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Improving dementia care with the Eden Alternative

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The Eden Alternative is a philosophy that encourages nurses to empower care home residents by recognising what they are able to do and engaging them in activities


The Eden Alternative philosophy is a vehicle to change the culture of care in nursing homes and the community from an institutional, medical model to a more person-centred approach. This article explains how it was developed and discusses its implementation in the UK over the past 10 years. It also explains the effect of the approach on the wellbeing of residents, staff and relatives, and on the status of the nursing and care staff in nursing homes across the UK and Ireland.

Citation: Burgess J (2015) Improving dementia care with the Eden Alternative. Nursing Times; 111: 12, 24-25.

Author: June Burgess is Eden Alternative regional coordinator for the UK and Ireland.


The Eden Alternative (EA) was developed in 1994 when the medical director of a US nursing home realised loneliness, helplessness and boredom affected residents more than the conditions precipitating their move into the home. Based on 10 principles (Box 1), it is a philosophy of care for older people and those with disabilities that aims to eliminate these negative emotional states and recapture a meaningful work life for staff (Thomas, 2006).

To successfully implement the EA, staff must be able to reflect on the care they would like if they were old, had a disability or dementia. The philosophy gives people with dementia a centrality that is absent from approaches that see dementia care as a set of problems to be managed (Brooker, 2007). Adopted in nursing homes, long-term care settings and community services world-wide, it has the flexibility to be applied to any situation or culture.

Box 1. The Eden Alternative Principles*

  • Loneliness, helplessness and boredom account for most suffering in older people
  • Ensure life revolves around close, continuing contact with plants, animals and children
  • There should be easy access to loving companionship – the antidote to loneliness
  • Give people the chance to give, as well as receive, care to counteract helplessness
  • Daily life should be imbued with variety and spontaneity to counteract boredom
  • The opportunity to do things we find meaningful is essential to human health
  • Medical treatment should be the servant of genuine human caring, never its master
  • Honour older people by giving them maximum decision-making authority
  • Creating an elder-centred community is a neverending process; human growth must never be separated from human life
  • Wise leadership is essential to prevent loneliness, helpessness and boredom

*The principles have been summarised; see them in full here.


Implementing the EA philosophy in UK care homes is led by certified Eden Associates – a cross-section of staff, including managers, registered nurses and carers who have done a three-day training programme. They are taught that culture change begins with themselves and their attitude to delivering care, and are invited to take a step back and consider how it could be done differently. They then cascade the knowledge down to all staff, residents and relatives to develop a shared vision of the future. Effective leadership and the ability to develop a culture focused on this shared vision is vital before any real progress can be made.

The aim of implementing the EA is to achieve the optimum wellbeing of all residents, staff and relatives. This involves:

  • Creating a vibrant atmosphere;
  • Getting to know residents and the things that have meaning for them;
  • Enabling residents to continue to do things they are able to do, giving them a sense of purpose.

Creating small communities with dedicated staff enables close relationships to be formed between staff and residents, and between residents themselves. Staff must be empowered to be creative in their care approach and develop better relationships with residents – essential tasks must be done and routines are key but these routines should be those of residents, not staff. 

EA principles focus on maintaining the momentum of culture change until it is the way things are done, rather than the “alternative”. The philosophy enables residents to carry on living their lives with dignity, respects privacy and gives them as much independence, choice and control of their lives as they can manage.

Organisations using the EA have found empowering staff to care in this way increases job satisfaction, leading to reduced turnover, lower absenteeism and less need for agency staff.

The EA emphasises the importance of empowering care staff, residents and relatives but acknowledges that accountability remains with qualified nurses. Empowering care staff allows nurses to develop new dimensions to their role, such as:

  • Teaching residents and staff about falls prevention, continence management and dementia;
  • Building trust with GPs so they know visit requests are clinically necessary, increasing the likelihood of early action being taken to prevent residents’ health deteriorating, and reducing the need for hospital admissions;
  • Identifying incident causes so preventative measures can be put in place;
  • Ensuring excellent end-of-life care.

