smsmaarrtthistoryhistory. . . G UI D E T O . . .ANC.docx

smsmaarrtthistoryhistory
. . . G U
I D E T O . . .
ANCIENT
ROMAN
ART
Smarthistory guide to Ancient Roman Art
Smarthistory guide to Ancient Roman
Art
DR. JESSICA LEAY AMBLER, DR. DARIUS ARYA, DR.
JEFFREY A.
BECKER, DR. LEA CLINE, DR. ANDREW FINDLEY, DR.
STEVEN FINE,
DR. JULIA FISCHER, DR. VALENTINA FOLLO, DR.
BERNARD
FRISCHER, DR. BETH HARRIS, DR. JACLYN NEEL, DR.
ELIZABETH
MARLOWE, DR. PAUL A. RANOGAJEC, DR. LAUREL

TAYLOR, DR.
FRANCESCA TRONCHIN, AND DR. STEVEN ZUCKER
Smarthistory ● Brooklyn
Smarthistory guide to Ancient Roman Art by Dr. Jessica Leay
Ambler, Dr. Darius Arya, Dr. Jeffrey A. Becker, Dr. Lea Cline,
Dr. Andrew
Findley, Dr. Steven Fine, Dr. Julia Fischer, Dr. Valentina Follo,
Dr. Bernard Frischer, Dr. Beth Harris, Dr. Jaclyn Neel, Dr.
Elizabeth Marlowe,
Dr. Paul A. Ranogajec, Dr. Laurel Taylor, Dr. Francesca
Tronchin, and Dr. Steven Zucker is licensed under a Creative
Commons
Attribution-NonCommercial-ShareAlike 4.0 International
License, except where otherwise noted.
AP® Art History is a trademark registered by the College
Board, which is not affiliated with, and does not endorse, this
publication.
https://creativecommons.org/licenses/by-nc-sa/4.0/
https://creativecommons.org/licenses/by-nc-sa/4.0/
Contents
xi About Smarthistory
xiii Editors
xv Map

Part I. An introduction to the art of Ancient Rome
1. Introduction to ancient Roman art
3 Dr. Jessica Leay Ambler
2. The classical orders of architecture
3. Damnatio memoriae—Roman sanctions against memory
13 Dr. Francesca Tronchin
4. Digging through time
A conversation
19 Dr. Beth Harris and Dr. Darius Arya
5. Pompeii, an introduction
6. The rediscovery of Pompeii and the other cities of Vesuvius
7. An introduction to ancient Roman architecture
8. Forum Romanum (The Roman Forum)
39 Dr. Jeffrey A. Becker
9. Imperial fora, Rome
v
10. Roman domestic architecture: the domus

11. Roman domestic architecture: the insula
12. Roman domestic architecture: the villa
13. Roman funeral rituals and social status: The Amiternum
tomb and the tomb of the Haterii
65 Dr. Laurel Taylor
14. Looting, collecting, and exhibiting: the Bubon bronzes
A conversation
69 Dr. Elizabeth Marlowe and Dr. Steven Zucker
Part II. Ancient Roman Wall Painting
15. Ancient Roman Wall Painting Styles
16. Painted Garden, Villa of Livia
A conversation
81 Dr. Beth Harris and Dr. Steven Zucker
17. Still Life with Peaches from Herculaneum
85 Dr. Lea Cline
18. Pompeii: House of the Vettii
19. Pompeii: Dionysiac frieze, Villa of Mysteries
A conversation

Part III. Ancient Roman Republic
20. Temple of Jupiter Optimus Maximus, Rome
101 Dr. Andrew Findley
21. Temple of Portunus, Rome
22. Temple of Portunus, Rome
A conversation
23. Maison Carrée, Nîmes, France
vi
24. Capitoline She-wolf
117 Dr. Jaclyn Neel
25. Bronze Capitoline Brutus
A conversation
26. Tomb of the Scipios and the sarcophagus of Scipio Barbatus
27. Veristic male portrait
A conversation

28. Head of a Roman Patrician
Part IV. Ancient Rome: Early Empire
29. Augustus of Primaporta
135 Dr. Julia Fischer
30. Augustus of Primaporta
A conversation
31. Ara Pacis Augustae (Altar of Augustan Peace)
32. Ara Pacis Augustae (Altar of Augustan Peace)
A conversation
33. Dioskourides, Gemma Augustea
153 Dr. Julia Fischer
34. Preparations for a Sacrifice
35. The Colosseum (Flavian Amphitheater)
A conversation
161 Dr. Beth Harris, Dr. Steven Zucker, and Dr. Valentina Follo
36. The Arch of Titus and the Roman triumph

