Appendix II

Designing for Eden AlternativeTM

Emi Kiyota, M.S., M.Arch



I still remember my first visit to a nursing home. It was on a cool spring day. My parents and I were visiting my grandmother. When I walked into my grandmotherfs quarters, I was shocked to see her living environment. The memory of this disturbing and traumatic experience still remains.


When an individual enters a space, he or she has a unique feeling about the surroundings. And this sensation is determined by the specific characteristics of the environment he or she is experiencing. Although it is difficult to describe, many nursing homes have distinctive attributes, by which they have come to be known as gnursing homesh. Dr. Bill Thomas introduced the Eden Alternative in the attempt to eliminate these attributes of the nursing home as an ginstitutionh.


The Eden AlternativeTM was developed by William Thomas, M.D. and Judy Meyers-Thomas in 1991 in order to improve quality of life for nursing home residents. The Eden philosophy identifies feelings of loneliness, helplessness, and boredom as three serious problems in long term care. As a practicing geriatrician, Thomas found that nursing home residents frequently suffered from those maladies. While medical technologies have led to many improvements in nursing home clinical status, medicine offers little to lonely and bored people living in long term care institutions. Thomas advocates transforming nursing home environment into a human habitat filled with companionship, opportunities to give and receive care along with de-emphasis of medical treatment. (Thomas, 1996)


Why should a nursing home have a gnursing home-likeh appearance and atmosphere? The time has come to change this notion of the nursing home-like into the home-like environment. Numerous studies have been done in a variety of disciplines that recognized problems of conventional nursing home environments. (Cohen, and Weisman, 1991; Namazi, 1994; Regnier, 2002). Due to these contributions, nursing home environments have been improved in ways that enhance the residentsf quality of life. However, the institutional metaphor remains the dominant paradigm. As a result, the Eden Alternative movement is aiming at transforming the institution into rich human habitat, which will promote therapeutic outcomes for the both residents and staff.


In the last ten years, much of effort has been made to transform the nursing home environment into a human habitat with the introduction the Eden Alternative philosophy. Eden Alternative advocates creating a human habitat where elders are able to enjoy their lives and grow. However, transforming a nursing home-like environment into a human habitat requires tremendous effort to change the culture, organization, and physical environment.


Among the changes made by the Eden Alternative, I focused on studying the relationship between the physical setting of the gEdenizedh facility and residentsf everyday environmental experiences. A case study was conducted to explore the impact of physical changes on residentsf everyday environmental experience in the facility where the philosophy of the Eden Alternative has been adopted. In the study, I had an opportunity to live as a resident in an gEdenizedh nursing home in Fargo, North Dakota. In order to understand nursing home residentsf everyday environmental experience, I was in a wheelchair and restricted my left arm in a sling for three weeks. It was such an eye opening experience for me to learn about the nursing home environment not only from the observerfs perspective but also from a nursing home residentfs perspective. Through my research, I also evaluated design related issues of the physical environment where Eden Alternative was embraced.


In this paper, I would like to discuss what architectural contributions could be made to create an environment that maximizes the benefit of the Eden Alternative. The suggested design implementations are addressed based on the my interpretation of the philosophy of the Eden Alternative guided by Thomas who is a founder of the Eden Alternative, my first hand-experience from participant observation, content analysis of multiple in-depth interviews with residents, and results from behavior mapping research. This paper is organized in four sections, the background of conventional nursing home environment, the introduction of the Eden Alternative, the design objectives to create the human habitat that Eden Alternative has been advocating, and the suggested practical design implementations.


What is the conventional nursing home environment?

Many traditional nursing homes operated within the so-called gmedical modelh, which comes from hospitals. Under this model, so named from its mirroring of hospital care, professional staff members provide treatment to dependent elderly residents. Life in such places revolves around the facilityfs routine; activities are programmed and structured, staff works impersonally from resident to resident. There is a general sense that the facility belongs to the staff members. Residents come to be known and discussed by their diagnoses and weaknesses, not their strengths.

