The EDEN Alternative
Roxie Hipp Certified EDEN Alternative Associate and Regional Coordinator Fayettville, NC:
The Eden Alternative was first developed by Dr. Thomas, who is a graduate of Harvard University. He took a job as Medical Director in a nursing home and decided that, when he got in there, there was more plaguing these residents than just their physical ailments. After looking at it, he decided that it was three plagues: boredom, loneliness, and helplessness that affected these residents inside the nursing home. The Eden Alternative is about building a human habitat. Cold, sterile walls are no longer acceptable. They're not acceptable to today's residents, and they're certainly not acceptable to us, looking at a nursing home in the future.
So what Dr. Thomas has decided to do was literally to build a human habitat. In doing this, he started looking at what we have in our own everyday lives. Ask yourself, "what do you have?" Do you have plants? Do you have children? Do you have animals? Imagine yourself living in a hospital all the time. It's not very comfortable surroundings. In order to build a human habitat, you must address the three plagues of our nursing home, boredom, loneliness, and helplessness. Loneliness is the pain we feel when we want companionship and cannot have it. Helplessness is the feeling that we get when we can receive care, but we can no longer give it. And boredom is the feeling we get when our lives lack variety and spontaneity.
This is a picture of a typical nursing home. This is not our nursing home, although our nursing home still does lack some of the three plagues. Available medical treatment for loneliness, helplessness, and boredom-- no, there's not, but yes, there is a solution. It's called the human habitat. The Eden Alternative is not a program; it is a process of life. It is ongoing; it never ends. The human habitat is to build the human spirit; it's to nurture it; it's to give life where there was no longer any before. To do this, we have three steps: vision, education, and implementation. In the vision, you want to figure out where you want to go, how you want to build your human habitat: what you want in your nursing home, what do you desire? The key to education is your staff, residents, assistants, you community. Everyone must be involved in order to build your human habitat.
The Eden Alternative test: is the intervention close to the residents? Does it offer continuous access? Do you have companionship in your nursing home? Are your employees empowered? Although the animals are a big part of the Eden Alternative, if you get anything out of this, it's not the Eden Alternative itself. The pets, plants, and children are the tools that we use for the Eden Alternative. The real thing in the Eden Alternative is empowering your staff. Bringing these animals into a nursing home would not work full time if your staff were not empowered.
Empowering the employees is so important because when you tell your staff that you're bringing these animals into the nursing home, the first thing the CNAs and the front-line staff says is "Why? We've got plenty to do. We are overworked. We are underpaid. We don't have time to care for these animals. Who's going to care for them?" And that is a very legitimate question. Teamwork is so important in the Eden Alternative, because without it, you don't have anybody caring for these pets, plants, and animals. It's really a paradigm shift: you take the pyramid and you turn it upside down. The administrator who was on the top before is now on the bottom. The front-line staff is the one making decisions. They're the ones living the day to day lives with the residents. They are closer to the residents; they know the residents better than anyone else. They are most capable to do the decision-making. They know what our residents need more than anyone else. When it comes to the animal being in a nursing home and caring for them, of course, the front line staff is part of it. But the big part of it is getting the residents involved, and if the front-line staff is feeling overworked as it is, then it's very important that they feel like they are important and they are part of the decision-making authority.
Every one of our employees is on a team. Our nursing home is 60 beds, so we have a small facility. We've broken our facility up in 4 teams. Everyone working there is on a team. We have interdisciplinary teams: dietary, CNAs (Certified Nurses' Assistants), nursing, maintenance, laundry, everyone. So everyone has a say of what goes on in the nursing home. Then we have subcommittees (it gets very confusing): a plant subcommittee, animal subcommittee, and a children subcommittee, etc. What happens is, for example, the animal subcommittee comes together and tells us what we need in order to maintain pets in the nursing home. They tell us what the pets need as far as food, care (when they need to be walked, how often, etc.). They take it to the team. The teams are the ones who decide who will do what. A CNA is more likely to walk a dog if she makes that decision than if the top management tells her she has to, and she'll like her job much better because it's her decision, not the management's. Saying that, we do have plants in the nursing home and that is part of the Eden Alternative because, like we said before, not everyone likes animals. So, those who do not like animals have plants or children. They do have a choice.