37. The Spoils of Jerusalem, Arch of Titus
A conversation
169 Dr. Beth Harris and Dr. Steven Fine
vii
38. Portrait Bust of a Flavian Woman (Fonseca Bust)
A conversation
39. Portrait Bust of a Flavian Woman (Fonseca Bust)
A conversation
175 Dr. Beth Harris and Dr. Elizabeth Marlowe
40. The Forum and Markets of Trajan
41. Markets of Trajan, Rome
A conversation
42. Forum of Trajan, Rome
A conversation
43. Column of Trajan, Rome

44. Column of Trajan, Rome
A conversation
195 Dr. Beth Harris, Dr. Steven Zucker, and Dr. Valentina Follo
Part V. Ancient Rome: Middle Empire
45. The Pantheon, Rome
201 Dr. Paul A. Ranogajec
46. The Pantheon, Rome
A conversation
47. A virtual tour of Hadrian's Villa, Tivoli
A conversation
213 Dr. Bernard Frischer and Dr. Beth Harris
48. Maritime Theatre at Hadrian’s Villa
A conversation
217 Dr. Bernard Frischer and Dr. Beth Harris
49. Pair of Centaurs Fighting Cats of Prey from Hadrian’s Villa
A conversation
viii
50. Medea Sarcophagus
A conversation

51. Equestrian Sculpture of Marcus Aurelius
52. Equestrian Sculpture of Marcus Aurelius
A conversation
53. The importance of the archeological findspot: The
Lullingstone Busts
A conversation
237 Dr. Elizabeth Marlowe and Dr. Steven Zucker
54. Severan marble plan (Forma Urbis Romae)
55. Ludovisi Battle Sarcophagus
A conversation
Part VI. Ancient Rome: Late Empire
56. Trebonianus Gallus — emperor or athlete?
A conversation
251 Dr. Beth Harris and Dr. Elizabeth Marlowe
57. Portraits of the Four Tetrarchs
A conversation

58. Basilica of Maxentius and Constantine
A conversation
259 Dr. Beth Harris and Dr. Darius Arya
59. The Colossus of Constantine
A conversation
60. Arch of Constantine
265 Dr. Andrew Findley
61. Arch of Constantine, Rome
A conversation
ix
62. The Symmachi Panel
A conversation
277 Acknowledgements
x

At Smarthistory® we believe art has the power to transform
lives
and to build understanding across cultures. We believe that the
brilliant histories of art belong to everyone, no matter their
background. Smarthistory’s free, award-winning digital content
unlocks the expertise of hundreds of leading scholars, making
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This book is not for sale, it is distributed by Smarthistory for
free.
Editors
Ruth Ezra
Ruth is a doctoral candidate at Harvard University, where she
specializes in the art of late-medieval and
Renaissance Europe. Upon completion of her BA at Williams
College, she studied in the UK on a Marshall
Scholarship, earning an MPhil in history and philosophy of
science from the University of Cambridge and an MA
in history of art from the Courtauld Institute. A committed
educator, Ruth has recently served as a Gallery Lecturer
at both the Museum of Fine Arts, Boston and the National
Galleries of Scotland, as well as a Teaching Fellow at
Harvard.
Beth Harris, Ph.D.

Beth is co-founder and executive director of Smarthistory.
Previously, she was dean of art and history at Khan
Academy and director of digital learning at The Museum of
Modern Art, where she started MoMA Courses Online
and co-produced educational videos, websites and apps. Before
joining MoMA, Beth was Associate Professor of art
history and director of distance learning at the Fashion Institute
of Technology where she taught both online and
in the classroom. She has co-authored, with Dr. Steven Zucker,
numerous articles on the future of education and
the future of museums, topics she regularly addresses at
conferences around the world. She received her Master’s
degree from the Courtauld Institute of Art in London, and her
doctorate in Art History from the Graduate Center
of the City University of New York.
Steven Zucker, Ph.D.
Steven is co-founder and executive director of Smarthistory.
Previously, Steven was dean of art and history at Khan
Academy. He was also chair of history of art and design at Pratt
Institute where he strengthened enrollment and
lead the renewal of curriculum across the Institute. Before that,
he was dean of the School of Graduate Studies at
the Fashion Institute of Technology, SUNY and chair of their
art history department. He has taught at The School of
Visual Arts, Hunter College, and at The Museum of Modern
Art. Dr. Zucker is a recipient of the SUNY Chancellor’s
Award for Excellence in Teaching. He has co-authored, with Dr.
Beth Harris, numerous articles on the future of
education and the future of museums, topics he regularly
addresses at conferences around the world. Dr. Zucker
received his Ph.D. from the Graduate Center of the City
University of New York.
xiii