Under the medical model, efficiency was the main interest for designing buildings. The physical settings were supporting the notion of the gTotal institutionh to achieve physical and economical efficiency (Goffman, 1961). The hospital-like buildings were designed to accommodate maximum numbers of elders and facilitate staff membersf work, rather than focusing on the residentfs needs. In general, identical residentsf rooms, long corridors, nurse stations, and hallways reflecting shinny glare light were the norms.

Although elders were expected to reside in nursing homes for their remaining days, their opinion regarding their living environment have not been not taken into consideration. Moreover, the environment was heavily regulated to minimize risks of incidents. One of the main concerns also was to achieve safety and hygiene in the environment. As a result, elders stayed in sterile and cold hospital-like setting.


What has been done with the introduction of the Eden Alternative Philosophy?

Unlike hospitals, which treat acutely ill patients, nursing homes ought to be places where people can feel at home. In many cases, residents stay in nursing homes for long periods of time and may even live there for their remaining days. The Eden Alternative changes conventional nursing home environments into places where people can enjoy living and growing.

With the culture change movement, which includes The Eden Alternative, a paradigm shift has been made to improve residentsf quality of life. This movement acknowledges residentsf expediency as the priority rather than that of the staff members. Under this paradigm of resident-centered care, elders are involved in decision-making concerning their own living environments; many facilities organize resident-council meetings.

In many Eden Alternative faculties, residents organize an art council and select all the pictures, photographs, and art works for public areas. Some of the art works are donated or purchased based on residentsf decision, and others are art works done by residents.@

Thomas believes that the human habitat can provide a milieu where the three plagues of loneliness, helplessness, and boredom may be treated. With existing buildings, when the Eden philosophy is introduced, the setting is progressively transformed into a human habitat with many plants and animals. Some nursing homes also operate child daycare centers within their premises to create environments similar to the outside world.

Plants are introduced to provide nursing home settings with a natural appearance, and also afford the residents the opportunities to take care of them. Animals are introduced to live in nursing homes as residentsf pets rather than being brought in temporary for some activities. Children from daycare and schools visit elders in nursing homes. Family members are also encouraged to bring their children to nursing homes.

In these facilities, amelioration the residentsf everyday life has been observed. Both residents and staff members seem to enjoy living with animals, plants, and children in the nursing home environment. These gliving thingsh help make the nursing home a more agreeable place. They also attract visitors and make their visitation a pleasurable experience. This is especially true for children.

The Eden Alternative model has considerably improved nursing home residentsf lives. However, there are still many issues that remain to be discussed. Until now, it has been mostly staff members who have made changes to these nursing homes. Consequently, the areas used by staff members have a more natural appearance and more living things than the areas frequently used by the residents. In other words, the introduction of the Eden Alternative philosophy currently benefits staff members more than the residents. Due to the little understanding of residentsf needs, gdecorationsh have been made in the places where staff members frequently performed their work routine.

In the course of my research, I observed that residents were not so interested in gdecorated spaceh outside of their personal living quarters. Thus as the staff members failed to grasp their residentsf preferences, daily routines, and physical conditions, the expected benefits of the gHuman Habitath could not be observed in residentsf everyday life. For example, many birdcages and potted plants were placed much higher than where residents with wheelchair could reach. The selections of plants did not necessary reflect residentsf interests or familiarity. Moreover, most plants or animals were out of reach or out of sight for wheelchair-bound residents. Such barriers prevented residents from interacting with the living things placed there for them.

The facility where I conducted my research project was built thirty years ago with a design philosophy that mirrored the gmedical modelh. In terms of its physical setting, the size of the existing building, space usage and configuration, and the natural setting as well represented issues in the Edenizing process.

While I was in wheelchair, I felt that all the places where I needed to go were far away from my room. The areas where major activities were taking place were scattered around the building. Due to the large size of the building, I needed to wheel through the long corridor to get to any place. Finally, I decided to stay in the room all the time because I was tired of wheeling to places.

