Introduction

Geriatric patients entering nursing homes or assisted living facilities often give up contacts with their family members, close friends and personal possessions. Often the number of personal items they are allowed to bring to long term care facilities is limited.  In addition, relationships with pets often have to be severed, resulting in residents experiencing depression, social withdrawal, increased stress, loss of security, and loneliness.  Interactive alternative programs such as pet, music, art, and exercise therapies add stimulation to daily routine and create more home-like facilities, easing the transition period for residents moving into long term care facilities. “The theory behind alternative therapies is that such treatments balance the human mind and body, restoring the body’s protective immune system and relieving symptoms of illness and pain” (Lopez, 1996, p. 51).

Antiseptic, strictly controlled nursing homes are becoming less attractive to residents.  Various stimulating therapies are being added to long term care activities.  The results vary with the limitations of each program.  Pet visitation programs, planned periodic visits by an animal and its handler, have suggested short-term results (Neer, Dorn & Grayson, 1987). Visitation pet therapy programs only offer short-term stimuli for the residents who are ambulatory and interested in pets. Exercise therapy is usually confined to a small recreational or all purpose room, limiting the number of participants experiencing the therapy due to the size of the room or the residents’ physical limitations.  Art therapy focuses on those who can still do hand and finger manipulations.  Music stimulation is limited to those who are ambulatory and are not hearing impaired. However, resident pet therapy allows for an animal living in a healthcare facility, providing a more continuous stimulation to those interacting with the animal ( Winkler, Fairnie, Gericevich & Long, 1989). Although the resident pet programs can be experienced by a larger number of residents, they are limited to those residents near the location of the animals or only those patients desiring contact with the animals.  Alternative therapy programs are slowly gaining acceptance as enhancing the lives of the elder nursing home and assisted living populations (Robinson, 1995).  Research is supporting these methods for counteracting emotional, social and health issues.  As employees become active participants in these programs, the results are not only good for the residents but also can increase job satisfaction for the employees (Winkler et al.,  1989;  Kongable, Stolley & Buckwalter, 1990).

Stimulation from alternative therapies and changing the internal culture of a long term facility may help reduce the high turnover in healthcare and improve the patients’ quality of care.

The healthcare industry is, however, notorious for high staff turnover (White, 1995).  This article suggests that by changing the internal climate of  healthcare facilities through participatory management, continuous training, empowerment and a multi-dimensional alternative therapy program, higher retention may result and consequently, profits may increase.  Future research recommendations are also outlined in this important healthcare business area.

One such alternative care environment is The Eden Alternative philosophy.  Dr.William Thomas has been promoting The Eden Alternative’s “living habitat”, a biological diversity program which uses an holistic approach to care of multi-dimensional living stimulation from animals, plants, and associations with nearby children’s day care centers.  Numerous stimuli have been added to the residents’ daily activities, consequently, continuously improving the quality of the “living habitat” (Thomas, 1993).

The Eden Alternative offers a more complete and longer lasting alternative for long term care facilities.  Eden’s three phase program consists of vision, education and implementation components.  Employee participation, planning, and empowerment are crucial to its success and a part of the alternative emphasis.  The Eden program requires twelve to twenty-four months of employee training and involvement before the program can begin.  Only one journal article has been published concerning the integration of the Eden Alternative and its implications on employee turnover and absenteeism, drug use and pressure sores (Ransom, 1997).  Currently, Ransom is conducting a follow-up study of an Eden Alternative facility at Southwest Texas State University (Ransom, 1997).

The Literature Review

Alternative care studies seem to suggest that by increasing stimulation for the elderly in institutions, nursing homes, and assisted living facilities, positive results can be produced.  Periodic music, art, exercise, and pet therapies, as well as continuous therapy programs, such as The Eden Alternative, suggest that long term stimulation produces positive results for residents and employees (Ransom, 1997 and Thomas, 1993 and 1996).  While some studies assess alternative therapy use, employee training, empowerment, and job satisfaction (Thomas, 1996), others report that by choosing the correct employee for a position can result in a reduced employee turnover rate (Dingus, 1994 and Barry, 1996).