Map
xv
PART I
An introduction to the art of Ancient
Rome
1. Introduction to ancient Roman art
Dr. Jessica Leay Ambler
View of the Roman forum, looking toward the Colosseum
(photo: Steven Zucker,
CC BY-NC-SA 2.0)
Roman art: when and where
Roman art is a very broad topic, spanning almost 1,000 years
and
three continents, from Europe into Africa and Asia. The first
Roman
art can be dated back to 509 B.C.E., with the legendary
founding of

the Roman Republic, and lasted until 330 C.E. (or much longer,
if you
include Byzantine art). Roman art also encompasses a broad
spectrum
of media including marble, painting, mosaic, gems, silver and
bronze
work, and terracottas, just to name a few. The city of Rome was
a
melting pot, and the Romans had no qualms about adapting
artistic
influences from the other Mediterranean cultures that
surrounded and
preceded them. For this reason it is common to see Greek,
Etruscan
and Egyptian influences throughout Roman art. This is not to
say that
all of Roman art is derivative, though, and one of the challenges
for
specialists is to define what is “Roman” about Roman art.
Greek art certainly had a powerful influence on Roman practice;
the
Roman poet Horace famously said that “Greece, the captive,
took
her savage victor captive,” meaning that Rome (though it
conquered
Greece) adapted much of Greece’s cultural and artistic heritage
(as
well as importing many of its most famous works). It is also
true that
many Romans commissioned versions of famous Greek works
from
earlier centuries; this is why we often have marble versions of
lost
Greek bronzes such as the Doryphoros by Polykleitos.

Doryphoros (Spear Bearer), Roman copy after an original by the
Greek sculptor
Polykleitos from c. 450-440 B.C.E., marble, 6’6″
(Archaeological Museum, Naples)
(photo: Steven Zucker, CC BY-NC-SA 2.0)
The Romans did not believe, as we do today, that to have a copy
of an artwork was of any less value that to have the original.
The
copies, however, were more often variations rather than direct
copies,
and they had small changes made to them. The variations could
be
made with humor, taking the serious and somber element of
Greek
art and turning it on its head. So, for example, a famously
gruesome
Hellenistic sculpture of the satyr Marsyas being flayed was
converted
in a Roman dining room to a knife handle (currently in the
National
Archaeological Museum in Perugia). A knife was the very
element
that would have been used to flay the poor satyr, demonstrating
not only the owner’s knowledge of Greek mythology and
important
statuary, but also a dark sense of humor. From the direct
reporting of
the Greeks to the utilitarian and humorous luxury item of a
Roman
enthusiast, Marsyas made quite the journey. But the Roman
artist was
not simply copying. He was also adapting in a conscious and
brilliant
way. It is precisely this ability to adapt, convert, combine
elements

and add a touch of humor that makes Roman art Roman.
Republican Rome
The mythic founding of the Roman Republic is supposed to
have
happened in 509 B.C.E., when the last Etruscan king,
Tarquinius
Superbus, was overthrown. During the Republican period, the
Romans were governed by annually elected magistrates, the two
3
consuls being the most important among them, and the Senate,
which
was the ruling body of the state. Eventually the system broke
down
and civil wars ensued between 100 and 42 B.C.E. The wars were
finally
brought to an end when Octavian (later called Augustus)
defeated
Mark Antony in the Battle of Actium in 31 B.C.E.
In the Republican period, art was produced in the service of the
state, depicting public sacrifices or celebrating victorious
military
campaigns (like the Monument of Aemilius Paullus at Delphi).
Portraiture extolled the communal goals of the Republic; hard
work,
age, wisdom, being a community leader and soldier. Patrons
chose
to have themselves represented with balding heads, large noses,
and
extra wrinkles, demonstrating that they had spent their lives

working
for the Republic as model citizens, flaunting their acquired
wisdom
with each furrow of the brow. We now call this portrait style
veristic,
referring to the hyper-naturalistic features that emphasize every
flaw,
creating portraits of individuals with personality and essence.
Imperial Rome
Augustus’s rise to power in Rome signaled the end of the
Roman
Republic and the formation of Imperial rule. Roman art was
now put
to the service of aggrandizing the ruler and his family. It was
also
meant to indicate shifts in leadership. The major periods in
Imperial
Roman art are named after individual rulers or major dynasties,
they
are:
Augustan (27 B.C.E.-14 C.E.)
Julio-Claudian (14-68 C.E.)
Flavian (69-98 C.E.)
Trajanic (98-117 C.E.)
Hadrianic (117-138 C.E.)
Antonine (138-193 C.E.)
Severan (193-235 C.E.)
Soldier Emperor (235-284 C.E.)
Tetrarchic (284-312 C.E.)
Constantinian (307-337 C.E.)
Imperial art often hearkened back to the Classical art of the