Also there was an on-site child daycare but its location was not adequate for promoting daily spontaneous interactions between residents and children. The daycare center was indeed located so that there was only limited visibility from either the resident rooms or the living rooms. Obviously, because it was built under the gmedical modelh there were structural limitations making it difficult to fully embrace the Eden Alternative philosophy in this facility


Design objectives to maximize the benefit of the Eden Alternative

In the past, the role of architecture had been given little attention in the Edenizing process. However, with the evolution of the Eden philosophy, it has been recognized that designed environments have a great impact on the gEdenizingh process and, consequently, on the daily life of the people who work and live in nursing homes. Creating a human habitat requires an innovative and original way of thinking in transforming the institutions into places where elders can enjoy and grow. In this section, design objectives to maximize the benefits of the Eden Alternative are discussed.


Warm environment

One of the first steps of the Edenizing process is to create warm environments to nurture human growth. The Eden Alternative believes that this warm environment can be achieved through the creation of small-scale nursing homes, the flattening of the organizational structure, and informality. When facilities are built on large scales, it becomes a challenge to be acquainted with people who live and work there. Similarly hierarchical organization systems sometime prevent personal connections with others from the work environment. Therefore Eden Alternative encourages creating environments where people are able to know each other on a personal level.

To carry out this concept, the design should consider breaking the large numbers of rooms commonly seen in nursing homes into smaller scale clusters where workers as well as residents meet in informal settings. Also, in order to stimulate more informal communications, the locations of residentsf rooms, staff work areas, and the management offices should be intertwined, rather than placed into separated areas.


Introducing animals, plants, and children is different from creating Human Habitat

The objective of transforming the institution into a human habitat is to create an environment where people can work and dwell, and enjoy their lives and grow. In order to attain this ideal, there is a great need to introduce animals, plants, and children in eldersf daily life and to provide them the opportunities to spontaneously interact with a variety of living things. Although introducing living things is an essential part of creating the human habitat, it would be incorrect to equate introducing animals, plants, and children to the gEdenizingh process. Also, without interactions, benefits of Edenized environment cannot be expected.

With a true understanding of the objective of human habitat, the design effort should be made to facilitate the cohabitation of animals, plants, and children with elders in nursing home setting. For example, an innovative design would provide a place where every elder, in various physical or mental conditions, has opportunities to spontaneously interact with living things. An appropriately designed environment with careful planning will maximize the benefits of the Eden Alternative philosophy.


Each facility is different

Contrary to the institutional nursing homes, which are often built in chains like big corporation hotels, gEdenizedh homes are not to be franchised or reproduced because The Eden Alternative believes in respecting the uniqueness of every individual, organization, and culture. As a result, communities are encouraged to capitalize their own gEdenizingh process and circumstances in order to maximize the potentials of their facilities, which are tailored to suit their specific needs.

In order to make the most of The Eden Alternative, facilities and designers should jointly take their specific journey to create a human habitat to meet their elderfs needs. Both facilities and the communitiesf qualities ought to be expressed in the design of the interior and exterior of the building.


Every resident is different

Although the levels of residentsf physical and mental conditions may vary, every resident in a nursing home should be respected as a unique human being. Therefore the environment should afford all residents the possibility to freely decide, and to freely express themselves concerning the space where they live most of the time. To meet the diverse needs of the residents, a certain amount of flexibility should be taken into account in the designing process to allow residents to personalize their individual space. For example, installing large fixed commercial furniture in the rooms will not only minimizes the opportunity for residents to personalize their space; it will also limit the flexibility of the space usage.


Resident-Centered design

In the medical model, the environment is arranged to facilitate work and economical efficiency rather than resident convenience. Although the gEdenizingh process influenced organizational routine and decision-making in many nursing homes, residentsf voices have not always been well reflected in the design of the physical setting. However, because residents are so wise, they learn to quietly accept what they are offered to avoid being labeled as recalcitrant. Consequently, they give up their daily customary routines and accept (sometimes against their will) the ways of the institution. One could jokingly say that they are almost trained to be nursing home residents.

