THE EDEN ALTERNATIVE AS A ROADWAY FOR CHANGE: A SERVICE LEARNING QUALITY IMPROVEMENT PROJECT Developments in Business Simulation and Experiential Learning, Volume 31, 2004 THE EDEN ALTERNATIVE AS A ROADWAY FOR CHANGE: A SERVICE LEARNING QUALITY IMPROVEMENT PROJECT Susan A. Chesteen University of Utah mgtsc@business.utah.edu The author wishes to acknowledge the work, dedication and contributions of the following students who participated in this project: Meagan Greider, Allen Michaelis, and Gregory Moesinger. ABSTRACT This paper presents a case study of a service-learning project and its results. Honors Program students in an undergraduate quality management course conducted the project. The project required the use of various skills taught in the business curricula in the setting of a skilled care facility. Students assisted the facility with its efforts to implement the “Eden Alternative”. In this project students were required to use the fundamental elements of service learning: planning, experience, and reflection. Some of the aspects of the project that enhanced learning and promoted commitment to community service are discussed. INTRODUCTION This paper discusses an unusual and innovative project conducted by freshman students in an Honors Program management course “Quality in Professional, Public, and Personal Life” which was designed, taught, and officially recognized as a university service learning course. The course usually has an average class size between 8 and 12 students. All students who successfully complete the course conduct a team project and all receive a service learning designation on their transcripts. Students in the course function as members of teams that perform quality management projects for nursing homes, health care clinics, and other “not-for-profit” agencies and organizations in the region. Many people become isolated as they age or as they experience physical or mental limitations that curb their abilities to function outside an institution. This phenomenon often is due to illnesses and disabilities that often accompany the aging process or serious accidents. Isolation can lead to further declining physical and mental health and loneliness. In turn, the loneliness can result in more vulnerability to depression. Susan Sample (1998), editor University of Utah Health Sciences Report, states: “The thought of growing old often is shrouded with loss: of jobs, financial security, professional identity, health, friends and loved ones. We see ourselves losing the control we once had. It can seem as if someone, under cover of darkness, is stealing the richness, the color out of our lives.... In nursing homes, the rate of depression reaches 51 percent in those recently admitted.” (pp. 16-21) In long-term care settings there is a tendency for the elderly to become more dependent; it can be inferred that their life satisfaction is lower, and the likelihood of depression is greater. In the Seattle Longitudinal Study (Schaie, 1998) it was found that people who have greater health problems are more likely to be those who are isolated [and] who have the least social contact… Nevertheless, there is a substantial body of empirical research to support that the more control older persons have in regards to their environment and daily activities, the higher they score on life satisfaction surveys. Since the course was designed so that students would have an opportunity to see how an organization can integrate its public responsibilities and corporate citizenship into its business planning and performance improvement practices, a long-term residential and skilled care environment proved to be an ideal setting for students to implement a quality management project. By physically working on site with the elderly and disabled of a skilled care facility, students did not find it difficult to understand that their expertise and contributions can provide a much needed service to the community. One goal of the service-learning component is to foster in students a lasting sense of responsibility to community and to enable them to involve themselves in areas of community service by using service and quality improvement methodologies learned in the course. The quality management projects serve to balance empirical work and quality concepts in an experiential approach. Before the beginning of the semester the instructor met with the Associate Director of the Utah Health Care Association and the administrator of Rocky Mountain Care-Clearfield to discuss the needs of its residents and staff and their ideas of future improvement projects. During this meeting the goals for the service-learning project were agreed upon and the link was formally established for the students to help Rocky Mountain Care- Clearfield “prepare the ground” to Edenize (Thomas, 1994) its facility. It was evident from comments at the meeting that the administrator was enthusiastic about utilizing the skills of the students in an innovative future undertaking to bring about major changes in the facility. This new enterprise involved adopting the “Eden Alternative” and fully integrating its principles (Appendix A) and processes throughout the facility. (Thomas, 1996) The first on-site student activity for the quality improvement project began during the second week of the semester by coordinating a conference of the quality improvement team, the former Executive Director, and the Director of Staff Development of Rocky Mountain Care-Clearfield whereby a common vision for the center was shared, the project goals were established, and a strategy for project implementation was mutually established. 