The original studies in the area of pet therapy suggested a relationship between  pet ownership and a sense of patient well-being.  While Seales (1960) reported on the experience of animal/people interaction carrying over to human relationships; Levinson (1972) suggested that the petting of an animal could facilitate the relationship of patient and therapist.  During Levinson’s counseling sessions, patients also became more communicative with their therapists and the animals seemed to act as catalysts in the therapy process.

The emotional adjustment of patients seemed to improve with their interaction with animals.  Goldmeir (1984) related that feelings of loneliness lessened.  Garrity, Stallones, Marx and Johnson studied the relationship of pet therapy and emotional stress levels.  Stress seemed to lessen as a result.  Cusack and Smith (1984) and Brickel (1984) indicated that pets have a significant impact on mood adjustment and actions to treatment.  Wallace and Nadermann (1987) reported less depression, although social improvement in this study did not extend past the specific sessions.  This study also raised the issue of the short-term and long-term benefits of therapy programs.  Siegel (1990) also suggested that elderly-pet bonding reduced self-initiated doctor visits. And although cats, dogs and birds were used in this study, only dog owners specifically reported increased feelings of security, less stress, greater pet involvement, and more companionship.

Some of the studies differed, however. Miller and Lago (1989) using a sample of pet owning, older women living alone, reported that pet relationships had little impact on the elderly’s psychological or physical well-being.  Kongable, Stolley and Buckwalter (1990) however, studying the social behavior of Alzheimer patients, reported a positive effect of pet therapy on socialization in an institutional setting.

Brickel (1979) also used resident cat mascots.  The utilization of cats living in an institutional setting, revealed a valuable social connection between some patients and the cats and also increased socialization between staff members and patients. The costs of providing the pet interaction programs proved insignificant compared to the positive responsiveness of the patients when interacting with the cats and staff members. Corson, Corson and Gwynne (1975) also reported an increase in elderly residents’ self esteem when resident pets were in the facility.  While Winkler, Fairnie, Gericevich and Long (1989) also suggested the importance of choosing a gregarious, affectionate resident animal when pet interaction was desired.  In their study, the dog tended to attach itself to the caregivers, and the staff, thus breeding patient feelings of jealousy.  Winkler et al. (1989) suggested the importance of the patients, rather than the staff, grooming and feeding the animal.

Kongable et al. (1990) also reported that the success of an alternative therapy program related to the staff making decisions about the implementation of the program.  Since the staff would ultimately be responsible for the sanitation, grooming, feeding, and medical requirements of the animal, it was suggested that staff members assist in planning and implementing the pet therapy programs.  Francis and Odell, (1979) also agreed that when a home-like atmosphere existed in the nursing home, less loneliness occurred, and that by adding pets to the home-style nursing home, residents were stimulated by the contact with the animals.

Residents entering nursing homes or assisted living facilities have been removed from stimulation with most living things.  Some have had to sever emotional and physical contact with friends, relatives, plants, and pets.  As noted, various studies have reported that by returning pets  back into their lives, some emotional, psychological, social and physical improvements have occurred.  Robb, Boyd and Pritash (1989) reported on the importance of pet visitation therapy sessions for the overall well-being of the residents.  However, Katcher (1985) documented the lowering of the residents’ blood pressure when verbal communication or tactile stimulation with a pet was present.  Corson and Corson (1981) reported stimulation from pets increased interaction between staff and nursing home patients, leading to an overall improvement in the atmosphere of the healthcare facility.

Thomas (1993 and 1996), however, stressed the importance of  improving the overall climate of the long term care facilities by initiating the “living habitat” for residents using daily stimulation from animals, plants and children from nearby day care centers.  Thomas’ intent was to reduce loneliness, helplessness, and boredom.  Furthermore, Thomas (1993) stressed the importance of staff involvement in the daily nursing home operation, using The Eden Alternative program. He also (1996) reported a decrease in the use of tranquilizing medications and a cost reduction of drugs. Ransom (1997), using Thomas’ (1993)  Eden Alternative “living habitat” approach, also suggested improvement in the residents’ physical, social, psychological, and emotional well-being when they were continuously exposed to various stimulations.  In addition, there was less need for antidepressant drugs, fewer in-house pressure sores, less employee absenteeism and a reduction in employee turnover.

Employee turnover can undermine both the effectiveness and efficiency of an organization.

Cavanagh (1987) reports high turnover causing adverse effects on patient quality care, employee morale, and profits of healthcare organizations.  Wah (1998) also reports that employee under staffing and underdevelopment can have a negative influence on employee turnover.