This is one of our residents caring for our plants and this relates to helplessness. Children in the nursing home are important, too. We have childcare nursery schools that come in, we have after-school day care programs. We have community groups, 4-H, Boy Scouts, Girl Scouts. That all plays a big importance to our nursing home. It brings spontaneity to our lives, because we never have any idea what the children are going to do or say. And we don't want to; we don't want to control activities. Before, you had a regular activity calendar in a nursing home. Dr. Thomas believes that if you take your activity calendar and you are able to place it in any nursing home, that is not part of the Eden Alternative. You must build this activity calendar towards your home. What are your residents doing? Personalize it. And it's very important that this human habitat is very personalized towards the people who live there, not just anybody walking in off the streets.
This is one of our after-school day care children coming, and she helps a resident watering the plants, reads to them, whatever, it just gives them that companionship. And, the children that we have coming: we like the same children coming so they build that bond between each other. If we had different children daily, they don't build any kind of relationship with them, they aren't able to communicate with them as well. These children come every day, 5 days a week after school and sometimes on weekends with their parents. And they know the residents; they know which ones need help with plants and watering, which residents like to be read to, which residents like to go out for walks with the animals. They build that relationship, and residents actually look forward to that bus pulling up. They're in their rooms, and when that bus pulls up, they're wheeling out; they're ready to go.
Dogs in a nursing home are very important, and not just coming in for visits; these animals live there 24 hours a day. The selection process we use: we go to a no-kill animal shelter through the Haven, and we use training dogs and staff. Actually (believe it or not), the staff is harder to train than the animals. The animals adapt very well. We do use the Delta Society test to see if they are adequate in coming. We decide what equipment they need, health needs. We do like older dogs, but we do pick the healthy ones. It would be unfair to our residents to bring in an unhealthy dog and they build a relationship, and it dies. This is one of our gentlemen that would probably never get out of bed if it weren't for the animals. He loves the animals, and he loves to participate in grooming them. He participates in walking them. He would sleep his life away. This gentleman is funny because, we first brought these dogs into the nursing home and we asked him if we could bring them into his room. He agreed that we could keep a kennel in his room. First, we left him in there during meal time. The animals run free in the nursing home 24 hours a day except for three times a day and that's breakfast, lunch, and dinner. Not only would they like to help the residents eat their food, but our state requires that we are not allowed to have the animals in Dietary, where food is being prepared or served. So, he finished eating early as usual and went back to his room, and had let Angel out of the kennel and shut the door. When I went in there to let Angel out, I saw this big hump in his bed, and he turned and looked at me and he said, "Are we allowed to have the dogs in bed with us"? And I said, "Do you want the dog in bed with you"? And he said, "Yes." And I said, "Okay." And so, he uncovers this dog, and the head pops up, and he's so excited that he could keep this dog in there on his bed. This the same man walking in the morning. He just decided he wanted to get out and take a walk with this gentleman.
The dog selection process-- it's recommended one dog per 20 residents. Right now, we have 2 dogs. We did have a 3rd one, but she did not work out. We are in the process of looking for another dog that will fit. The reason our dog did not work out is because Dr. Thomas says, "Do not use puppies." My boss says, "Let's prove him wrong." Puppies do not work, and she wanted a Jack Russell, and I warned her against this, because knowing what a Jack Russell is like, but she said, "I don't care, we can make it work. They'll be fine with the cats and animals. You'll train him." And, our dog loved cats and animals. She did wonderful. Her only problem was strangers coming into the nursing home. She decided they weren't welcome. Of course, we select healthy dogs, and we select a different variety (shapes, sizes, textures) for the residents. Wheelchair residents can pet dogs that are larger and then, of course, we want lap dogs for residents that want them in their laps. We always do a health screening before we bring them into the nursing home. And, we like a playful, gently disposition.
