting where residents receive around-the-clock care.

A number of successes have been realized. Residents are now more involved in and more responsive to new activities, such as walking the facility’s animals or sharing time with children from an on-campus day care center and local schools. The residents are participating increasingly in their own care. This change in the “nursing home environment” has been accomplished by making the residents’ needs a priority and the facility’s needs secondary.

Examples of this prioritization include allowing residents to choose their bath times, mealtimes, and wardrobes. Staff is taking an active role in working with and learning about each resident; as staff work and interact with each resident, and review the resident’s history, they learn about the resident’s work history, family and significant others, hobbies, habits, and likes and dislikes, and they incorporate this knowledge in helping manage the resident’s daily life.

Basic to the EA, animals, plants, and children play an active role at the facility. Dogs, cats, birds, and fish are all visible, and the residents join, at least in part, in caring for and loving them. Children from the on-campus day care come and seek instructions from residents, who teach and mentor them, and actively participate with them in activities. Family members look forward to visiting the residents because they too enjoy the transformation from the typical, sterile LTC setting to a more homelike environment.

The manner in which managers interact with the nursing staff and CNAs is slowly changing. The facility recognizes that it needs continued improvement in its approach to management; decision-making power is gradually being distributed to frontline staff, such as CNAs, allowing them to respond to residents’ needs and wants. For example, if a resident would like to change his/her mealtime or wants to eat outside instead of in the dining room, the CNAs are allowed and encouraged to make these changes without first seeking approval from their managers. As a result of these efforts to divest decision-making power, the organization has experienced a significant decrease in staff turnover and a significant increase in overall staff satisfaction.

The facility continues to invest resources in getting residents and staff to understand and promote the Eden concept. The organization is indeed transforming into an Eden facility, realizing that it takes time, commitment, and a willingness to recognize and learn from mistakes to achieve the goal of Edenization.

Nevertheless, three years after implementing the EA, the organization continues to face significant challenges. For example, the facility’s large size has been an inherent obstacle to implementation. Attempting to educate sufficient numbers of the right employees, residents, and management on the EA concept has proven difficult. Although the organization has provided numerous educational sessions, only seven management-level employees have actually gone through the training necessary to become certified “Eden Associates.” Most of the certified associates are middle- to upper-management-level employees who have responsibilities across the campus in areas other than LTC, and who do not provide day-to-day frontline care. Training too few employees with too many diverse responsibilities-along with not fully involving the frontline staff (CNAs and LPNs), most particularly by failing to select one of them to be an associate-has led to an insufficient level of education regarding the EA, particularly among those who conduct day-to-day patient care.

The EA calls for a new way of managing employees. Founder William H. Thomas, MD, states that empowering frontline staff is key to gaining their total commitment and participation3. Others have observed that an initial period of education involving residents, employees, and families is vital to the successful implementation of the EA4.

For the Eden concept to be fully effective in this facility, new methods of education must be adopted. All staff-whether CNAs, dietary workers, activity assistance employees, transportation workers, or management-must receive at least some initial hands-on, face-to-face training regarding the process. Eden Associates should represent a diversified group of management and frontline personnel, able to understand and attack issues from numerous viewpoints.

Although residents in the facility were not entirely involved in the decision to undertake Edenization, they have generally accepted the EA, with only a few residents voicing opposition. Some have opposed, for instance, the inclusion of animals, fearing that they will cause infections, are dirty, and will require staff to spend time caring for the animals rather than the residents. A facility must try to respect and support such feelings and concerns without limiting the EA’s functional effectiveness.

Because of staff’s aforementioned exclusion from the educational process, it has sometimes been difficult to judge their reaction to the EA. Some have complained about the extra work the animals might, at times, require of them, causing them to realize the EA’s burdens but not its potential benefits. It is these long-standing mind-sets that are the hardest to change. Aside from expanding the educational process, another helpful step might be that when interviewing and selecting new staff members, management should make sure that the EA is a major focus of the interview.

Selecting and caring for the appropriate animals has been another obstacle to successful Eden implementation at this facility. Unfortunately, some of the dogs initially chosen had to be removed. Their personalities did not always fit in comfortably with particular residential areas: the dogs may have been too large and active, or they became too protective of residents-barking, posturing in a threatening manner-and making staff uncomfortable when attempting to provide care. Also-and contrary to the EA’s intent-the residents are not sufficiently involved in the care of the animals. Staff members provide most of the care, such as walking, feeding, and grooming. However, relinquishing environmental control to allow more resident involvement has been especially difficult for this organization to accept. It is vital that a facility understands the need to allow the Eden concept to flourish by allowing residents to control their environment at least to the extent of caring for the animals.

Finally, the facility has been reluctant to open its doors to the community. It has been slow in encouraging and supporting resident participation in community activities outside of the nursing home, such as fire service auxiliaries, historical commissions, library boards, etc., and inviting local businesses to come in and actively participate in daily facility events, all of which would help make the LTC facility more a part of the community.

The Nurse as Focal Point
It is the professional nurse who can become a key link in creating the new LTC environment described here5. The geriatric nurse is the coordinator of resident care plans and resident assessments, and in general acts as the principal advocate for the resident. Professional nurses are also key direct-care team members, charged with overseeing the efforts of CNAs and LPNs in providing practical patient care. Having professional nurses in both management and direct-care roles makes them the perfect vehicles for bridging the gap between the development of new ideas, such as the EA, and the application of those ideas to nursing practice. The professional nurse will prove to be the linchpin in successful implementation of the Eden Alternative. NH

Bethany G. Sampsell is a graduate nursing student at the Pennsylvania State University. For further information, e-mail To comment on this article, e-mail to


  1. Tavormina CE. Embracing the Eden Alternative in long-term care environments. Geriatric Nursing 1999;20:158-61.
  2. Tolley M. Power to the patient. Journal of Gerontological Nursing 1997;23(10):7-12.
  3. Thomas WH. Life Worth Living: How Someone You Love Can Still Enjoy Life in a Nurs- ing Home. Massachusetts: VanderWyk & Burnham, 1996.
  4. Reese D. ‘Alternative’ lifestyle: The Eden Alternative is more than just life gone to the dogs! Contemporary Long Term Care 2000;23(7): 38-42.
  5. Barba BE, Tesh AS, Courts NF. Promoting thriving in nursing homes: the Eden Alternative. Journal of Gerontological Nursing 2002; 28(3):7-13.
  6. Drew J, Brooke V. Changing a legacy: The Eden Alternative nursing home. Annals of Long-Term Care 1997;7:115-21.
The Eden Alternative Summarized

The concept of the Eden Alternative (EA) had its origins with the medical director of an LTC facility in New York, William H. Thomas, MD, who developed and implemented the program in 1992. His goal was to eliminate the three plagues of nursing homes, which he identified as helplessness, hopelessness, and boredom3. The EA was designed to combat these three plagues and to change people’s perceptions of LTC. The EA focuses on transforming the sterile LTC environment into a rich human habitat filled with companionship that fosters and nurtures interactive caring5. The three key components of this cultural transformation are children, companion animals, and plants. The EA, however, is also about changing the overall culture of an organization by empowering employees to make independent decisions and treating employees as one would want them to treat the residents6. More information is available at

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