Reducing the high turnover rate is essential for the profitability of healthcare organizations.  By changing the internal culture of the organization, Singh (1998) reported a reduction in employees’ stress levels. In this study, autonomy, feedback, task variety and participation as a means of enhancing people’s jobs were examined.  Thomas (1993) also used these management concepts in The Eden Alternative “living habitat” programs for the elderly.  Similarly, Johnson and McIntye (1998) noted the correlations between organizational culture and job satisfaction, empowerment, communication, decision-making, innovation, and employee recognition.

Changing the organizational culture, however is no small task (Marquis & Silva, 1996). Henry (1997) even discusses the difficulty and importance of overcoming resistance to organizational change while Owen (1995) suggested using motivational techniques to change employees’ attitudes and improve their performances.  Umiker (1997), Thomas and Velthouse (1990) also talk about empowerment and training as being motivational strategies and Nakata and Saylor (1994) noted that as participative management styles increase, so does a higher level of job satisfaction among staff nurses.  Also, Gemignani (1998)  reported a positive correlation between improvement of productivity and employee well-being.  Similarly, Morrison, Jones and Fuller (1997) also noted the relationship between leadership style and empowerment and its effect on staff nurses’ job satisfaction, while Tjosvold (1998) stressed the importance of employee involvement, productive work and strong relationships in an effort to reduce costs without sacrificing the quality of care and customer satisfaction.  Finally, Pascarella (1998) also supported employee involvement but warned that information concerning operational costs must be available to employees to facilitate cost cutting procedures and Moravec, Johannessen and Hjelmas (1998) identified the need for well-managed self-managed teams, using a manager as the facilitator.

Effective and continuous training is also important.  Barry (1996) found this to be important in order to reduce the turnover of healthcare employees and Mlynarek and Mondoux (1996) agreed that training was a necessary factor in retaining employees but suggested that increasing the number of qualified applicants for healthcare positions could also have positive results.

Screening and realistic job previews are two proactive methods of helping to choose  the best employee for a particular job position.  Kettle, Zbib and Motwani (1998) and Morvec, Johanessen and Hjelmas (1997)  report how background data can be good predictors of employee turnover and Dingus (1994), Montague (1997) and Barry (1996) suggest that turnover can be reduced by identifying common personality traits of potentially good employees. Solomon (1994) suggested that when empowerment and decision making were requirements of the organization’s culture, care had to be taken to hire the right employee. Montague (1997) is of the opinion that using an expanded interview process to question candidates on their views of the elderly, pets in the nursing home, and on helping residents with bathroom and hygiene visits can be useful. Eliminating poor prospective candidates can be beneficial to the residents’ quality of care, overall employee satisfaction, and increased retention. Once employees are in the organization, Singh (1998) reported that providing greater variety on job tasks can enrich job satisfaction and lower the stress level of employees’ jobs.  Also, Owen (1995) reports that once employees are hired, creating well designed jobs, continuous training, and providing employees with the tools and authority to assist in daily operations are important in motivating employees and improving productivity.  Similarly, Umiker (1994), Solomon (1994) report on the importance of training in the retention of employees.

Realistic Job Previews (RJP), a hiring process aimed at hiring the correct employee for the corresponding culture of an organization by giving them a glimpse of the job and screening for criminal and drug problems, are techniques used to choose the employee who has a better chance of fitting into a particular position or corporate culture. Careful screening and Realistic Job Previews (RJP) are two methods that should reduce turnover.  Roth and Roth (1995) suggest that during the hiring process, interviewers provide applicants with realistic job descriptions with both positive and negative aspects of the job. Montaque (1997) even suggests that employees assisting in the hiring selection can result in the improved quality of the new employees. This is especially important since teamwork is important in the organization’s corporate culture.  Fottler, Crawford, Quintana and White (1995) note that using open-ended attitude surveys during the employment period can give management an opportunity to intervene, identify the symptom, and solve the problem.

Thomas (1996) suggests the value of participatory management approaches for employees and the value of never-ending stimulation for the residents.  Winkler and Janger (1998) also stress that using a more participative management process with employees can lower employee turnover and that it may provide additional healthcare profits.