Basic obedience is obviously important. A slow introduction to the nursing home is also important. You just don't want to take these dogs out of a shelter and throw them into your nursing home. They get very confused. So what we've done is we've given them a 2-week process. We bring them in daily, basically from 9-5. We were fortunate-- our own busman would drop them off in the morning (she was our foster mother for a while), and then would pick them up after work. And we did this for about 2 weeks. After that, we let Angel stay during the week, but then, for the first couple of weekends, we gave her a break. This worked out very well, and we did this with pretty much all our dogs.
This slide shows companionship. This is a gentlemen who will be sitting out in the porch (and we live inside the city limits, so, of course, the dog has to be on a lead), but, she'll just sit out there with him for hours, not caring. She's just there for him, and that's what's most important.
This is a little lady who feels that this is her dog. When it came into the facility, it was put into her lap, so therefore, she claimed it. And she would be very upset when anybody else wanted this dog. She would pout. But, if you asked her, she would do it, but she would sit and stare and pout the entire time. She tried to feed him, you name it. I'd tell her that Niki could not have chocolate, it was not good for him. Her words were, "Shut up, he's my dog. I'll do as I please." So, we tried to give Niki a break one weekend, and in doing so, we learned our lesson well. Our D.O.N. took him home for the weekend, and this lady got very upset Saturday because Niki was not there. When one of the CNAs explained that he left for the weekend, he will be back, she was very upset: "They did not ask me." Sunday came, and she got more upset, and was telling the CNAs that we did not know what we were doing, that we cannot take her dog, and did not have anything nice to say. Come Monday morning at 6am, she was found in bed without a pulse, and part of me wonders if it wasn't because we took Niki away. That was her only companion. She did not have family members coming to visit her. That was her companion, we took him away for the weekend, and we learned our lesson: we'll never take a dog out without asking the residents first.
Cats in the nursing home are very important. Cats are very easy; they do their own thing. We recommend you use one cat per every 10-20 residents. We have 1 cat per 10 residents, because you can go a day or two without seeing a cat. They literally do their own thing. We do not select kittens. Dr. Thomas recommends us not to, although we have selected 8-10 month-old cats and it has worked out very well. We do check them for leukemia, and again we get various shapes and sizes and colors, which is very important. And, cats should be very playful and affectionate. We do declaw our cats, just because our residents do have paper-thin skin. I don't like to declaw them, but in our facility, it is a must. This is one of our cats-- this just shows how easy and playful she is. You can hold her upside down, you can do the accordion on her. She really doesn't care what you do to her. This is our administrator's baby, and this is a cat that I picked out.
This is a gentleman that is bed-bound who literally does not want you to turn his lights on; does not want you to open his blinds, will not allow the TV on his poor roommate is not permitted to do anything hardly, he lays in his room. He's just very depressed and he sits there and listens to country music all the time. When we brought the animals in, we knocked on his room and I asked him if I could bring this cat in. His eyes lit up and his smile got real big, and I said "Can I come in with the cat," and he shook his head, "Yes," and I said "Can I flip the light on," and he allowed me to put the light on. And he wanted the cat. He kept petting it and petting it, and petting it and he looked at me and he pointed to the brush and I said "Do you want to brush her," and he shook his head and petted her and petted her. He'll allow me to take pictures of her with him, and he just changed his whole life. And he'll actually get out of bed a couple of times after that since we've gotten the animals. He will allow you to get him up in a chair just to be with the animals. Now the children and the plants he really has no use for, but he does like the animals.
