Eleanor Feldman Barbera, Ph.D.

I was speaking about leadership to a group of administrators recently when the discussion turned to person-centered care. “Culture change, the Eden Alternative, whatever you call it,” I said, “things are moving in that direction. MDS 3.0 has the team asking residents questions that staff members would have answered in the past, such as whether or not residents feel depressed.”

We talked about the impact of this and I continued, “In my experience, the nursing home I worked in that was most attentive to the psychosocial needs of the residents was the one that was in the process of becoming an Eden Alternative home.”

I’m not in any way affiliated with the culture change movement, but I certainly noticed the difference in the atmosphere in the Eden facility and its impact on the residents’ mental health. In traditional facilities, an enormous amount of the residents’ psychotherapy time is devoted to addressing how to work in or around the nursing home system if possible, and how to maintain their equanimity and sense of humor if not. This was less of a focus for residents in the Eden home.

When I work with the staff in a traditional nursing home, I’m often an emissary of the residents, delivering their messages in a way that can be heard by the staff. In the Eden facility, there are more emissaries and more people listening to what the residents have to say in the first place. Being heard is essential for good mental health.

The Eden Alternative

In 1996, I read the book, “Life Worth Living,” by William H. Thomas, MD, founder of The Eden Alternative. It outlined a different philosophy of care that focused on creating a more homelike environment. It got me excited about the possibilities for eldercare, but it didn’t match what I was observing in person. When I mentioned the Eden Alternative to my coworkers, they didn’t seem to know much about it, except that it was “that thing with the birds and the plants.”

I once worked in a Nurse Rached kind of place with two lovely cats and I could tell it wasn’t about the pets or the plants. By contrast, there were no pets in the nursing home I worked in that was in the process of culture change, but staff had conversations like this: “If Mrs. Jones wants to get up at 11a.m., it’s her home and we have to figure out a way to accommodate this.” Nice.

Visit to an Eden site

Last month, I went to visit two nursing homes to see culture change in action. One used a Green House model and I’ll tell you about that in my next post. The other home, Canterbury at Cedar Grove in New Jersey, was in the process of “Edenizing.”

Canterbury had birds, fish, and, yes, plants in the lobby, along with coffee and tea. But its long halls and nursing stations looked much like any traditional nursing home I’d ever been in. (Read: You can do it too.) One thing that was different: joining the “elders” in the dining room were family members with their own lunch trays and “caregivers” having tea while assisting with dining.

In a revealing conversation with the team after the tour, one of the members said, “Before, we just thought of them as residents, now we think of them as people. Before, we were focused on getting the job done, and now we’re focused on meeting their needs.”

This frank statement echoes my observation that when the focus is on accomplishing all the tasks to avoid getting in trouble, the residents’ needs and desires get lost. If all the beds are supposed to be made by 10 a.m. or the aides will be chastised, it doesn’t matter in the least if Mrs. Jones wants to sleep until 11 a.m., the way she’s done all her life. Mrs. Jones can sulk or fume in the hallway with everybody else.

The questions we ask

We can’t blame the aides, though, if the nursing supervisors come onto the floor and ask, “Why aren’t all the beds made?” rather than “Why is Mrs. Jones crying?” And we can’t blame the supervisors if the administrator’s focus is on order rather than on happy residents; the nursing supervisors are following the lead of the administrator — and the administrators are following the lead of the surveyors. Now that CMS, via the MDS, has begun asking the residents whether or not they’re depressed, there’s a greater chance that everyone along the line is asking better questions.

Creating change

It’s not easy to alter a system that’s been in place for so many years. Not only do we need to ask different and better questions, we have to train staff to think differently and then back up the training by rewarding the new behaviors we want to see. Using employee recognition programs is a good way to reinforce what’s been taught to the team and to emphasize its continued importance over time.

Culture change organizations have vetted new models of providing care and can help ensure compliance with legal and regulatory guidelines while making changes.

For those interested in learning more about culture change, here are some resources:

The Pioneer Network

The Eden Alternative

The Green House Project

In my next post, I’ll tell about my mind-blowing visit to a Green House.

Eleanor Feldman Barbera, PhD, author of The Savvy Resident’s Guide, is an accomplished speaker and consultant with over 17 years of experience as a psychologist in long-term care. This blog complements her award-winning website, MyBetterNursingHome.com, which has more on how to create long-term care where EVERYBODY thrives.