Encouraging staff planning and involvement in the long term care facility’s transformation to a more home-like atmosphere can also have a positive financial effect (Ransom, 1997).  Low paid health care employees responsible for planning and implementing changes may feel more content and encouraged when working in an improved work environment.  By altering the organization’s internal climate, then, it is thought that turnover can be reduced, profits increased, and the quality of care can be improved.

High employee turnover may be a result of the hiring process and internal negative symptoms.  Attitude scales and exit interviews may be used to identify the reasons for leaving  healthcare jobs. Determining the causes of high turnover in elder care settings can help to focus on changing and improving the internal culture, resulting in higher retention and possible better care for the clients.  The validity and accuracy of exit interviews remains in question (Fottler, Crawford, Quintana & White, 1995).  Exiting employees are reluctant to be open and honest with the interviewer for fear of jeopardizing future employment references.  Seldom is the exit interview used to salvage  an unhappy employee but rather “to  identify internal problems, verify poor personnel practices, examine the soundness of the original hiring decision, and create a smoother transition for a dissatisfied employee into a public relations arena” (Fottler, Crawford, Quintana & White, 1995, p. 279). But they ought to be considered.

Due to the costly effect of high employee turnover, healthcare administrators should be motivated to reduce turnover, thereby, reducing costs.  It would appear that giving employees the opportunity to voice their opinions, concerns, and dissatisfaction may be the initial step in maintaining or changing the internal culture of the organization.  Determining the factors that may cause employees to leave and improving daily working operations, are two areas that frequently appear on attitude surveys (Fottler et al., 1995).  As mentioned, enhancing the hiring process for  supervisors and employees, acquiring top management support, developing training programs, using participative management approaches, collecting employee ideas, and utilizing empowerment programs are necessary components when initiating and implementing positive internal changes (Marquis & Silva, 1996; Mlynarek & Mondoux, 1996).

Before attempting to reduce employee turnover, it is important then to understand the organization’s internal culture.  Employee under-utilization and under-development may cause job dissatisfaction, low morale, lost productivity, disappointment, and depression, resulting in high employee turnover (Wah, 1998).  These factors should be further examined in elder care employment settings.

The business implications of turnover can be great then. “Employee turnover can undermine the profitability and overall efficiency of a company” (White, 1995, p.15).  Rapid turnover can lead to excessive costs, instability, turmoil, poor reputations, and loss of credibility for the healthcare facility (White, 1995).   Employees suffer stress, uncertainty, job dissatisfaction, and additional work responsibilities when the facility is understaffed, has an inadequate training program, or is not working efficiently or effectively (Wah, 1998; Nataka & Saylor, 1994).  In addition, residents may experience inconsistency of quality care, more frequent accidents, emotional, social, psychological, and physical implications (Mlynarek & Mondoux, 1996; Cavanagh, 1987).  Kongable, Stolley and Buckwalter (1990) and Winkler, Fairnie, Gericevich and Long (1989) have reported the value of including healthcare employees in the decision-making process in daily operations of therapy programs. Allowing employees to choose and implement the correct therapies in long term care facilities, may help their own job satisfaction and personal fulfillment when providing patient care. In addition, employees who receive strong support from management are more likely to increase their attachment to the facility and voluntarily go beyond their job description requirements (Morrison, Jones & Fuller, 1997).

The Eden Alternative is such a program and it may improve the quality of care for the majority of the residents. This alternative program may also help the organization and the individual employees by focusing on employee participation, empowerment, the team approach, and continuous training.  These management approaches may positively influence the morale, attitude, productivity, job satisfaction, depression, and ultimately, the quality of resident care (Thomas, 1996).

Changing the processes of elder care is time-consuming, and difficult, but it may be cost-effective in the end. The benefits may far outweigh the costs.  If the Eden Alternative process is coupled with improving the process for hiring new employees by using RJP and through screening,  turnover can be reduced and profits may be realized.  If employees can also become  part of the solution, they may promote feelings of empowerment, remove barriers, improve communication, limit their over-dependence on others, and encourage employee leadership.  Without changing the internal culture and improving standard hiring practices, the employee turnover rate then is not likely to improve in elder care settings.

