The Eden Alternative: “People started to thrive”

In the early 1990s, doctor and geriatrician Dr Bill Thomas was working in a nursing home when a resident approached him about a rash. She also mentioned that she was lonely. Dr Thomas was able to prescribe a cream for the rash, but when he consulted his Harvard medical books for how to treat loneliness, of course there was no prescribed remedy.

This incident set Dr Thomas on a path for change, and he and his wife, Jude Thomas, developed The Eden Alternative®.*

The philosophy was based on Dr Thomas’s belief that people were dying in nursing homes from loneliness, helplessness and boredom. He believed that the antidote to loneliness was loving companionship, the antidote to helplessness is the giving and receiving of care, and the antidote to boredom is variety and spontaneity.

Dr and Mrs Thomas trialled The Eden Alternative® principles in a nursing home in Texas over two years. “It was amazing the changes in people they saw,” Sally Hopkins, Executive Director of Eden in Oz NZ, told HelloCare.

“People started to thrive,” she said.

The Eden Alternative® is about “continuing to live a life with meaning rather than being in an institution,” Ms Hopkins said.

Eden in Australia: “There’s no magic fix”

When Dr Thomas presented his findings of the trial at a conference in Hawaii, The Eden Alternative® was picked up and brought to Australia by Eden in Oz (now Eden in Oz NZ).

Eden is now well established in Australia, with 25 homes employing the philosophy along the East coast and in Western Australia. Eden in Oz NZ is a not for profit organisation, and receives no government funding.

Eden in Oz NZ works with organisations in residential aged care, community care and disability services.

The Eden Alternative® is about empowerment, choice and autonomy for older people in care, and getting to understand the history and motivations for every resident, Ms Hopkins said.

Though the Eden principles are developed at an organisational level, they have to filter down through the organisation to the staff who are closest to the residents.

But “culture change is hard work,” she said. “There’s no magic wand. People want an easy fix, but it just doesn’t work that way unless we can change the hearts and minds of staff.”

Ms Hopkins said she believes that some traditional aged care can be soul destroying for residents, and much of the coverage we see of aged care in the media reflects this fact.

“The way we’ve been treating them [traditionally in aged care], we think we’re being well meaning, but in actual fact we’re destroying their souls,” she said.

Language to appeal to “hearts and minds”

Language is also crucial to The Eden Alternative®. The aim is to remove institutional language, and instead to think about the person themselves with the aim of connecting with “hearts and minds”.

For example:

  • ‘Patient’ becomes ‘Elder’ or Client / Resident;
  • ‘Allow’ becomes ‘Enable’;
  • ‘Dementia Patient’ becomes ‘person living with dementia’;
  • ‘Behaviours of Concern’ becomes Unmet Needs;
  • ‘I’m doing the Feeds’ becomes ‘assisting xyz with their meal’; and
  • ‘Toileting’ becomes ‘freshen up’.

Homes are called ‘Elder Centred Communities’, showing that the Elder or older person is at the centre of everything they do.

Addressing unmet needs

Getting to know older people’s life histories is critical to The Eden Alternative®, and it is essential that staff understand who each resident is.

Older people often come to feel their lives “appear not to matter”, but this is not the case at Eden.

Understanding people’s pasts can help staff diffuse situations that might lead to residents acting out their frustrations.

“Any potential challenge around behaviour is around an unmet need and if we know that person’s story as much as possible then we’ve got a better chance of getting to the root cause of what that challenge might be,” Ms Hopkins said.

She gave the example of a former farmer who wanted to go out at three o’clock in the afternoon because he wanted to milk the cows – as he had done for 60 years previously.

“If you don’t know the man’s story you might stop them, and the person might lash out because you’re stopping them from doing what they believe they need to do. But if you understand, you can take them down the road to look at the cows, the man’s happy when he sees the cows. It’s meaningful for him,” she said.

“People say we’re too busy to do Eden. But we say you’re not doing your job and then doing Eden. Your job is seeing an alternative way.”

The Eden effect

Ms Hopkins said it’s obvious to her when the Eden Principles are well established in a home.

“We notice a lot more noise – in a good way. There’s lots of energy, there’s lots of discussion, there’s lots of people moving around, whereas before they might have just been sitting and falling asleep. They’re a lot more engaged,” Ms Hopkins said.

There are also a lot more volunteers – one centre has an astonishing 800 volunteers from the ages of 10 to 80.

“Staff morale is through the roof” with Eden, Ms Hopkins said.

“One of the benefits of the Eden Alternative is you have low staff turnover,” although initially some people might leave it they feel they are not suited to a new approach.

Families and relative are also “really happy”, and often there are cases when a family member will continue to volunteer at a home, even when their loved one has passed away.

“They have made friends there. They want a sense of place as well. That sense of connectedness is powerful,” Ms Hopkins said.

A decline in the overuse of medication

Homes applying the Eden Principles also have lower rates of medication overuse, according to Ms Hopkins.