past.
“Classical”, or “Classicizing,” when used in reference to
Roman art
refers broadly to the influences of Greek art from the Classical
and
Hellenistic periods (480-31 B.C.E.). Classicizing elements
include the
smooth lines, elegant drapery, idealized nude bodies, highly
naturalistic forms and balanced proportions that the Greeks had
perfected over centuries of practice.
Marble bust of a man, mid 1st century, marble, 14 3/8 inches
(The
Metropolitan Museum of Art)
Augustus and the Julio-Claudian dynasty were particularly fond
of
adapting Classical elements into their art. The Augustus of
Primaporta
was made at the end of Augustus’s life, yet he is represented as
youthful, idealized and strikingly handsome like a young
athlete; all
hallmarks of Classical art. The emperor Hadrian was known as a
philhellene, or lover of all things Greek. The emperor himself
began
sporting a Greek “philosopher’s beard” in his official
portraiture,
unheard of before this time. Décor at his rambling Villa at
Tivoli
included mosaic copies of famous Greek paintings, such as
Battle
of the Centaursand Wild Beastsby the legendary ancient Greek

painter Zeuxis.
Augustus of Primaporta, 1st century C.E. (Vatican Museums)
(photo: Steven Zucker,
CC BY-NC-SA 2.0)
4 Smarthistory guide to Ancient Roman Art
Relief from the Ara Pacis Augustae (Altar of Augustan Peace),
dedicated in 9 B.C.E., marble (Museo dell’Ara Pacis, Rome)
(photo: Steven Zucker, CC BY-NC-SA 2.0)
Pair of Centaurs Fighting Cats of Preyfrom Hadrian’s Villa,
mosaic, c. 130 C.E.
(Altes Museum, Berlin)
Later Imperial art moved away from earlier Classical
influences, and
Severan art signals the shift to art of Late Antiquity. The
characteristics of Late Antique art include frontality, stiffness
of pose
and drapery, deeply drilled lines, less naturalism, squat
proportions
and lack of individualism. Important figures are often slightly
larger
or are placed above the rest of the crowd to denote importance.
Chariot procession of Septimus Severus, relief from the attach
of the Arch of
Septimus Severus, Leptis Magna, Libya, 203 C.E., marble, 5; 6”
high (Castle

Museum, Tripoli)
In relief panels from the Arch of Septimius Severus from Lepcis
Magna,
Septimius Severus and his sons, Caracalla and Geta ride in a
chariot,
marking them out from an otherwise uniform sea of repeating
figures,
all wearing the same stylized and flat drapery. There is little
variation
or individualism in the figures and they are all stiff and carved
with
deep, full lines. There is an ease to reading the work; Septimius
is
centrally located, between his sons and slightly taller; all the
other
figures direct the viewer’s eyes to him.
Introduction to ancient Roman art 5
Relief from the Arch of Constantine, 315 C.E., Rome (photo: F.
Tronchin, CC BY-
NC-ND 2.0)
Constantinian art continued to integrate the elements of Late
Antiquity that had been introduced in the Severan period, but
they are
now developed even further. For example, on the oratio relief
panel
on the Arch of Constantine, the figures are even more squat,
frontally

oriented, similar to one another, and there is a clear lack of
naturalism.
Again, the message is meant to be understood without
hesitation:
Constantine is in power.
Who made Roman art?
We don’t know much about who made Roman art. Artists
certainly
existed in antiquity but we know very little about them,
especially
during the Roman period, because of a lack of documentary
evidence
such as contracts or letters. What evidence we do have, such as
Pliny
the Elder’s Natural History, pays little attention to
contemporary
artists and often focuses more on the Greek artists of the past.
As
a result, scholars do not refer to specific artists but consider
them
generally, as a largely anonymous group.
Painted Garden, removed from the triclinium (dining room) in
the Villa of Livia
Drusilla, Prima Porta, fresco, 30-20 B.C.E. (Museo Nazionale
Romano, Palazzo
Massimo, Rome) (photo: Steven Zucker, CC BY-NC-SA 2.0)
What did they make?
Roman art encompasses private art made for Roman homes as
well
as art in the public sphere. The elite Roman home provided an

opportunity for the owner to display his wealth, taste and
education
to his visitors, dependents, and clients. Since Roman homes
were
regularly visited and were meant to be viewed, their decoration
was
of the utmost importance. Wall paintings, mosaics, and
sculptural
displays were all incorporated seamlessly with small luxury
items
such as bronze figurines and silver bowls. The subject matter
ranged
from busts of important ancestors to mythological and historical
scenes, still lifes, and landscapes—all to create the idea of an
erudite
patron steeped in culture.
Ludovisi Battle Sarcophagus: Battle of Romans and Barbarians,
c. 250-260 C.E.,
preconneus marble, 150 cm high (Palazzo Altemps: Museo
Nazionale Romano,
Rome) (photo: Steven Zucker, CC BY-NC-SA 2.0)
When Romans died, they left behind imagery that identified
them
as individuals. Funerary imagery often emphasized unique
physical
traits or trade, partners or favored deities. Roman funerary art
spans
several media and all periods and regions. It included portrait
busts,
wall reliefs set into working-class group tombs (like those at
Ostia),

