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Keywords:

  • innovation;
  • research priorities;
  • residential aged care

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Themes from the literature
  5. Methods
  6. Findings
  7. Discussion
  8. Acknowledgements
  9. References

Aim:  The Eden model of care is part of discourse associated with innovation in aged care. There is, however, limited rigorous research to identify its essential claims. This paper examines the implementation of the Eden model in one integrated health service in rural Australia.

Methods:  Data are derived from a small qualitative study that explored the views of staff.

Results:  Findings highlight that while the discourse of the Eden model is accessible to all staff within aged care and is linked to person-centred care, there is tension with this practice of aged care within the Australian context.

Conclusion:  It is appropriate to ask if this form of care is innovative; what constitutes innovation and the importance of accounting for wider contextual factors. There is a need to build on this exploratory study with dialogue and research of not only the Eden model, but innovation in aged care within Australia.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Themes from the literature
  5. Methods
  6. Findings
  7. Discussion
  8. Acknowledgements
  9. References

The nature and form of residential care for older people remain central to gerontology's scholarship and practice. Indeed, a large body of literature explores and measures the myriad of factors that constitutes the care of older people. Within the USA in recent years, there has been a notable amount of literature concerned with culture change surrounding residential care facilities (see [1,2]). Termed a movement [2] in the USA, there has also been an adoption of the discourse of culture change in Australia [3]. One model of care, The Eden Alternative ™, often cited in nursing home culture change literature, is put forward as an innovative model of care. Facilities that operate with this model within Australia attract interest from the sector, from both policy makers and providers. However, within academic literature here is a lack of critical reflection of both the model and its operation.

This article seeks to stimulate discussion and critical analysis of this model of care. It is important to examine the innovative claims of Eden, and to do this in the context of Australia where resident focused care and consumer rights are built into legislation and policy. Here we draw on a small research project in one integrated rural health service which operates according to the principles of the Eden model of care. The aim of the study is to explore staff views in relation to implementation of the model. The intention is to understand better their lived experiences of change, and to separate these from the rhetoric associated with the Eden Alternative.

Themes from the literature

  1. Top of page
  2. Abstract
  3. Introduction
  4. Themes from the literature
  5. Methods
  6. Findings
  7. Discussion
  8. Acknowledgements
  9. References

The Eden Alternative is promoted as a comprehensive model for reform and management of aged care facilities. It aims to transform the physical, interpersonal, psychosocial and spiritual environments of an aged care facility as well as the culture of the organisation [4] (p. 28). In this section, we explore literature only concerned with the Eden model of care, but acknowledge that in a broader study of this model, it would be important to contextualise this model in relation to the recent broad and significant changes that have occurred to aged care within Australia.

Overall, a review of the literature concerned with the Eden model of care found only a small body of work characterised by a lack of rigorous scholarship. Most focus on perceived improvements to residents' quality of life, with some exploring organisational change. Studies generally fall into three categories: descriptive, quasi-experimental and case studies. The large majority are descriptive and written using promotional and somewhat partial language. It is common to read material with phrases drawn from the original proponent of the Eden alternative, William Thomas [5], such as ‘three plagues of loneliness, boredom and helplessness’, ‘parable’ and ‘wanted to breathe new life into the nursing home’[6,7]. Articles by authors such as Barba et al. [8], Olson [9] and Tavormina [10] provide an uncritical description of the Eden model and the so-called benefits to residents, staff and facility environments. Most are not empirical and do not draw on evidence. Mackenzie [11], for example, highlights positive outcomes for staff and residents, but draws on very limited empirical (n= 24) self-report on happiness as data.

One article outlining the change process of two nursing homes in Switzerland drew on management data that proposed staff improvements such as a decrease in turnover and in sick leave; as well as patient outcomes such as higher occupancy rates and a decrease in medication supply (see [12]). While interesting, these findings lack rigor as change is also linked to the implementation of a Total Quality Management system. The causal impacts are thus questionable.

Tesh et al. [4] (p. 32) proposed that facilities adopting the Eden model report anecdotally that restructuring is the most difficult component of the Eden alternative to implement and the most threatening to the administration. While clearly not rigorous evidence, this does highlight the importance of understanding the staff perspective in relation to organisational change.

There are also some quasi-experimental studies that attempt to quantify change, including the impact of the Eden model on residents' lives. Evidence from these studies is generally inconclusive, mostly because of methodological flaws. For example, three quasi-experimental studies sought to assess the impact of implementation of Eden on levels of loneliness, boredom and helplessness of older people within the care facility [13–15]. Two of these studies were small scale (n= 22 and n= 33, respectively) and involved administering scales at baseline and later post implementation [13,14]. One larger study (n= 95) compared the findings after 1 year of change with those from a control site [15]. Findings from the smaller studies suggested positive change in regard to boredom and helplessness; however, those from the larger study [15] were rather contradictory, suggesting that it may take longer than a year to demonstrate improvements attributable to the Eden model. One further mixed method study [16] aimed to measure the effect of the Eden model on resident's functioning in a comprehensive mixed methods study. However, no positive impact was found.