Birds in a nursing home are very important. We like a bird in every room, but if you don't like birds, you do not have to have a bird. The difference between the birds and the dogs is: if you're coming into our home and you have your own bird, as long as we check it you can bring your own bird. We don't recommend this for your dog or cat because this animal bonds to you and does not help anybody else. We don't recommend that you go to a pet store to get your birds, we do like a reputable breeder. If you go through the breeder and you get birds from the same flock, you can do a random test for psiticosis instead of doing everyone for psiticosis. And with the birds it's a little more important because their cages must be cleaned every day and they are very messy. What we do is if you're a resident and you're up and around and you're able to communicate with your bird, we give you one bird and It will bond very well to the resident. If you're not and you're bed-bound, we have given two birds per room so they kind of interact between the two of them and the birds have somebody.
This is one of our Cockatiels, Bluebird. The residents name the birds. This bird obviously has some blue on it, but that's what he wanted, so that's what he got. He allows us to take his bird out and around the building to different residents.
This is a lady who likes children and birds. You only get a response from her if you have children or animals around her. Her face lights up.
This is a lady who picked the first bird of the bunch. She picked this bird, a little blue parakeet. She loves this bird. She gets it out, she talks to it, and her words are, "It's just a joy." She's never owned a bird before coming to the nursing home.
The cats like the birds too. They don't hurt them, they just like to really watch them.
Caring for the birds is kind of like an activity. We didn't want it to be a chore so we incorporate it into our activities. For the "Bird Mobile," we took an old medication cart, and we got somebody from the local college to paint it for us. What we do is we go around to every room and we get the birds out with the residents, and then we'll clean the bird cage, feed and water the birds, allow them to feed and water them if they're able. And then of course we clean up after them, but it's also an activity going around. The "Bird Mobile" is fun because we keep treats in there, and of course all the dogs and cats follow us too. It's an activity on wheels.
As for other animals in the nursing home, we do not have any at this time. I have brought my ferret to work a couple of times, and they love it, bouncing across the floor. Ferrets are great, though there is an odor about them. Chinchillas are absolutely wonderful- they are very safe, clean animals. Rabbits, chicken, fish, etc. are wonderful. The only drawback about a rabbit (several homes have rabbits) is their back claws as you know are razor-sharp and you have to be careful handling them. Strollers work wonderful when you have a rabbit in the home. We're not allowed to have chickens. Several of our residents have asked for chickens, but inside city limits we're not allowed to have any farm animals. If you're outside city limits, farm animals are wonderful.
As far as cost-effectiveness of the Eden Alternative, you decrease on your drugs and your medication, so you use the money that you save there for the animals. Also, a lot of money we've had in activities before we now use for the Eden Alternative. We've reduced staff turnover, improved resident quality of life, and we also have reduced infection rate. Use of medications also decreases gradually. We have a lady in our own facility who was asthmatic before she came to the nursing home (in her younger days). She was very allergic to the animals, and when she came to the home, even though we had the Eden Alternative, her family wasn't too concerned because we didn't have them in her room. Well, this lady started asking for the cat in her room. So we had got a cat condo and put three cats in her room (mind you, they're only kept up during meal time), but she also requested a bird. Well this totally blew her family away- they just couldn't believe that we would do this to this woman having asthma and being on all these medications. But, this woman has a behavior problem and the language that she uses would make a sailor blush. When we brought these animals to her room, this woman started acting up and it took three CNA's to get this woman undressed and into bed. Several of them had bite marks, pinches, and bruises, and kicks. The D.O.N. happened to be working that night, and he came in, opened up the bird cage, let the bird run loose in her room, and she just started laughing and carrying on. She thought it was the funniest thing. After a few minutes, we put the bird back in the cage, and the CNA was able to undress her and put her to bed all by herself. Now, prior to the animals coming into the room, she was getting 18 anti-psychotics a month on the average. After 3 months of the animals being in the room, she's now getting them 2-3 times a month.