and elite decorated tombs (like the Via delle Tombe at
Pompeii). In
addition, there were painted Faiyum portraits placed on
mummies
and sarcophagi. Because death touched all levels of society—
men and
women, emperors, elites, and freedmen—funerary art recorded
the
diverse experiences of the various peoples who lived in the
Roman
empire.
The public sphere is filled with works commissioned by the
emperors
such as portraits of the imperial family or bath houses decorated
with
copies of important Classical statues. There are also
commemorative
works like the triumphal arches and columns that served a
didactic
as well as a celebratory function. The arches and columns (like
the
Arch of Titus or the Column of Trajan), marked victories,
depicted
war, and described military life. They also revealed foreign
lands and
enemies of the state. They could also depict an emperor’s
successes in
domestic and foreign policy rather than in war, such as Trajan’s
Arch
in Benevento. Religious art is also included in this category,
such as
the cult statues placed in Roman temples that stood in for the
deities
they represented, like Venus or Jupiter. Gods and religions from
other

parts of the empire also made their way to Rome’s capital
including
the Egyptian goddess Isis, the Persian god Mithras and
ultimately
Christianity. Each of these religions brought its own unique sets
of
imagery to inform proper worship and instruct their sect’s
followers.
It can be difficult to pinpoint just what is Roman about Roman
art, but
it is the ability to adapt, to take in and to uniquely combine
influences
over centuries of practice that made Roman art distinct.
Column of Trajan, looking up, Carrera marble, completed 113
C.E., Rome,
dedicated to Emperor Trajan in honor of his victory over Dacia
(now Romania)
101-02 and 105-06 C.E. (photo: Steven Zucker, CC BY-NC-SA
2.0)
Additional resources:
Clarke, John R. Art in the Lives of Ordinary Romans: Visual
Representation and Non-Elite Viewers in Italy, 100 B.C-A.D.
315. Los
Angeles: University of California Press, 2003.
Kleiner, Fred S. A History of Roman Art. Belmont: Thomson

Wadsworth, 2007.
Ramage, Nancy H., and Andrew Ramage. Roman Art: Romulus
to
Constantine. Fifth Edition. New Jersey: Prentice Hall, Inc.,
2008.
Stewart, Peter. The Social History of Roman Art. New York:
Cambridge
University Press, 2008.
Zanker, Paul. Roman Art. Los Angeles: J. Paul Getty Museum,
2010.
Introduction to ancient Roman art 7
2. The classical orders of architecture
Dr. Jessica Leay Ambler
An architectural order describes a style of building. In classical
architecture each order is readily identifiable by means of its
proportions and profiles, as well as by various aesthetic details.
The
style of column employed serves as a useful index of the style
itself,
so identifying the order of the column will then, in turn, situate
the order employed in the structure as a whole. The classical
orders—described by the labels Doric, Ionic, and Corinthian—
do not
merely serve as descriptors for the remains of ancient buildings,
but
as an index to the architectural and aesthetic development of

Greek
architecture itself.
The Doric order
Doric order
The Doric order is the earliest of the three Classical orders of
architecture and represents an important moment in
Mediterranean
architecture when monumental construction made the transition
from impermanent materials (i.e. wood) to permanent materials,
namely stone. The Doric order is characterized by a plain,
unadorned
column capital and a column that rests directly on the stylobate
of
the temple without a base. The Doric entablature includes a
frieze
composed of trigylphs (vertical plaques with three divisions)
and
metopes (square spaces for either painted or sculpted
decoration). The
columns are fluted and are of sturdy, if not stocky, proportions.
The Doric order emerged on the Greek mainland during the
course
of the late seventh century B.C.E. and remained the
predominant
order for Greek temple construction through the early fifth
century
B.C.E., although notable buildings of the Classical period—
especially
the canonical Parthenon in Athens—still employ it. By 575
B.C.E the
order may be properly identified, with some of the earliest