For implementation to be effective, a close working relationship between care staff and nurses is needed, with each party acknowledging the other’s contribution to the ultimate goal of resident wellbeing.

The EA can profoundly affect residents; for example, nurses in an Eden-registered home in Swansea recently described their practice of “reablement”, through which one resident with dementia, previously thought to be unable to live at home, was discharged back into the community. After visiting two nursing homes that implemented the EA, David Foster (2013), deputy director of nursing at the Department of Health, described it as resonating with the national nursing strategy embodied in the 6Cs (Cummings and Bennett, 2012).

Case studies

Taken from homes on the EA UK and Ireland register, the following case studies demonstrate how implementing the philosophy enhances residents’ quality of life and gives staff greater job satisfaction.

Case study 1: Changing staff thinking

Changing staff thinking at a home for people with severe dementia led to positive outcomes for staff and patients:

“Too often [care staff] ‘do for’, when actually allowing people to do more for themselves would help. One of our residents is always on the go. She helps to make the beds and tidy rooms, she does the induction for new staff members and sits with people when they’re upset or ill. She’s a good hostess and genuinely helps us out.

“The EA emphasises that the only difference between residents and us is the amount of support they need. It’s about trying to get staff to think differently, and encouraging meaningful conversations while they work. It helps staff get away from just doing tasks. Sometimes it’s just about slowing down.”

(Janet Blair, Eden associate, lead carer, Amy Woodgate House)

Case study 2: Understanding individual needs

In a four-bed hospital ward for people with dementia in Ireland, it took two staff half an hour to get one uncooperative patient up in the morning. When a single room became available they changed their approach: instead of getting her up, they left her in bed with a cup of tea. Around 10am she emerged fully dressed. Her clothes had to be adjusted slightly but, by fitting in with her routine instead of enforcing their own, an hour of staff time was saved.

Case study 3: Finding personal history

An activity officer at a care home in South Wales illustrated how a person-centred approach can transform residents’ lives:

“Mrs Dean [name changed], was starting to be labelled as having behavioural problems. She rarely spoke, her personal hygiene was non-existent, she pushed you away and was sometimes aggressive towards carers. She sat all day slumped in the chair in her own urine and faeces, refusing assistance and, on occasion, refusing to go to bed.

“Other residents would move away from her because of the smell. The more we tried, the more she would block us out. Her son’s visits were very upsetting for him - she wouldn’t even look at him. She was to be my challenge.

“My starting point was to find out more about Mrs Dean. Her son told me she had been a concert pianist. One morning I sat next to her and started talking to her…about the piano at the home, saying it was a shame it wasn’t played enough. I said I had been told she played and instantly she sat up, looked at me and said: ‘I haven’t played for years and I’ve heard that one and it’s out of tune.’ This made me smile and, for the first time ever, I saw her smile.

“We carried on chatting and I asked if she would teach me to play the piano. She told me I would have to practise my scales for two years, and showed me on the table how to place my fingers. I copied her and when I did it wrong she let me know.

“After several days I asked Mrs Dean if she would show me on the piano, which she did. She progressed to playing short pieces of music and Christmas carols, for which she always had a round of applause from other residents. She is now a different person: she lets us help with her personal hygiene, chooses her own clothes, chats to carers, and asks for the toilet. She still wants to be left alone on some days, but don’t we all?”


The EA is a relatively simple approach with far-reaching consequences. After attending short, intensive training sessions, Eden associates can introduce the philosophy to their own care setting to empower residents and improve their wellbeing, foster more effective relationships between staff and residents, help staff develop their own roles, and save time and resources that can be better used elsewhere.

Key points

  • Loneliness and boredom have a greater negative effect on care home residents than the conditions for which they entered the care home
  • The Eden Alternative philosophy has been proven to improve the care of people with dementia
  • Nurses can use the philosophy to develop their role and be creative in how they empower residents
  • Routines are important in nursing homes, but should be set by residents, not staff
  • Although residents and their relatives are empowered, accountability remains with nurses 
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