125 mailto:mgtsc@business.utah.edu Developments in Business Simulation and Experiential Learning, Volume 31, 2004 Rocky Mountain Care-Clearfield is a long-term alternative “not-for-profit” facility that provides treatment, care, and assistance for seniors and people who can no longer take care of themselves. Rocky Mountain Care-Clearfield currently has approximately 100 residents with the capacity to accommodate up to 110 residents. About 130 staff members are employed at the facility to rehabilitate and to help care for and assist its inhabitants. The management and staff members at Rocky Mountain Care-Clearfield currently embrace a goal to provide the best care possible to the residents. Shortly after the beginning of the student quality improvement project, the individual appointed as the new administrator of the facility decided to begin her leadership role by embarking on an initiative to help set goals for the facility and its employees. She used a decision-making process involving residents, staff, managers, and community representatives that resulted in a bold and innovative resolution. As the Director of Staff Development and the designated coordinator of this effort stated, “I have our collective objectives as a group and have talked to several residents and staff members; our goals are clear to everyone. We want to have the happiest residents in the state! The quality of life of our residents is the most important thing to everyone. They want to feel like they live in a home, not a ‘facility’.” Thus, with the encouragement of the new administrator and the blessing of corporate management the decision was made to change from a therapeutic environment to one that incorporated activities and responsibilities from a home environment. After a time of deliberation, the staff and residents decided to adopt the Eden Alternative, which they believed would bring a more optimistic and constructive atmosphere to the facility. The Eden Alternative, created by Dr. William Thomas (1996), is a pioneering paradigm that departs from conventional nursing home practices that are typically associated with emphasis on diagnosis and treatment. “ It [Eden Alternative] employs the principles of ecology and anthropology in the struggle to improve residents’ quality of life. It encourages the leaders of nursing homes to think less like administrators and more like naturalists. Finally, it summons us all to construct vibrant, supple human habitats in which residents can live.” (p. 2) Its system of practices generates variety in the residents’ daily activities, creates a sense of responsibility for the residents, and increases the residents’ sense of well-being and happiness. The Eden Alternative attempts to eradicate three significant problems that often plague long term care facilities: loneliness, helplessness and boredom. Proponents of the Eden Alternative believe that, in order for the human spirit to thrive, the need for companionship, the need to care for others, and the need for variety must be addressed. In order to enliven the institutional environment it proposes taking actions that will “humanize” the habitat, such as including companion animals, maintaining gardens and live plants, “on-site” and “after school” care for children, family style dining, and other practical activities that bring the real world into the facility and link the facility with the surrounding community. The Eden Alternative suggests that by allowing residents of long term care facilities to care for pets and plants, it will help them to feel needed and give them a sense of self-worth in their lives. It is thought by proponents of the Eden Alternative that an animal can provide companionship for the resident. This assumption is validated by the fact that Hasbro, a leading manufacturer in the toy industry, has successfully introduced a robot cat, FurReal Friends, into nursing homes for residents who want the company of a cat but without the responsibility of a litter box. (Hansell, 2002) The Center for Lifespan Environments recommend environmental changes at a nursing home facility that harmonize with those of the Eden Alternative and are planned in a way to create a warm and homey setting. These changes include such seemingly insignificant things as lowering the pictures on the walls six to twelve inches to give those in wheel chairs a better view without the glare from the lights and building grow boxes for gardens that are high enough to accommodate people who are in wheel chairs or who cannot stand for long periods of time. Family- style dining removes the stereotypical institutionalized items from dining area and replaces them with more typical “home style” kitchen table settings. PROJECT TASKS The function of the quality improvement team was to assist in assessing and introducing some of the proposed changes inherent in the Eden Alternative to ultimately help residents achieve a higher quality of life. One major task was to conduct a survey