As was mentioned, resistance to organizational change is common.  Hourly employees as well as salaried supervisors are often asked to modify their behavior.  Change is, however,  threatening to most people.  Fearing  the unknown or failing in the process are two common employee misgivings.  Increased work load, the inability to meet the new requirements, a lack of intelligence or skill, disruption in their work schedules, a loss of a job if the employee can’t handle the change, all can be additional  staff concerns in service oriented organizations (Marquis & Silva, 1996).  In addition, changing an organization’s culture can be a slow and labor intensive process.  But empowering employees to make decisions can be a stimulating, challenging and frightening experience.  The rewards of increased feelings of autonomy, competence, meaningfulness, and impact may be important factors in improving employee retention (Thomas & Tymon, 1994).

Another important personnel idea to consider is securing top management support. Without that support, changes will be short-lived.  A comprehensive proposal should be made to determine the positive and negative points of change efforts, realizing of course that healthcare executives often have their own agendas.  Expecting them to change their philosophy from a highly structured, antiseptic, tightly controlled long term care facility into an employee participatory management setting, emphasizing multi-dimensional stimuli for clients may be a very challenging prospect.  The Eden Alternative is one of these multi-dimensional structures.  It does require, however, that management be able to visualize the change before financially and emotionally buying into the new philosophy or said changes will not be successful.  Positive change demands vision, understanding the impact of the effort, acceptance of responsibility for the change, and flexibility to continuously alter the results if the change has not been positive (Marquis & Silva, 1996).  These concepts are all requirements of good management.

Addressing the prevention and reduction of internal problems by anticipating and eliminating some recurring negative symptoms not only can benefit the entire organization but it can also  reduce the stress and frustration level of current managers, employees, and residents. These points are often essential elements of Total Quality Management efforts. Identifying and solving underlying problems is an uncompromising point of a Quality Assurance or Total Quality Management process and these strategies can help in elder care situations (Marquis & Silva, 1996).

To summarize this major section, a five point formula then is offered for hiring and retaining the best employees:

1) To be competitive, the organization needs to review the salary and benefit package.  Quantifying the organization’s objectives is also necessary.  With annual turnover of 70%  and $1500 per lost employee, healthcare administrators have to be proactive in pursuing the right person for a specific job (Mlynarek & Mondoux, 1996, p.21).  Management has to identify the costs for training and development, orientation, marketing, loss of motivation and management time, the facility reputation, the overall stress and decreased morale of employees and residents.  Recording complaints from residents and their families and documenting labor expenses help set those quantifiable objectives (Mlynarek & Mondoux, 1996).

2) Understand your own daily operational needs and be prepared to hire only those who  fit into that culture.  Determining guidelines for specific job descriptions and the employee characteristics to fill those positions will help develop a well-prepared interview.  Using previous survey results of current employees, showing the positive and negative aspects of the job also helps the interviewer portray a realistic picture of the position. Emptying bed pans, hand feeding the disabled, walking a resident’s dog or working in teams should be daily job expectations (Mlynarek & Mondoux, 1996).

3) Not screening for drug and criminal backgrounds, rushing to hire employees to fill vacated job positions can be costly.  Pre-screening for drug and criminal backgrounds can prove to be a financially sound procedure. Putting residents and other employees in jeopardy with potential criminal employees can not only be costly in theft, violence, and morale problems, but also to the safety of employees and residents (Mlynarek & Mondoux, 1996).

4)  A well-planned interview can help choose the best employee for the job.  Having interview questions prepared in advance can help address the preferred characteristics for the position.  For alternative therapy situations, questions should refer to teamwork, decision-making, honesty, credibility, dependability, reliability, and attitudes about music, art, animals, plants, and children.

5)  Orientation and training are essential components in the retention of employees.  The Eden Alternative, for instance, has a 12-24  months training period including team building, empowerment, participatory management, perception of their roles, and adaptation to the bio-diversity culture.  As employees become immersed in the culture, loyalty, commitment and retention will hopefully follow.  Investment in an organization and its staff is crucial not only to  the well-being of the organization but also to the residents’ quality of care (Thomas, 1996).  The Eden Alternative Golden Rule for instance states,  “As management does unto staff, so shall staff do unto residents” (Thomas, 1993, p. 3).  To accomplish this, Eden focuses on the three developmental phases: vision, education, and implementation (Thomas, 1996).