More recent literature is case study based and involves the collection of baseline data prior to implementation of the Eden model and then later in time. Statistical evidence from these studies has proved inconclusive (e.g. [7,17]). One study, Robinson and Rosher [17], found staff and families had increased satisfaction and resident's depression had lessened. However, change cannot be attributed to the Eden model as management reverted to a traditional culture during the course of the study. In another study, the quantitative data showed no conclusive evidence of change, although qualitative data suggested that residents, staff and families all believed that change had occurred [7]. This study highlights a common problem in relation to the Eden model, and that is that many rely on anecdotal evidence of beneficial effects. The literature lacks rigor, and often commences from the proposition that Eden will by its very nature bring improvements to the operation of an aged care facility (see [15]).

Furthermore, most studies lack any theoretical framework that involves exploring the model within broader issues of care, agency and productive ageing (to name a few). They thus exist in somewhat of a vacuum, neglecting other changes that are happening across the sector. As a result, findings lack in-depth analysis and fail to build knowledge around the effectiveness of this model in delivering care to older people. This all suggests the urgent need for more rigorous studies concerned with the implementation and operation of the Eden model, and in particular, research within the Australian context given its unique aged care system, welfare model and culture.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Themes from the literature
  5. Methods
  6. Findings
  7. Discussion
  8. Acknowledgements
  9. References

This project explored the experiences and views of staff at one integrated rural health service in relation to the introduction of the Eden model of care. As noted earlier, the aims of the study were to explore the staff's views of the implementation process. As a result, a qualitative research design was utilised to provide rich and detailed data. In all, 10 semistructured interviews were conducted with staff, both paid and volunteers. While acknowledged as modest, the study sought the views of staff across different roles and responsibilities within the organisation.

The site was an integrated health service which incorporates a residential aged care facility, a respite centre and a community hospital, as well as community care services. The Eden model of care was adopted by the service in 2008. The site is located in a farming district about 1 hour's drive from a major regional centre, and in an area that has a larger proportion of older people.

Recorded interviews were conducted with a sample of staff involved in residential aged care, with data collected in the form of detailed notes taken from digital recordings of the interviews. The data were then analysed using thematic coding. It should be noted that in order to ensure confidentiality of staff within such a small service, direct quotes are generally not presented here. It is also important to note that the Eden model requires specialist training and six staff interviewed for this study had completed the training fairly recently, which may have influenced their responses. Overall, rigor was ensured by the systematic approach to data reporting, and inclusion of exceptions to coded themes.

Findings

  1. Top of page
  2. Abstract
  3. Introduction
  4. Themes from the literature
  5. Methods
  6. Findings
  7. Discussion
  8. Acknowledgements
  9. References

A change or more of the same?

Staff interviewed for this study generally saw the Eden model as a set of principles or a guide for providing care. Some viewed it as something to aspire to; a challenge to the practice of care delivery while others saw it in more practical terms as a set of tools. Consistently older people were framed as central to the model of care, with respondents asserting that practice was led by clients' preferences. A change in the organisational culture highlighted the need for aged care facilities to value older people, be more homely and address boredom. The physical design of the buildings and landscaping, and incorporation of the natural environment, was also viewed as integral to the operation of the Eden model. Finally, respondents highlighted that the organisation needed to be flexible and open to new ideas.

Most respondents suggested that Eden gave them permission to consider their role, and to think creatively and more broadly. Respondents highlighted the client-centred discourse of the Eden model, suggesting that relationships are more important than tasks. As a result, they suggested that the site's aged care facilities now have less of a clinical feel with a more relaxed atmosphere.

However, respondents across the work roles did not view the implementation of the Eden model as being a radical change process, but instead an extension and validation of existing practice. This was particularly the case as this health service is part of a small tight-knit rural community. Respondents overwhelmingly described the culture of the service and the local community using phrases such as ‘friendly place’, ‘supportive community’. The community is seen as settled, with a high proportion of volunteers and beautiful surrounding countryside. Respondents consistently referred to the strength of the local community and links to the service, and the historical resident-focus of its aged care facilities. Staff suggested, for example, that the facility had always integrated animals or items from a resident's home. Change in the work environment was thus not viewed as a result of the cultural change.