surviving
elements being the metope plaques from the Temple of Apollo
at
Thermon. Other early, but fragmentary, examples include the
sanctuary of Hera at Argos, votive capitals from the island of
Aegina,
as well as early Doric capitals that were a part of the Temple of
Athena Pronaia at Delphi in central Greece. The Doric order
finds
perhaps its fullest expression in the Parthenon (c. 447-432
B.C.E.) at
Athens designed by Iktinos and Kallikrates.
Iktinos and Kallikrates, The Parthenon, 447 – 432 B.C.E.,
Athens (photo: Steven
Zucker, CC BY-NC-SA 2.0)
The Ionic order
As its names suggests, the Ionic Order originated in Ionia, a
coastal
region of central Anatolia (today Turkey) where a number of
ancient
Greek settlements were located. Volutes (scroll-like
ornaments) characterize the Ionic capital and a base supports
the
column, unlike the Doric order. The Ionic order developed in
Ionia
during the mid-sixth century B.C.E. and had been transmitted to
9
mainland Greece by the fifth century B.C.E. Among the earliest

examples of the Ionic capital is the inscribed votive column
from
Naxos, dating to the end of the seventh century B.C.E.
Ionic capital, north porch of the Erechtheion, 421-407 B.C.E.,
marble, Acropolis,
Athens (photo: Steven Zucker, CC BY-NC-SA 2.0)
The monumental temple dedicated to Hera on the island of
Samos,
built by the architect Rhoikos c. 570-560 B.C.E., was the first
of the
great Ionic buildings, although it was destroyed by earthquake
in
short order. The sixth century B.C.E. Temple of Artemis at
Ephesus,
a wonder of the ancient world, was also an Ionic design. In
Athens
the Ionic order influences some elements of the Parthenon (447-
432
B.C.E.), notably the Ionic frieze that encircles the cella of the
temple.
Ionic columns are also employed in the interior of the
monumental
gateway to the Acropolis known as the Propylaia (c. 437-432
B.C.E.).
The Ionic was promoted to an exterior order in the construction
of
the Erechtheion (c. 421-405 B.C.E.) on the Athenian Acropolis
(image
below).
North porch of the Erechtheion, 421-407 B.C.E., marble,
Acropolis, Athens (photo:

Steven Zucker, CC BY-NC-SA 2.0)
The Ionic order is notable for its graceful proportions, giving a
more
slender and elegant profile than the Doric order. The ancient
Roman
architect Vitruvius compared the Doric module to a sturdy, male
body,
while the Ionic was possessed of more graceful, feminine
proportions.
The Ionic order incorporates a running frieze of continuous
sculptural
relief, as opposed to the Doric frieze composed of triglyphs and
metopes.
The Corinthian order
The Corinthian order is both the latest and the most elaborate of
the Classical orders of architecture. The order was employed in
both
Greek and Roman architecture, with minor variations, and gave
rise,
in turn, to the Composite order. As the name suggests, the
origins
of the order were connected in antiquity with the Greek city-
state
of Corinth where, according to the architectural writer
Vitruvius,
the sculptor Callimachus drew a set of acanthus leaves
surrounding
a votive basket (Vitr. 4.1.9-10). In archaeological terms the
earliest
known Corinthian capital comes from the Temple of Apollo
Epicurius
at Bassae and dates to c. 427 B.C.E.

Corinthian Capital, Odeon of Agrippa, Athenian Agora (photo:
Tilemahos
Efthimiadis CC BY-SA 2.0) <https://flic.kr/p/73uvoX>
The defining element of the Corinthian order is its elaborate,
carved
capital, which incorporates even more vegetal elements than the
Ionic
order does. The stylized, carved leaves of an acanthus plant
grow
around the capital, generally terminating just below the abacus.
The
Romans favored the Corinthian order, perhaps due to its slender
properties. The order is employed in numerous notable Roman
architectural monuments, including the Temple of Mars Ultor
and the
Pantheon in Rome, and the Maison Carrée in Nîmes.
Acanthus leaf (photo: Steven Zucker, CC BY-
NC-SA 2.0)
https://flic.kr/p/73uvoX
Legacy of the Greek architectural canon
The canonical Greek architectural orders have exerted influence
on
architects and their imaginations for thousands of years. While
Greek
architecture played a key role in inspiring the Romans, its
legacy

also stretches far beyond antiquity. When James “Athenian”
Stuart
and Nicholas Revett visited Greece during the period from 1748
to
1755 and subsequently published The Antiquities of Athens and
Other
Monuments of Greece (1762) in London, the Neoclassical
revolution
was underway. Captivated by Stuart and Revett’s measured
drawings
and engravings, Europe suddenly demanded Greek forms.
Architects
the likes of Robert Adam drove the Neoclassical movement,
creating
buildings like Kedleston Hall, an English country house in
Kedleston,
Derbyshire. …
Chapter 7
Organization, Environment, and Culture Change
What You Will Learn
• Delivery of care in long-term care facilities has been making
a transition from the medical model used in hospitals to
contemporary building designs, philosophies of care, and
practices that spotlight person-centered care.
• Person-centered care must integrate three major components:
socio-residential, clinical, and overarching human factors.
• Nursing homes encounter several challenges to a full
integration of the three main components. The challenges
include need for clinical care, economic necessity, patient-
related constraints, regulations, and conflicting rights. Yet,
compromises must be achieved.
• A nursing home is organized by departments, but a
multidisciplinary approach that works across the various
departments is essential.