to discover the staffs’ perceptions about 1) the spirit and attitudes of the residents; 2) the nature of the relationship between the staff and the residents; 3) the overall atmosphere of the center and 4) obtain a sense of what would bring the most happiness to the lives of the residents. Since the facility has a large number of employees who work both day and night shifts, the team decided that a written questionnaire was preferable to personal interviews primarily because, regardless of their working hours, the staff could easily complete it. The students developed a written questionnaire that sought staff perceptions about a variety of issues related to the proposed Eden Alternative changes, their suggestions in the specific areas of the external environment, dining, introduction of animals that would live in the facility, the use of computers for the residents, other ideas for improvement and, lastly, ways that management could help the staff to become more efficient. The results of the questionnaire were both enlightening and useful to management as it advanced with plans to Edenize the facility. The questionnaire discovered that in general the staff judged the overall attitude of the residents to be positive, but only one staff member said that it was excellent. A more unsettling finding was that not one employee felt that the facility was like a home. Twenty percent felt that the atmosphere was “fair but dreary.” Almost all of the staff agreed that visitors brought the most happiness into the lives of the residents. Some opposition by the staff to bringing animals into the facility caused a modest amount of uneasiness. Ten percent of the respondents expressed disapproval for the project and an equal proportion expressed anxiety about the added responsibility the animals might bring for the nursing assistants. It should be noted that several respondents commented on items of a personal nature about other staff members that could have been interpreted as signals to the administration that the overall morale of the staff needed more investigation. Nevertheless, the results of the survey were very beneficial and provided the administration with a reasonably accurate idea of what the staff was 126 Developments in Business Simulation and Experiential Learning, Volume 31, 2004 feeling and thinking about Rocky Mountain Care-Clearfield. The team strongly recommended implementation of a family- style dining method to rectify this isolating situation. Family-style dining requires that condiments and other food items be placed on the table to give the diners the opportunity to dish-up their own food and ask to have certain items passed. It is believed that this practice will increase the amount of communication among the residents, provide spontaneity in decision-making and increase involvement and human interaction. The transformation process began toward the end of the semester by following the steps outlined in the Family-Style Dining Checklist used by the Heber Rocky Mountain Care-Clearfield. Another modification made to the feeding policy was to offer residents the option of showering and dressing before or after breakfast in order to alter the overall philosophy to one of offering more choices to the residents and in so doing reduce their feelings of helplessness. One principle of the Eden Alternative incorporates the introduction of resident animals to a healthcare facility to provide the inhabitants with companions and to give them a sense of responsibility. This practice is believed to not only offer residents an opportunity to care for a pet, but also that it brightens the atmosphere of the facility. Moreover, it furnishes children an incentive to visit the center and become friends with the residents through their pets. Both children and animals allow for spontaneity, removing much of the boredom and loneliness that may be felt by residents. At first, the quality improvement team designed a written questionnaire for the residents that would help determine what kind of animals would be the most beneficial and what the feelings of residents were toward animals. However, after consideration of the needs and limitations of the residents, the students decided to directly interview the residents rather than ask them to write their answers. This strategy increased interaction between team members and the residents and helped to determine which individuals were most capable of caring for a pet. As a result of the interviews two birds were purchased for residents. At the beginning of the semester the students were given a camera to keep an historical record of their project work in the center. The camera enabled them to integrate the images of their experiences and feelings into their understanding of what was actually being learned. Photographs taken by the students are particularly representative of results of their efforts with the Resident Animals Program. One photograph was a picture of a long time resident who was given the responsibility to care for the cockatoo. Nurses reported that her whole life perspective had improved dramatically after receiving the bird. Later the facility director and director of nursing took a representative group of residents to the Humane Society to select a puppy and a kitten for the facility. After a