There is a need to re-examine the traditional approach. The environment should be designed to benefit residents foremost. Today, some nicely designed up-scaled facilities are trying to provide home-like settings to their residents. For example, they offer nice-looking entrances with residential furniture and beautiful decorations, which seem to appeal to family members and other visitors. However, the residents do not use those entrance areas on a daily basis. Moreover, residents show very little interests to decorations that do not belong to them. So if residents do not use those nice-looking spaces, it is important to re-evaluate the design and ask ourselves: gIs this environment meaningful to residents?h


Cultivating spontaneity in daily life and work

The Eden Alternative encourages residents to be involved in their daily activities. Living in nursing homes does not mean that residents should give up engaging in life. Evidently they are in various physical or mental conditions and require support from other people. However, appropriately designed environments can support and give them confidence to interact with living things and enjoy their every day life. Promoting residentfs spontaneous and informal involvement in life may cultivate more joy and self-esteem than programmed activities. For this reason, understanding eldersf routines is important in the process of designing supportive environments where residents remain engaged in life.


Practical design Implementations


In order to achieve the design objectives, some suggestions are introduced in this section. These suggestions are based on my observations and my experience living in a nursing home as a resident.


1. Understanding Residentsf Everyday Routine in Nursing Homes.

When I lived in a nursing home for my research project, I observed that residentsf lives were highly routinized and limited in options. Also, residents were often unable to explore unfamiliar places in the nursing home because of their limited physical strengths and endurance. By understanding these limitations and the need for residents to interact with living things, designers could create spaces, which will afford a maximum physical and visual access to the space filled with life.


2. Understanding and Compensating Residentsf Physical Abilities

Nursing home residents are physically challenged in many ways. Some simple tasks can be extremely difficult or impossible for residents to accomplish without adaptive tools and techniques. The combinations of these adaptive devices and a therapeutic environment must often be employed. However, because the creation of these techniques still remains in its infancy varieties of engaging daily activities should be provided to compensate with different types of residentsf physical shortcomings.


a. Distance

Getting around appeared to be a challenge for the residents considering their limited physical abilities. Going to any place from their room seemed be too far for them to walk or wheel by themselves. Since many residents experience some degree of difficulties with walking, staff members needed to push their wheelchairs anytime they wanted to get around. Consequently, residents need to experience gwaitingh before they can carry out any activities. In the light of these observations, there is a need to design environments where residents are able to accomplish their daily tasks without traveling a long distance; small-scale building and neighborhood design could be the answer.


b. Height

Residents in wheelchairs have eye levels that are much lower than those of people who are walking. In addition, many residents experience some difficulties with their upper body motor skills. Therefore the height that these residents are able to see and reach should be anticipated to be lower in the designing process.



c. Flooring

In order to create ghomelikeh settings, many long-term care facilities have their hallways carpeted. This is also beneficial for controlling the noise level. However, carpeted floors do not afford easy mobility or maneuverability for residents or anyone using a wheelchair. Many residents have experienced one or multiple strokes before they moved into the nursing home; as a result they have limited physical strength. Carpeted floors may not be the best option in nursing homes.


d. Technology

Nowadays, there are many adaptive tools or assistive-technologies available to maintain residentsf independence. Therefore the use of technologies to compensate residentsf physical or mental conditions should be considered in the future design process.


3. Enhancing Visual accessibility

Visual accessibility is important for residents to spontaneously engage with social life. Based on my observations and behavior mappings analysis, I found that residents did not go to places where they were not obviously visible. Thus enhancing visual accessibilities from the residentsf rooms to the public areas can stimulate socialization among people who work and live in nursing home.


a. Visual accessibility to animals and birds

The presence of animals usually makes residents happy. However, the location and the seating height are critical for residents to interact easily with the animals. If the spaces favored by the animals are not visible from where residents usually stay, interactions may not be expected. In terms of height, many birdcages were placed too high for the people who were sitting or in wheelchairs to enjoy watching the birds. In this regard, design effort should be made to create a place that attracts animals close to where residents usually stay. Moreover, the place should be visually accessible for the residents.