Addressing the three plagues

It is important to note that, irrespective of individual views on the Eden model, all respondents, whatever their work role, used language that was person-centred and put the quality of life of older people uppermost in discussions about their work. Indeed the attributes commonly seen as part of Eden model of care were consistently described by staff in complementary ways – humanist practice, person-directed and ‘working with, not telling’. In short, staff presented with a strong awareness of person-centred care, although there was no evidence that this was absent from the facility prior to the introduction of Eden.

Despite this, there were some issues in implementation of the Eden model. Several respondents noted that an increase in activities, or ‘organised spontaneity’ was a positive change in the delivery of aged care within the facility. They suggested that the Eden model encourages constant thinking of how to involve residents in life at the facility and gives residents ‘something to do’. While generally supported, some expressed concerns. One suggested that the low care section ‘overdoes activities’, and there is a need to check with residents if this is what they really want to do. Another staff member suggested that not all residents suit group activities and that there was a need to tailor individual activities. The practical difficulties of this were acknowledged. Furthermore, some staff were concerned that older people themselves were excluded from the consultation and implementation of Eden on the site.

In particular, respondents noted the lack of acknowledgement of prior practice. One staff member, for example, reported a number of anecdotes from colleagues who were concerned about this. They believed that the model was introduced in response to a belief that existing care provision was based on a medical model of care within a sterile environment where older people are undervalued. Some long-term staff suggested that this premise is flawed and felt that their existing valuable practice was discounted.

By contrast, others noted that Eden has given ‘clout’ to existing practice at the integrated health service by giving a name and reason for what was already happening. As one suggested, this gave a framework for the service's care practices. However, responses diverged as to whether this framework provided sufficient practice guidance, as some noted that Eden did not provide policies and programs around issues of care and ways of working.

Management practices

Some concerns were expressed that the Eden model is based on a doctrine, and that, as a result, the positive dimensions of other models of practice are not considered. They proposed that ongoing consideration of alternatives was vital to innovative practice, and in the best interests of older people. Thus senior management needed to both support practice and be open to new ideas. They also needed to provide the additional time and resources necessary to implement this model of care and also for change to occur. Support from all levels of management, including continual dialogue about ways of working, was deemed crucial if continuous improvement was to be possible.

Being open to new ideas was seen as particularly important, with recognition that this is healthy within an organisation. However, some noted that staff who challenged ideas were seen as impeding the implementation of Eden and that critical reflection was lacking. Yet this is consistent with the principles of Continuous Improvement Model recommended by the Aged Care Standards and Accreditation Agency. On the other hand, some respondents noted that management within the facility was open to new ideas, and let staff ‘go for it’. This might be, as one respondent suggested, because middle managers have developed more confidence and direction.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Themes from the literature
  5. Methods
  6. Findings
  7. Discussion
  8. Acknowledgements
  9. References

This research reports a small study of staff views in one rural aged care facility that has adopted the Eden model of care. The small size of the study is acknowledged; however, this study needs to be seen in the light of previous published work in this area, much of which lacks rigor and critique. The present study incorporated a qualitative methodology, which has generated in-depth and nuanced data exploring the experiences of staff involved in the implementation of the Eden model. As such, this study provides impetus for a critical analysis of a model of care that is often simplified in practice to the introduction of animals or plants, and rejected as naive by some gerontologists.

In this modest study, it was found that the concepts of person-centred practice, the professionalism of staff and the principles of the Eden model are complementary. The marketing of the Eden model of care as transformative may not be as pertinent in Australia where person-centred practice exists. However, the Eden model permits inclusivity as it provides all staff working in aged care with training and continued involvement in the daily management of resident-focused care. The discourse associated with Eden, while criticised, provides a rights-based language for all staff within a facility. Staff are able to link what they do, varying from cooking to nursing, to the rights of older people to have a say in their care. For all respondents, the resident's quality of life was the focus of their work. While this may be part of professional education of nursing, allied health and management, it is not necessarily a part of the knowledge base of kitchen staff, some carers and tradespeople.

Gerontologists, such as Peter Townsend, assert the application of a human rights framework in relation to the older people, the rights of older people to dignity and participation in decisions concerning the living conditions of institutions [18]. The tension between living in long-term care and rights was evident in the implementation of Eden at this facility. Respondents highlighted the contradictions associated with the implementation of the Eden model, pointing out that all older people have the right for quality care but that a one size fits all approach may not suit all residents. Consultation is needed to ensure all are comfortable with the changes due to the Eden model. These all raise significant issues in relation to person-centred care and what this means in practice.

It is also clear from this study that the Eden model was not being applied to a blank slate. The town, its rural environment, cohesive community and long history of person-centred practice were very important. This suggests that research and commentary of aged care provision need to be systemic and take into account the context in understanding issues relevant to the care of older people in both rural and urban settings.