trial period with the puppy and kitten, the facility planned expand the number of animals living there. RECOMMENDATIONS OF THE TEAM The team members concurred with the facility director that Rocky Mountain Care-Clearfield should apply for registration (www.edenalt.com) as an official Eden Alternative Center. Over 750 facilities across the United States have embraced the Eden philosophy. However, only just over a hundred have been registered. The advantage of registration includes having the name of the facility listed on the registry, which allows consumers the use of the information, a free web site sponsored by the Eden Alternative, and the recognition and publication of the facility’s experience with “edenizing” recorded by the Eden Alternative Foundation. Because the Resident Animals Program and the Family Style Dining Program were in the beginning stages, it would have been difficult to predict what all of the outcomes of executing these changes in the social and physical environment would be for the center and its residents and staff. The students reasoned that it would take more time and effort to fully implement the other proposed changes throughout the environment, but the groundwork for implementation had been carefully laid. They thought that the success of those efforts could be assessed by the sense of wellbeing and happiness of the residents as well as measured empirically; for example, by comparing the amount of anti-depressant drugs used before and after the initiatives were implemented. Another activity of the project involved the team conducting training for management and staff members of committees about the process and use of the Nominal Group Technique to help them foresee some of the problems that might occur with resident animals being introduced into the building. The committees still exist and continue to use this same technique in some of their future efforts. Finally, three more suggestions were made by team members: (1) The administration should consider integrating other ideas recommended by the Eden Alternative into the process of health care delivery by Rocky Mountain Care-Clearfield, such as “on site” child care or “after school” care to provide access to children for those who have the most need for connection with them, and a nursing home garden to provide social, spiritual and dietary benefits. (2) Management should make more frequent use of committees for future decision-making processes. (3) Management should take into account and act upon staffs’ suggestions reported in the survey results. The team members believed that acknowledging and taking actions in accordance with these suggestions would give to the staff a stronger feeling of trust and empowerment and promote stronger “buy in” from the staff to ensure success in the projects. After being requested to study and report their observations related to the dining customs and practices at the center, the project team scrutinized conditions in the dining area. Following analysis and discussion of their observations, they reported their findings and made some suggestions to the Eden Committee members. They had observed that there was little communication between the residents while they were seated. Moreover, the current dining area of the center appeared to be quite institutionalized, as evidenced by the fact that food was served on trays and that there were no napkins, salt, pepper, or water on the table available for diners to pass to others. 127 Developments in Business Simulation and Experiential Learning, Volume 31, 2004 LEARNING OUTCOMES As a service learning management course its structure provided time in class and outside of regular class hours for reflection and discussion about service experiences, linkages to course content, and social responsibility. Thus, the framework, activities, and experiential-based consulting project achieved a course objective to assist students in understanding personal involvement in setting directions and building and maintaining a system conducive to high performance, individual development, and learning. Wheatley (1992) proposes that management needs to be “comfortable with uncertainty” in order to help create organizational growth and renewal. This concept was pervasive from the beginning to the end of the project as students were asked to use their ingenuity to address unpredictable problems in an actual organization undergoing change, realize that their answers had consequences, and deal with the outcomes of their solutions. The opportunities offered them valuable experience in their training sessions for staff and management in ways to use the Nominal Group Technique as a planning, decision making, and consensus-building tool in addition to increasing their understanding of the applicability of specific quality management tools and principles to institutions. Their interviews with the center’s residents and staff gave them a clearer understanding of the problems and opportunities associated with actual practices from organizations and individuals. The conduct of the staff survey provided team members experience with research methodology and various approaches to improvement and innovation. The team members’ close work with the Director and Director of Nursing of Rocky Mountain Care-Clearfield enhanced their appreciation for the importance, need, and role of leadership skills in organizations. Both of these much admired individuals were exemplary in “walking the talk” of leaders who are willing to courageously embrace change, take risks, empower their employees, commit to teamwork, and respect the individual. The tangible nature of their work in a “learning organization”, such as Rocky Mountain Care- Clearfield, bolstered with class discussions and reflection sessions made it easier for the students to comprehend the notion stated by Thomas (1996) that “the principles of the Eden Alternative can be applied anywhere people are troubled by loneliness, helplessness, and boredom.”