b. Visual accessibility to nature

In Edenized facilities, there are many houseplants in public areas, especially in the entrance. In many cases, staff members introduce plants in the environment. Consequently, the areas that staff members frequently use and visit have more plants than those where the residents usually stay. It is important to introduce plants to promote the spontaneous activities in places where residents visit frequently. In the facility where I conducted my research, some residents had views to the courtyard from their rooms but others did not. I believe that visual accessibility should be equally provided to residents both from their own rooms and from the living rooms. Also, although some residentsf rooms had windows facing to the courtyard, ornamental shrubs next to the windows often blocked the view for the residents who had to be in bed. Consequently, I believe that a close communication between architects, landscape architects, and the maintenance staff is essential in the design and operations process in order to maximize the benefits of the natural environment.


c. Visual accessibility to children

I have also observed that residents appeared to enjoy watching children in the daycare. However, because the daycare was located at the end of a hallway, residents had a limited view of its interior spaces. The locations of the child daycare and play areas have strong influences on motivating residentsf spontaneous interactions.


d. Visual accessibility to outside world

Nursing home residents would like to feel connected with outside world. Providing a space where residents could observe what is happening outside of the nursing home should be considered an important designing issue.


4. Maximizing choices

Providing more choices of places to accommodate residents outside of their own rooms is an important issue in creating an gAlternativeh environment. In the facility where I conducted my research, there were few common areas where residents could stay during the day. Staff members always filled those areas with residents in order to oversee them. There was no alternative provided to residents who would like to enjoy being in quiet spaces.

Some residents mentioned that they did not like to go to the common areas because there were animals or children; others were worried about allergy to plants. Since The Eden Alternative encourages introducing variety of living things in residentsf environment, a variety of physical settings should be provided to residents. In other words, creating spaces where residents are able to choose to either enjoy engaging with living things or not should be anticipated in the design process.


5. Creating The Place Where Residents Are Able to Find Meaning

a. Feeling of ownership/responsibility

Residents often feel for taking care of the animals that they feed, the plants that they own, and the children whom they interact everyday. Creating a place where residents can enjoy taking care of such living things is important. For example, although there were many plants in public spaces in the facility where I conducted my research, residents did not seem to show interest in interacting with them. On the other hand, they enjoyed taking care of the plants in their rooms. There was a general sense that plants in the resident rooms belonged to the roomsf occupants, while plants in public spaces were seen as belonging to the facility. This demonstrates that the sense of ownership can encourage a spontaneous interaction with plants. Not only encouraging residents to have a sense of ownership, but also accommodating their need for interacting with living things in everyday life will be critical for success in creating human habitat.


b. Display their efforts

The importance of personalizing residentsf room by allowing them to bring their own furniture and decorating with things related to their memories is now widely recognized. Since Edenized facilities encourage residents to be involved in life with other living things, they should be encouraged to not only express their memories from their past but also their new experiences and accomplishments in their nursing home. I observed that residents were proud of the plants and animals that they were taking care of in their rooms. The residents were pleased to show and share with others stories about their plants and pets. In the light of this, nursing home designers should provide a place where residents can display such efforts as a means to enhance their motivation and self-esteem.


c. Living things with personal attachment/family involvement

Plants kept in resident rooms were mostly ones given by their family members. Residents seemed to validate and strengthen the feeling of attachment to their family members through the act of taking care of the plants. Plants with personal attachment are more highly valued and that value seems to be associated with a high degree of spontaneous interaction with these plants. Providing personal attachment with animals, birds, and children should also be encouraged for the same reason. A place should be provided to allow elders to enjoy such attachments.


d. Introducing the Arts

Animals, plants, and children are not the only agents to help making home-like environments. The role of the arts should be taken into account for creating resident-centered environments. Usually, there is at least one art work decorating every residentfs room. They are mostly brought from residentsf homes. I believe that the artworks in residentsf rooms can be special ones for them because residents are able to bring only very limited belongings into nursing homes. Familiar artworks may be able to enrich residentsf everyday life in these environments that are so far in many senses from their own homes.