As you can see in this transparency this is from five nursing homes... Starting the Eden Alternative is a big change, so it's important that you educate your staff because change is hard for anybody, and without the education you're going to lose staff, but after the first 2-3 months of adjustment you can see how the CNA absenteeism really declines. Anti-depressants, again, it takes a few months to get into the flow of things, but it is a steady reduction after that. And, again, anti-psychotics, at first, when you first started, it does, go way up, but again, we do go down after that. Change is very difficult for anybody, and bringing this in is just, literally, a paradigm shift. You totally turn your whole facility upside down, because you're used to the administrator making decisions and it going right down, and now we're telling the CA's and the front line staff, "You make the decisions, and it will come down to us." It's also very important that you know that the department and the administrator never give up control- they make the decisions but we're still responsible when the state comes in- we can't throw up our arms and say, "We don't know what they're doing but they're doing something." So it's very important that we're always in control, we know everything that they're doing, but they're in the position to make the decision.
Incontinence has gone way down. This is funny- we took the residents on a fishing trip (one of the gentlemen who came in for our computer was so impressed with the Eden Alternative and our facility that he invited us to his place at a lake to let them go fishing). We loaded up eight of our residents (half of them incontinent), three of our children, three staff members, and this golden retriever named Angel. We were an hour and a half late because we had several people incontinent, bathroom stops, etc. But these residents, on the average (especially three of them), are incontinent every hour, and we thought, "What are we going to do? They want to go, so we'll just deal with it." We were expected to be back at 1. We got there at 10:00 and did not get back to the facility until 3:00. The residents did not want to leave, and we never had one incontinent accident and nobody was tired and ready to go back to bed, they all wanted to stay. But there were shift changes and the CNA was ready to go.
You can see how skin sores decrease. The residents are up and around, they literally do get out of bed more. And I think part of it, because the CNA's are more attentive and a lot more caring. In-house pressure sores, again, like the gentlemen with the cat, he's up in the chair instead of being in the bed all the time. There's a reason to be out of bed, there's a reason to move. That's it.
A man and his dog were walking along a road. The man was enjoying the scenery, when it suddenly occurred to him that he was dead.
He remembered dying, and that the dog walking beside him had been dead for years. He wondered where the road was leading them.
After a while, they came to a high, white stone wall along one side of the road. It looked like fine marble. At the top of a long hill, it was broken by a tall arch that glowed in the sunlight.
When he was standing before it, he saw a magnificent gate in the arch that looked like mother of pearl, and the street that led to the gate looked like pure gold.
He and the dog walked toward the gate, and as he got closer, he saw a man at a desk to one side. When he was close enough, he called out, "Excuse me, where are we?"
"This is Heaven, sir," the man answered.
"Wow! Would you happen to have some water?" the man asked.
"Of course, sir. Come right in, and I'll have some ice water brought right up." The man gestured, and the gate began to open.
"Can my friend," gesturing toward his dog, "come in, too?" the traveler asked.
"I'm sorry, sir, but we don't accept pets."
The man thought a moment and then turned back toward the road and continued the way he had been going with his dog.
After another long walk, and at the top of another long hill, he came to a dirt road which led through a farm gate that looked as if it had never been closed. There was no fence. As he approached the gate, he saw a man inside, leaning against a tree and reading a book.
"Excuse me!" he called to the reader. "Do you have any water?"
"Yeah, sure, there's a pump over there." The man pointed to a place that couldn't be seen from outside the gate. "Come on in."
"How about my friend here?" the traveler gestured to the dog.
"There should be a bowl by the pump."
They went through the gate, and sure enough, there was an old fashioned hand pump with a bowl beside it. The traveler filled the bowl and took a long drink himself, then he gave some to the dog.
When they were full, he and the dog walked back toward the man who was standing by the tree waiting for them.
"What do you call this place?" the traveler asked.
"This is Heaven," was the answer.
"Well, that's confusing," the traveler said. "The man down the road said that was Heaven, too."
"Oh, you mean the place with the gold street and pearly gates? Nope. That's Hell."
"Doesn't it make you mad for them to use your name like that?"
"No. I can see how you might think so, but we're just happy that they screen out the folks who'd leave their best friends behind."