(p. 171) As noted by Thomas (1996) a number of people believe that “the specter of the nursing home haunts the infirm elderly and their families. They know in their hearts that to enter a nursing home is to take an irreversible step down the path toward disability and death.” (p. 7) Yet, statistics do not support this grim indictment of nursing homes. Moreover, associations, such as the American Health Care Association, administrators, staff, community volunteers, educators and students are proactively making a passionate effort to transform the nursing home atmosphere from one of the past that led to such a pessimistic image to one of the future that is vibrant, encouraging, and optimistic. The beneficiary organization of the project was selected in order to help the students reinforce their understanding of how people create values and expectations and set directions while also fulfilling their humanitarian responsibilities. Through their involvement in the day-to-day attempts of the management, staff and the residents to enrich resident quality of life, the students came to understand that sometimes it is necessary for organizations to redefine their mission before fundamental improvements can be made. It also assisted students in becoming aware that while their professions may or may not be inherently service-oriented, they can utilize their professional skills and expertise beyond the workplace for community benefit and personal growth. CONCLUSION Thus far, few business school academics have chosen to embrace a service-learning component in their courses due to many challenges posed by the service-learning pedagogy. The results of a survey (Chesteen & Miller, 1998) indicate that the challenges are administrative in nature, the most serious challenges arising from perceived incompatibilities between discipline-specific learning objectives, on one hand, and service objectives on the other. And there are certain risks and difficulties inherent in integrating service learning as a component of the curricula that have not been mentioned, such as the theoretical risk of a lawsuit arising from a potential accident to a student in transit to a client site either by his/her own personal transportation or the instructor actually transporting the student in a personal vehicle. However, if the acquisition of new skills, knowledge, and social networks can help enhance students’ learning, expand their horizons, and foster good citizenship behaviors, then this service learning quality improvement project was worth the risks. It provided them with the opportunity to learn in a way different from the classroom, become more self-directed, and help significantly increase satisfaction and enrich the lives of both senior citizens and the students alike. AFTERWORD A note sent to me after the completion of this course furnished the personal testimony of one team member whose grandmother was a resident of Rocky Mountain Care-Clearfield at the beginning of the project. The grandmother died shortly before the semester ended. His appreciation and tribute affirmed my conviction to continue to use service learning as an important component in my future courses: Susan, I just had to express my appreciation to you. The Edenizing project meant a great deal to me personally. I loved my grandma a great deal, and it meant a lot to me to know that what I was trying to do would also help her. It’s hard to know that she won’t be able to experience all the wonderful changes herself, but it still gives me a wonderful feeling to that, even if it couldn’t be mine, someone else’s grandma will be happier because of the project. Thank you so much for caring enough to provide these opportunities. I learned more about life and quality—true quality—in this class than any other I have ever had. Thank you. 128 Developments in Business Simulation and Experiential Learning, Volume 31, 2004 129 REFERENCES Chesteen, S., & Miller, J. (1998, August). Identifying challenges to service learning educators in management. Academy of Management All-Academy Symposium: What Matters Most, San Diego. Hansell, S. Building a better cat. (2002, December 5). The New York Times. Retrieved from http://www.Nytimes.com. Sample,S. (1998). “Shattering stereotypes” of depression in aging adults. University of Utah Health Sciences Report, Winter, 16- 21. Schaie, K. W. (1998). The Seattle Longitudinal Studies of adult intelligence. In M. P. Lawton & T. A. Salthouse (Eds.), Essential papers on the psychology of aging ( pp. 263-271). NY: New York University Press. Thomas, W. H. (1996). Life worth living: How someone you love can still enjoy