Introducing art into nursing homes also has a positive potential for community development. The walls of hallways, bathing rooms, kitchens, and family rooms can be offered to artists from community to paint and for residents to enjoy. Meaningful places can be created to display artworks of residents and local artists.



5. Creating attractive outdoor spaces

A Variety of living things should be introduced into garden spaces to maximize the benefit of the Eden Alternative. A garden space can be an informal area where residents, children, and animals meet. Integrating the space for animals to exercise, children to play, family members to visit residents, staff members to take a break, and residents to get away can make the garden space a positive and lively place. In such a garden, it would also be important to create short cuts to maximize informal interactions between nursing homes residents and personnel.


a. Location and number of exits to the outdoor space.

Considering residentsf physical and mental condition, traveling long distance to reach the exits from their rooms can discourage them from going out into the courtyard.@ It important to consider the location and number of exits in order to maximize the use of the outdoor space.


b. Gap at the doorways

Gaps in the flooring of exit doorways can prove critical. Even if they are small, such gaps remain a very difficult barrier for residents using wheelchairs or walkers to negotiate.


c. Pathway design

The pathways design in the courtyard can be critical for some residents. Long-straight pathways and sharp corners are difficult to negotiate when residents self-propel their wheelchair.


d. Shade

Many residents are susceptible to sunlight. For residents who would like to stay outside but not able to be under the sun, shaded spaces allow them to enjoy being outside, safely.


e. Appropriate seating areas

Nursing home residents have limited physical strength. Appropriate seating areas should be provided for residents to rest, when needed. Shaded seating areas will be also recommended


f. Height of flower beds

Physical limitations make it difficult for many residents to garden on the ground level. Raised flowerbed allows residents to have easy access to interact with plants.


g. Avoidance of Toxic plants

Residents with cognitive impairments may be accidentally tempted to taste the plants in the garden. Staff members should avoid sowing or potting toxic plants where they can be reached.


h. Insects

Flowers attract not only butterflies but also bees. These insects usually fly at eye level for residents in wheelchairs. Insect control should be taken into account in any nursing home environment.


i. Attractive design from the residentsf bed

For residents who are staying in their beds all day, outdoors space should be designed in a fashion that enables them to enjoy the outside world from their beds.


The Eden Alternative is a holistic program, which is aiming to transform the elderly institution into a human habitat. Although it plays a significant role, the design itself cannot per se create the human habitat. The most important part of the Eden Alternative is genuine care. The role of Architecture is to create a supportive environment for staff to provide genuine care and to ensure that each resident has a life worth living. In other words, architecture is the setting for the play. Staff members help residents to play their life role on the stage-- under the theme of elderhood.

Architecture has an important role in the Edenizing process but it is important to note that the design should emerge from the residentsf perspective. To achieve this objective, communication is the key. There has to be effective communication among Architects, organizations, floor staff, and residents to create a successful Eden Alternative environment.




Eden Alternative Photos (By Emi Kiyota)



Literature Cited@@


Cohen, U. and Weisman, G. 1991. Holding on to Home: Designing Environments for People with Dementia. John Hopkins University Press, Baltimore


Goffman, E. (1961) Asylums; essays on the social situation of mental patients and other inmates. Garden City, N.Y., Anchor Books


Searls, F. H(1960) The Nonhuman Environment. International Universities Press, New York.


Namazi, K. H., and Haynes, S.R. (1994) Sensory stimuli reminiscence for patients with Alzheimerfs disease. Relevance and implications. Clinical Gerontologist. 14(4): 29-46


Regnier, V. (2002). Design for Assisted Living: Guideline for Housing the Physically and Mentally Frail. John Wiley & Sons, Inc., New York.


Thomas, H.W. (1996). The Life Worth Living: How Someone You Love Can Still Enjoy Life in a Nursing Home. VanderWyk and Burnham, Acton.