The Eden Alternative is an example of alternative care that utilizes some important management approaches such as empowerment, motivation, self-managing teams, and continuous training that may result in increased job satisfaction, higher quality care for residents, and lower employee turnover and absenteeism.  Eden’s first step, for instance, is to share the mission statement and vision with all employees.. This process takes 1-2 months.  Creating The Eden Alternative attempts to: eliminate the three plagues of the long term care institution, loneliness, helplessness, and boredom. We want to show others how comparison animals, the opportunity to care for other living things, and the variety and spontaneity that mark an enlivened environment can succeed where pills and therapies fail.  Our goal is to weave together that philosophy of  The Eden Alternative with the practical applications and make it work in the real world of long term care (Thomas, 1993, p.3).

Education is the second and most lengthy step in creating and implementing The Eden Alternative. This phase occurs 12-24 months before implementation.  Staff, families, residents and the community are key to understanding and implementing the Eden process.  Empowerment, participatory management, and teamwork are essential ingredients in this changing culture.  All participants must not only understand their role in the process but also take responsibility for the change in their daily work activities and responsibilities.  Cross training, decision making, dividing the work among themselves, and encouraging each employee’s potential is the prime focus of such processes.  Each team member shares equal authority in such efforts (Thomas, 1996).

The final phase of the Eden Alternative, implementation, is usually completed in 4-6 months. The level of funding and facility development are factors that can delay the final phase.  Once implemented, all must understand that the Eden Alternative is a never-ending process.  The key is for all team members to interact with residents in every aspect of their daily activities.  Various, continuous stimulations are essential to the improved well being of all residents in such programs (Thomas, 1996).

Summary and Conclusions

Changing the culture of long term care facilities is a never-ending process.  Using short-term stimulation to enhance residents’ lives only allows for short-term improvement.  Our elderly deserve continuous stimulation in their lives.  Shutting them off from animal, plant, and human stimuli is a cruel and debilitating life-style.  Boredom, loneliness, and helplessness is not a pleasant way to end one’s life.  Elderly people in long-term care facilities deserve more than just care.  Residents have spent most of their lives caring for husbands, wives, children, grandchildren gardens, pets and then suddenly, this stimulation is suddenly removed.  When a “habitat for living” is added to high quality care, the residents remaining years can be more fulfilling and rewarding.

The Eden Alternative, and other similar programs, hopefully bring that bio-diversity culture back into the residents’ lives.  With a well-trained staff, participating teams, residents and their families, and interaction with the community, the quality of care and overall well-being of the individual flourishes (Ransom, 1997).  Most would agree that adding stimulation to resident’s daily activities is an improvement.  At the same time, employees’ attitudes and production improve with the self-management, team-building, empowerment, self scheduling, continuous training and self fulfillment required in such programs.

By conducting careful screening and RJP interviews, the number of poor work candidates can be reduced. Choosing the right person for the job can only help add to a more cohesive and content workforce.  Turnover can be dramatically decreased.  Better quality of care, more job satisfaction, higher morale, less depression, and more loyalty and commitment will produce higher retention levels and ultimately more profits for the organizations.  Everyone wins; the organization, the employees, the plants, the animals but most importantly, the residents of the long term care facilities.

Very little research has been done to document the success or failures of such programs.  To date, only one study has been completed (Ransom, 1997) with a follow-up study currently taking place.  Future studies need to document the success or failure of programs that use participatory management, proactive hiring practices, alternative job design, and multi-dimensional stimulation.

Bench marking turnover or retention rates in healthcare facilities using approaches similar to The Eden Alternative, coupled with alternative proactive personnel approaches such as screening and RJP could change the view of current long-term care.  Not only can the well being of the residents improve, but also employee retention and profits can be affected.  Not only can savings be achieved from the reduction of turnover, but employee satisfaction and resident care can be improved.

Much needs to be learned about the links between managing a long term care facility, the types of client programs, and the personnel programs that seem to make a difference in happiness for the residents and those that affect employee retention, productivity, and profitability.  Future research should examine these links in order to determine what works best for the clients, employees, and profits.

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BY

Erna Marquis, MA

Peter Simmons, PhD

University of Sarasota

Articles, Information systems, Research
alternative care environment, bio-diversity culture, Eden Alternative philosophy, emotional adjustment of patients, healthcare, healthcare administrators, healthcare industry, requirements of good management