“You find there’s a decrease in the overuse of medication, particularly antipsychotics,” she said.

“Most of the time it’s about unmet needs and what the Eden Alternative enables people to do is have tools to show people that if we actually know people quite well and we understand who they are and what is meaningful to this person, we use the Eden Domains of Wellbeing® as part of the framework, and nine times out of 10 we can get to the root cause,” she said.

Complying with the new standards

Ms Hopkins says she believes the new aged care standards are a “game changer” and that they “weave” into the Eden Principles neatly.

The new standards are “truly looking at the individual and looking at what their needs are, from their perspective,” she said.

For homes applying the Eden principles, they will be “ahead” when the new standards come in because The Eden Alternative® is already about person centered care.

Elders allowed to feel “useful” and “give back”

Demand for places in The Eden Alternative® homes is high.

“When they [families and prospective residents] come to visit, they see it’s different. It looks different.”

“I know when I’m walking into a home that’s really engaged with its elders there’s lots of energy, there’s lots of stuff going on, staff become the facilitators, the conductors, and ultimately the elders also start to do stuff.”

Ms Hopkins gave the example of a young man with a disability who was in care being given a job in maintenance at his home. He was given simple chores to do around the nursing homes, such as restock bathrooms, tasks that were meaningful and enabled him to be engaged. He had his own staff shirt. “He was part of the team,” Ms Hopkins said, adding that he “stood so much taller, it was phenomenal watching him”.

Other residents help nurses on their rounds, they can hold stethoscopes or help wheel bed carts.

A former nurse who was living in a nursing home in Queensland was able to deliver an education course on the side effects of UTIs in older people.

Residents might offer to get another resident a cup of tea. Meals are sometimes served in buffets, so people can help themselves and be involved in preparation such as setting the table.

“It’s the most powerful thing – it’s the stuff you do at home,” Ms Hopkins said.

A resident might be reading out the newspaper to others, they may be doing a quiz, or playing the piano. One might lead an art class. Ms Hopkins said one resident teaches an English as a Second Language class at a community centre across the road from the home where she lives.

She said, “They’re being really useful and they’re giving back.”

* The 10 Eden Principles

The 10 Eden Principles are:

  1. The three plagues of loneliness, helplessness and boredom account for the bulk of suffering among our Elders.
  2. An Elder-centred community commits to creating a Human Habitat where life revolves around close and continuing contact with people of all abilities, plants and animals. It is these relationships that provide the young and old alike with a pathway to a life worth living.
  3. Loving companionship is the antidote to loneliness. Elders deserve easy access to human and animal companionship.
  4. An Elder-centred community creates opportunity to give as well as receive care. This is the antidote to helplessness.
  5. An Elder-centred 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. An Elder-centred community honors its Elders by de-emphasizing top down bureaucratic authority, seeking instead to place the maximum possible decision-making authority into the hands of the Elders or into the hands of those closest to them.
  9. Creating an Elder-centred 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.

The Eden Domains of Wellbeing®:

  • Identity,
  • Autonomy,
  • Connectedness,
  • Security,
  • Meaning,
  • Growth and
  • Joy.

If you would like to find out more about Eden in Oz NZ, please visit their website.

Please note: The image used to illustrate this article does not represent actual people or events. Image: iStock.

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  1. Being a sceptic, having had 14 years exposure of what goes on in nursing homes, I prefer to rely on evidence. However, if what has been recounted in this article is firmly based in fact then I applaud the founders of this aged care model and the Directors of Eden Oz NZ for promoting the Eden Alternative.

    The assessment of needs etc. regarding elderly people has been well articulated in the article and I am heartened to see that at least some service providers are implementing this model which treats elders with kindness and respect. Not all nursing homes are vile but most of them are. Those that adopt the Eden Alternative certainly would not appear to fall in the latter category.

    If we could clone Ms. Hopkins, Dr. Thomas and the 10 Eden Principles and roll them out in every State, the
    aged care crisis would be in a far better shape than it is today. When the Government throws funding to
    all and sundry in the nursing homes business, demanding no transparency and accountability, it is not surprising that the wrong people and organisations are operating in this area of care. Just as those greedy service providers are guilty of horrendous abuses towards the elderly, so too is the Government for not doing its job responsibly. It is not lack of Govt. funding that has caused a crisis in aged care – it is the greedy
    operators who have no morality or ethics and feed happily from the Govt. trough and the fees they extort from the elderly. Rot starts from the top!

    Thank you for publishing this article because it gives one reassurance that there are some decent nursing home operators out there who value and respect society’s most vulnerable. Perhaps that model of care should be submitted to the Royal Commission for its consideration as an example of a well thought out and proven model of care rather than have it rely on the vacant minds in Canberra who create policies about issues they know nothing about. The way in which the NDIS debacle was created by bureaucrats certainly speaks volumes and questions their competencies..

  2. This needs to be discussed in EVERY nursing home. The institutional model is unhealthy.
    Great to read WA and New Zealand are taking this seriously.


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