Successful Edenization through education: suggestions for encouraging LTC staff to embrace the change of the Eden Alternative.

In the December 2003 issue of Nursing Homes/Long Term Care Management, an article by Bethany G. Sampsell chronicled one LTC facility's experience with the Eden Alternative[TM]. The article, "The Promise, Practice, and Problems of the Eden Alternative," described the facility's struggle to achieve the fullest possible benefit from the process of Edenization.

In response to that article, we offer suggestions on how to introduce the Eden Alternative to a long-term care facility using an approach developed by BEAM (Bringing the Eden Alternative to Michigan), an organization which began as a coalition of senior advocacy groups, providers, people from government, and regulators who were frustrated with the lack of progress in care and services to our elders. The group also realized that punitive regulations did not contribute to improving quality outcomes.

The Eden Alternative came to Michigan in January 1998 when Dr. William Thomas trained 40 members of the coalition as Certified Eden Associates (CEAs). These people then began the difficult work of influencing state policy on creating incentives for nursing homes to design innovative projects to improve quality. Nearly three years later, in December of 2000, the coalition organized itself as a nonprofit, 501c3 organization, committed to transforming the culture of nursing homes in Michigan through training and education programs designed to recognize and support commitments to best practices and the 10 principles of the Eden Alternative.

Since June 2001, BEAM has been actively promoting the Eden Alternative in Michigan, touching more than 150 nursing homes, training 1,150 CEAs, and supporting 30 nursing homes and assisted living residences already on the Eden Registry.

Transforming the long-term care culture has been no easy task. The roots of nursing homes run deep, back to the medical/institutional model. The traditional nursing home operates through a very regimented and rigid hierarchical system. The Eden Alternative, on the other hand, seeks to create a human habitat where the focus is on relationships, and the locus of decision making is with the resident. So the question is: Can a traditional, institutional culture be transformed to a sustainable, growing, thriving, relationship-oriented culture? The Michigan experience may provide the answer.

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In the early days of BEAM, training was based on the personal transformation of individuals. Individuals from various long-term care settings would gather at CEA training sessions to learn the Eden philosophy and principles. Enlightened to Eden, each CEA then had the daunting task of returning to his or her respective nursing home and transforming its culture. As indicated in the Sampsell article, it is very difficult for one or two or even 10 persons, especially if they are not a part of a facility's formal leadership, to teach the Eden concepts, create a vision for the future, and ignite Eden in the hearts of the rest of the staff. BEAM had to ask itself, "Have we set people up for failure?"

BEAM has since learned that deep-rooted organizational change requires not only personal transformation, but also a change in organizational systems; hence the birth of the On-Site Training Model. This model incorporates individual, personal responsibility (ownership of the process) with an organizational systems overhaul (management style and structure).

On-Site Training Model

The On-Site Training Model focuses on the whole organization, looking back at its history, assessing its current reality, and envisioning a clear picture of the future it hopes to create. Additionally, mentoring (consulting) services provide support, infuse staff with new ideas, act as a catalyst to maintaining the momentum, and provide regular updates on benchmarking goals. These services are available through the 14 Eden Alternative Regional Coordinators (EARCs) who comprise the Eden Alternative organization.

The On-Site Training Model follows this seven-step process:

1. Conduct a brief organizational assessment of the existing culture and
   set the vision for the future with the formal leadership (i.e.,
   administrators, directors of nursing, department heads and, often,
   representatives of the board of directors) of the organization. The
   assessment is presented in a written report. This step requires a
   great deal of diplomacy.
2. Provide on-site CEA training for a minimum of 30 employees (or 15% of
   total staff--whichever is greater).
3. Provide "Eden immersion" training for 80% of remaining staff on the
   Eden Alternative concepts. This is a condensed (four-hour) version of
   CEA training that introduces the Eden Alternative's major concepts,
   jargon, and 10 principles.
4. Hold a Management Team (made up of the administrator, DON, and all
   department heads) planning session and present to the team a
   follow-up report of completed trainings. The purpose of this meeting
   is to develop a "next steps" action plan that all formal leadership
   will support.
5. Select a Core Team (selection is made by the Management Team and
   CEAs). The Core Team includes the administrator, the DON and other
   department heads, but mostly consists of direct caregivers, some who
   are CEAs and some who are not. Its purpose is to build strong
   relationships with coworkers and to assume responsibility for moving
   the education and communication process forward.
6. Provide individual management coaching (in Michigan, this is
   BEAM-facilitated).
7. Hold a vision-setting session with the Core Team, developing
   benchmarks and outcomes goals (again, in Michigan, this is
   BEAM-facilitated).

These seven steps are implemented within the Eden Alternative organization. In Michigan, BEAM provides additional motivation and support; in other states, these are provided by the EARCs. Effective January 1, 2004, BEAM has been assigned six more states in which to replicate this organizational training process: Indiana, Illinois, Wisconsin, Minnesota, Kansas, and Missouri.

The aim of the On-Site Training Model is not only to educate individuals on the Eden concepts, but also to better position the facility for a future of continued growth and success. The benefits of conducting the Eden Associate Training with at least 30 members from one organization include the development of relationships (the cornerstone of the Edenizing process) among staff, greater teamwork, and the ability to focus on concrete, rather than merely hypothetical, issues affecting the organization.