life in a nursing home. Acton, MA: VanderWyk & Burnham. Thomas, W. H. (1994). The Eden alternative: nature, hope, and nursing homes. Sherburne, NY: Eden Alternative Foundation. Weis, W. L. (2000). Service-Learning in Business Curricula: Walking the Talk. NSEE Quarterly, Summer, 11-16. Wheatley, M. J. (1992). Leadership and the new science: Learning about organization from an orderly universe. San Francisco: Berrett-Koehler Publishers. http://www.nytimes.com/ Table of Contents Volume 31, 2004 Controlling the Complexity and Orenting Target Groups by a Modular, Server-Based Business Game System Learning Network Demonstration: Delivering Business Education in a Distance Learning Environment Economic Evolution, Human Capital Investment, and Adult Distributed Electronic Learning: A Literature Review Designing a Globalization Simulation to Teach Corporate Social Responsibility Developing and Teaching an Online / In-Class Hybrid: A Demonstration A Model for Evaluating Online Instruction An Evaluation of a Distributed Learning Course: A Students'-Eye Perspective Blended Learning Strategy Improved Business Writing Skills How to Receive and Process Attachemnts while Greatly Reducing the Risk of Viruses and Trojans Introducing Online Components to a Class: How to Increase teh Likelihood of Success Teaching Strategic Communications Online: Using Learning Outcomes to Develop a Case-Based Course Implementing Distance Approaches to Education: A Panel Discussion for ABSEL: Las Vegas, 2004 MANDI: Learning Management Through Field Sales Experience An International Capital budgeting Experiential Exercise A Primer To Combating Terrorism: Playing It Safe While On Overseas Assignment (An Experiential Exercise) Integrating The Business Curriculum With A Comprehensive Case Study: A Prototype The Case Brief: A Model For Case Analysis, Writing And Discussion Technology Infused Pedagogy And Delivery – A Sure Bet? A Proposal For Panel Discussion Absel Conference 2004 Research Strategy And The Bkl: Getting The Most From The Absel Archives Simple But Effective: Rediscovering The Class Discussion Needle And Thread: An Activity For Examining Various Management Behaviors A Customized Excel Data Analysis System For Use In Undergraduate Marketing Research Team Leader Selection - Does It Matter? The Power Of Perspective: Reframing Your Framing Skills For Innovative Instruction In Leadership And Influence Exercise: How Should Merit Raises Be Allocated? An Online Situation For Problem-Based Learning In A Junior-Level Management Course The Eden Alternative As A Roadway For Change: A Service Learning Quality Improvement Project Avoiding Catastrophe: The Role Of Individual Accountability In Team Effectiveness Omega Systems: A Change Management Exercise The Risks And Rewards Of Providing Students A Structured Cheating Opportunity Experimentation With Assessment Techniques: A Proposal For Panel Discussion Using A 2 - Page Case To Introduce Concepts Of Business Strategy Interactive Session The Integration Of Appreciative Inquiry And Experiential Learning For Peak Performance Appreciative Inquiry Case Story: New York City Leadership Challenge Individual Achievement Versus Team Performance: An Empirical Study With Business Games Some Strategists Don't Learn Or Can't Learn Computer Simulation: A Design Architectonic On The Value Of Bugs In Simulation Environments Online Sales Forecasting With The Multiple Regression Analysis Data Matrices Package Simulation Exercises And Problem Based Learning: Is There A Fit? A Study Of Business Game Stock Price Algorithms Assessing Individual Performance In A Total Enterprise Simulation Information Use In A Business Game Determining The Value Of A Firm Unsorting Algorithms For An Ordered List And Its Application To Business Simulations Teaching Public Finance Management Through Simulation Antecedents Of Game Performance Student Expectations Of Classroom Teaching Practices In Developing And Presenting Course Information In Hong Kong Implementation And Impacts Of The Balanced Scorecard: An Experiment With Business Games Impact: Shocking The Legacy Mindset Implementation Of The Eepad Framework Of Business Processes In An Accounting Information Systems Course Are Business Games Really Delivering What Students Are Led To Believe?? Reporting Lessons Learned: What Gets Reported; Who Gains Value Teacher Expectations Of Classroom Teaching Practices In Developing And Presenting Course Information In Hong Kong Student Reactions To The Use Of A Computer-Based Simulation As An Integrating Mechanism For A Mba Curriculum A Cognitive Investigation Of The Internal Validity Of A Management Strategy Simulation Game The Casino Challenge: Making Simulation Delivery A Safe Bet! Accounting For Company Reputation: Variations On The Gold Standard Foreign Currency Hedging: A Simulation The Influence Of Variables Easily Controlled By The Instructor/Administrator On Simulation Outcomes: In Particular, The Variable, Reflection. Absel Awareness Among Business School Faculty Validating Business Simulations: Does High Market Share Lead To High Profitability? Simulation Debriefing Procedures Coaching And Business Simulations: A Formula For Success? A Seminal Inventory Of Basic Research Using Business Simulation Games The Influence Of Scorecard Evaluation On Decisions And Outcomes