• The clinical organization of a nursing home includes nursing
units and adequately staffed and well-equipped nursing stations.
• The socioresidential environment should emphasize both
personal and public domains. These domains emphasize security
of person and property, safety against potential hazards,
wayfinding, autonomy and self-determination, personal privacy,
compatible relationships, the dining experience, and
opportunities for socializing.
• Modern architectural designs, such as neighborhood design
and nested single rooms, emphasize many of the
socioresidential factors.
• Aesthetics are an important element of homelike
environments that also promote a sense of well-being. Lighting,
colors, noise reduction, and furnishings require special
considerations in creating therapeutic environments for nursing
home residents.
• Enriched environments incorporate the theories of biophilia
and thriving. These environments must provide a moderate
degree of positive stimulation and also opportunities for silent
contemplation and inner reflection.
• Culture change is a growing movement that will characterize
future nursing homes. Culture change requires person-centered
care, enriched environments, and staff empowerment based on
adoption of new mindsets for managing people.
• The Eden Alternative and the Green House Project are two
contemporary models of culture change.
• Environments for dementia patients are based on the modern
concepts of creating enriched environments.
Introduction
The internal environment and organization of nursing homes
traditionally evolved as both a direct and indirect result of
health policy, which promoted an environment patterned after
hospitals. As hospital building codes were adapted for nursing
homes during the 1960s, hospital-like long corridors, shared
occupancy, and cafeteria-style dining rooms became the norm in
nursing home construction. Licensing and certification rules

further reinforced the hospital design because the nursing home
was viewed as a place where convalescent treatment would
continue following discharge from hospitals, as laid out in
Medicare rules. Clinical organization in nursing homes also
followed the hospital-based medical model, with central nursing
stations, buzzers, and call signals; noisy shower and bathing
areas; lack of privacy; scheduled routines; and hallways
cluttered with medication carts, soiled linen hampers, food
carts, housekeeping carts, and similar items.
During the 1980s and beyond, construction of new nursing
facilities and renovation of existing ones began emphasizing
residential and aesthetic features. These changes were triggered
mainly by market competition, which created the need to attract
new patients to keep the beds filled and also cater to the
private-pay clientele. Competition also came from the
emergence of modern assisted living facilities.
It took some time for nursing home professionals and regulators
to fully grasp the fact that, unlike hospitals, a nursing facility is
both a clinical and a social establishment. Unlike hospitals,
patients stay in nursing homes for extended periods of time. For
some, the stay is permanent and, in a sense, the nursing home
becomes their home. Hence, new choices and alternatives to
traditional nursing home care have molded people’s
expectations about long-term care (LTC), and have influenced a
gradual transformation from traditional hospital-inspired
facilities to contemporary architectural features that have
homelike living environments. Yet, at the same time, patients’
clinical needs are addressed while improving both quality of
care and quality of life.
Many nursing homes across the United States, and indeed, in
many developed nations, are adopting a culture change. As a
result, tomorrow’s nursing homes will be much different than
what they are today as person-centered care and other aspects of
culture change become the centerpieces in long-term care
delivery.
Philosophy of Care in Transition

Traditional methods of treating patients in health care
institutions have been driven by the sick-role model explained
by Parsons (1972). The patient is expected to relinquish
individual control to medical personnel and comply with their
directives. The sick role promotes an institutional orientation to
patient care, which is manifested in four ways: (1) rigid daily
routines; (2) social distance between staff members and the
patient; (3) care practices that lend to depersonalization, such as
loss of privacy; and (4) “blocking routines” that require patients
to do certain things at prearranged times, mainly for the
convenience of staff (Kruzich & Berg, 1985).
Although patients are admitted to skilled nursing facilities
primarily to receive therapeutic interventions, increasing
emphasis is being placed on care delivery according to the
philosophy of person-centered care, which integrates physical
layout and design with empowerment of the residents and their
families. It requires a focus away from what is best for the
organization to what is best for the patient. It requires a
commitment to treating each patient as an individual, not as
products in an assembly line. Even the Affordable Care Act puts
emphasis on creating environments of person-centered care
(Grabowski et al., 2014).
The contemporary philosophy of person-centered care (also
called resident-centered care or client-centered care) in modern
nursing facilities is guided by three main factors (Figure 7–1):
• The socioresidential component creates the physical
environment in which the resident receives room-and-board
services and considers the nursing facility as his or her home.
Various amenities, such as personal and social spaces, aesthetic
décor, and various conveniences such as a barber/beauty salon,
are incorporated into facility designs. Privacy, opportunities to
pursue individual interests, and leisure are balanced by social
interaction and engagement. Meals not only meet the nutritional
and therapeutic needs but are also palatable and attractively
served.
• The elements of clinical care (listed in Figure 7–1) are highly