One of the principles the Eden Alternative teaches is that Edenization is a process, a journey that never ends. Celebrating successes along the way is an important ingredient in the process of change. Homes are therefore encouraged to record their Eden journey in a facility journal and to share their story with the community, family members, and residents.

Why the On-Site Training Model Works

It is helpful, when the day-to-day demands of the nursing home environment threaten to overshadow Edenization efforts, for staff to realize they are not alone. Using this model, an ample number of an organization's staff members have been "Eden educated" and can help keep the home focused on its Eden journey. In our state, BEAM provides continued support and encouragement to the organization, as well as being a conduit of best-practices ideas gathered from organizations around the state.

Indicators of Success

As with many developing systems, the Eden Alternative and BEAM have not yet developed sophisticated data collection processes. However, data gleaned from existing datacollection methods--such as the MDS, Medicare Compare, Quality Indicators, and internal human resources records--can be used to measure progress.

A reduction in staff turnover has emerged as a major benefit of Edenization. Administrators successfully implementing the Eden Alternative report staff stability approximately 6 to 10 months into the cultural transformation process. One Michigan facility reported an annual turnover reduction from 106% to 24% over a three-year period. (The statewide average of turnover for nursing home employees is about 69%.) Seven of the 30 Eden Registered Homes in Michigan have reported an average turnover reduction from 72% to as low as 9%, the average being 15% (visit www.mibeam.org for more details). Some Michigan nursing homes are saving in excess of $100,000 per year in reduced staff turnover costs.

As anyone in long-term care knows, a stable staff correlates with improved quality of care, which translates into greater customer (resident and family) satisfaction, as well as a reduction in recruitment costs. Additionally, a stable staff creates opportunities for staff members to develop ongoing relationships with residents.

Relationships, particularly those between hands-on caregivers and residents, are at the core of the Eden philosophy. As these relationships develop, decision making for residents is put into their own hands (or into the hands of those closest to them, their caregivers) instead of upper management's. This important Eden Alternative principle often presents the greatest challenge to directors of nursing, nurse managers, and administrators where Edenization is taking place, because it requires that they change the top-down way they've been operating. However, the problems many nursing homes face--decline in census, financial instability, and concerns about their reputation--tend to strengthen their leadership's resolve to "become different" from others and commit to improving residents' quality oflife. They are further motivated by the expected benefits of stabilizing staff turnover, as mentioned previously.

Other benefits of successful Edenization include reduced medication use (e.g., sleeping pills, antianxiolitics, and antidepressants) and fewer complaints from residents, families, and staff. The concept that "friends do not hurt friends" prevails because of the strengthened interpersonal relationships between residents, staff, families, and administration. This correlates with the Eden belief that everyone is important, equal, respected, valued, and honored for his or her daily contribution to a warm and caring place to live and work. Because the Eden Alternative is as much a personal transformation as it is an organizational one, every person in the organization is valued and respected, irrespective of job role or title. The objective is building "community" in the purest form, where trust and honor are not just words but actions.

More Than Plants, Animals, and Children

People often view plants, animals, and children--the fur and the feathers--as the focal point of the Eden Alternative. These elements are important in eliminating what Bill Thomas calls the "plagues" of longterm care--loneliness, helplessness, and boredom--by providing companionship and a spontaneous atmosphere. However, another significant, but often overlooked, benefit of the presence of plants, animals, and children is the opportunity they afford residents to balance their receiving care with ways they can give care. Edenization gives them a chance to "give back" to someone or something, fulfilling their human need to be needed. Residents may not be able to change a litter box or walk a dog outside, but petting a dog or talking to a bird are nonetheless opportunities for them to give.

Plants, pets, and children should only be introduced when the organization has prepared for them. Furthermore, the choice to introduce them needs to be by mutual consent and with the full involvement of both residents and staff. And we must realize that having plants, pets, and children in the facility will not serve the intended purpose if they are not properly and purposefully incorporated.

Where to Now?

As we look to the future, one thing is certain: Tomorrow's purchasers of long-term care (i.e., baby boomers) will not be satisfied with "the way we have always done it." They will expect--no, demand--that it be different. The next generation of long-term care organizations may be small, planned communities, such as those in the Green House project. For now, however, the Eden Alternative seeks to transform the traditional medical model of care into an environment where daily life is filled with spontaneous activities and caregiving opportunities.

As long-term care communities begin changing their culture through the Eden Alternative, Michigan's On-Site Training Model can help them create within their organizations a critical mass of staff dedicated to the process, integrated support, and the engagement of 75 to 80% of all staff through the "Eden immersion" process. Having employees engaged in the On-Site Training Model increases the momentum and strengthens the resolve of the organization to transform itself into a warm, caring human habitat that respects the facility's medical treatment mission, but is not a slave to it.

Jack Steiner is an Eden Alternative Regional Coordinator and the Executive Director of BEAM. Cean Eppelheimer and Marla DeVries are BEAM employees. For further information, phone [phone], fax [phone], or e-mail [e-mail].

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