This study has highlighted both the challenges inherent in the implementation of this model, as well as its potential contribution to aged care. More in-depth research is now clearly needed to provide a greater understanding of what the model offers others, particularly residents and their views on care in an Eden facility. Furthermore, the issue of innovation is contentious, and more comparative work is needed to demonstrate what the Eden model offers, how it differs from other models and what implications this has for practice. As integrated health services begin to roll out community services based on the Eden model, research is urgently needed to explore how this can best be achieved.

Findings, such as from the present study, highlight yet again the importance of staff's values, education and the acknowledgement of their contribution are all vital to the well-being of older people living in an aged care facility. Furthermore, research that explores the mix that makes up the practices of care facilities is urgently needed to provide evidence to assist in shaping and providing care and services for older people in Australia.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Themes from the literature
  5. Methods
  6. Findings
  7. Discussion
  8. Acknowledgements
  9. References

We wish to acknowledge and thank Mary-Anne Grunow, Director of Client Care and the staff of Tallangatta Health Service for their contribution to the research.

Key Points

  • • 
    The Eden model of care, while often associated with innovation in aged care, lacks rigorous academic research.
  • • 
    While the discourse of the Eden model is accessible for all staff and is person-centred, there is tension with practices within the context of Australian aged care.
  • • 
    There is a need for research not only of the Eden model of care but also of innovation in aged care within Australia.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Themes from the literature
  5. Methods
  6. Findings
  7. Discussion
  8. Acknowledgements
  9. References
  • 1
    Baker B. Old Age in a New Age: The Promise of Transformative Nursing Homes. Nashville, TN: Vanderbuilt University Press, 2007.
  • 2
    Rahman AN, Schnelle JF. The nursing home culture-change movement: Recent past, present, and future directions for research. The Gerontologist 2008; 48: 142148.
  • 3
    Weiner AS, Ronch JL, eds. Culture Change in Long-Term Care. New York: Haworth Press, 2003.
  • 4
    Tesh AS, McNutt K, Courts NF, Barba BE. Characteristics of nursing homes: Adopting environmental transformations. Journal of Gerontological Nursing 2002; 28:2834.
  • 5
    Thomas WH. Life Worth Living. Acton, MA: Vander Wyk & Burnham, 1996.
  • 6
    Weinstein LB. Eden alternative: A new paradigm for nursing homes. Activities, Adaptation and Aging 1998; 22:18.
  • 7
    Kruschke C. Eden Alternative and Rosebud Nursing Center: Does the Eden Alternative Improve Resident Outcomes in a Long Term Care Setting? [Doctural]. Milwaukee, WI: Cardinal Stritch University, 2006.
  • 8
    Barba BE, Tesh AS, Courts NF. Promoting thriving in nursing homes: The Eden Alternative. Journal of Gerontological Nursing 2002; 28:713.
  • 9
    Olson JK. Is this really a nursing home? Contemporary Long Term Care 2001; 24:1921.
  • 10
    Tavormina CE. Embracing the Eden Alternative in long-term care environments. Geriatric Nursing 1999; 20:158161.
  • 11
    Mackenzie S. Implementing the Eden Alternative in Australia. In: WeinerAS, RonchJL, eds. Culture Change in Long-Term Care. New York: Haworth Press, 2003:325338.
  • 12
    Monkhouse C. Beyond the medical model – The Eden Alternative in practice: A Swiss experience. In: WeinerAS, RonchJL, eds. Culture Change in Long-Term Care. New York: Haworth Press, 2003:339354.
  • 13
    Bergman-Evans B. Beyond the basics: Effects of the Eden Alternative on quality of life issues. Journal of Gerontological Nursing 2004; 30:2734.
  • 14
    Parsons M. The impact of the Eden Alternative on quality of life of nursing home residents [PhD]: University of Nebraska; 2004.
  • 15
    Coleman MT, Looney S, O'Brien J, Ziegler C, Pastorino TC. The Eden Alternative: Findings after one year of implementation. Journal of Gerontology 2002; 57A:422427.
  • 16
    Hinman MR, Heyl DM. Influence of the Eden Alternative on the functional status of nursing home residents. Physical & Occupational Therapy in Geriatrics 2001; 20:120.
  • 17
    Robinson S, Rosher RB. Tangling with the barriers to culture change: Creating a resident-centered nursing home environment. Journal of Gerontological Nursing 2006; 32:1925.
  • 18
    Townsend P. Policies for the aged in the 21st century: More ‘structured dependency’ or the realisation of human rights? Ageing and Society 2006; 26: 161179.