individualized. Care is delivered in accordance with prevailing
standards that incorporate evidence-based practices.
• The overarching human factors—autonomy, independence,
dignity, and self-esteem—blend into every aspect of the
patient’s life and the delivery of services. Such integration is
not achieved without ongoing staff training.
When human factors are integrated into the other two
components, it creates an environment in which a person’s
physical, mental, social, and spiritual needs are met. In sharp
contrast to the sick-role model, person-centered care is
characterized by shared control between the patient and the
facility personnel. It promotes individual autonomy and
decision making, even when a resident’s decision-making
capacity is limited. It gives equal weight to promoting quality
of care and quality of life.
Challenges to a Full Integration
Integration of the three components will continue to be a
challenge for nursing home professionals. Just as it is with
improving the quality of care, the goal of achieving person-
centered care is never fully realized, but it becomes an endless
pursuit. This is because five main challenges present an ongoing
struggle: primacy of clinical care, economic necessity, patient-
related constraints, regulatory burden, and conflicting rights.
Successful juggling through these challenging aspects is what
sets apart an effectively managed facility from the mediocre
ones.
Figure 7–1 Main Components of Person-Centered Care
Primacy of Clinical Care
The fundamental purpose of a nursing home is defeated if it
does not provide clinical care in accordance with up-to-date
standards, best practices, and use of appropriate technology,
while also complying with regulatory requirements. The sick-
role model can be compromised but cannot be entirely
dispensed with. For example, giving medications and other
treatments in a patient population of any size requires certain

routines based on medical directives. Medical examinations
result in some loss of personal control by the patient. Necessary
staff assistance with daily living activities does create some
dependency and loss of autonomy.
Economic Necessity
Nursing facilities exist because of economic necessity. If it
were feasible, almost every nursing home patient would choose
to be cared for in a private residence by a private-duty nurse.
The reality, however, is that unless an individual is very
wealthy, neither the individual patient nor the society can afford
to incur the expense that private-duty care would entail.
Expensive as it is, delivery of care in a nursing facility is highly
cost effective compared with private-duty nursing. A nursing
home must, by necessity, provide services to a relatively large
number of patients 24/7. Hence, the fact remains that nursing
facilities must function as efficient organizations.
Patient-Related Constraints
Nursing homes face constraints related to patient
characteristics. Examples include behavioral problems, such as
frequent combativeness or screaming episodes that can disrupt
the environment. By its very nature, any group living
arrangement creates an environment in which small-scale
conflicts of everyday life are likely to occur. First, respecting
autonomy can be “vexatious because the conditions that bring
elders into long-term care—confusion, dementia, wandering,
and a host of chronic conditions associated with being old—are
such that the very capacity for choice and rational decision
making is seriously compromised, if not absent” (Agich, 1995,
p. 113). Yet, a conscious effort must be made to return to the
elder patient some of the responsibilities for his or her own
health care in a caring and respectful way.
Regulatory Burden
The nursing home industry particularly views the regulatory
process to be onerous, adversarial, and punitive. As a result, the
culture of nursing home administration has suffered from
paranoia of the regulatory system. Inadequate financing under

Medicaid, the largest payer for nursing home care, is also seen
as a major constraint to procure needed resources. Historically,
the nursing home industry’s response has been largely reactive,
mainly to protect itself against possible regulatory sanction
(Collopy, 1995, p. 149). However, the industry has been
evolving by gradually abandoning its highly risk-averse stance
and adopting innovative approaches to create organizations that
are most desired by its clients. The culture change, discussed
later in this chapter, is an effort in this direction initiated by the
industry’s leadership, not by any regulatory requirements. Yet,
adoption of person-centered care and culture change are not
pervasive, and regulatory oversight is here to stay.
Conflicting Rights
A perfect integration of clinical, socioresidential, and human
factors is almost impossible. In person-centered caregiving,
balance and compromise are often necessary. The nursing
facility can help with the process of adjustment. Familiarity and
closeness in the caregiver–patient relationship that is built on
the foundation of respect for the patient can also help patients
maintain their sense of identity despite the ravages of
impairment (Agich, 1995). In a nursing facility, each resident’s
desires, interests, and rights can directly affect the interests and
legitimate expectations of other residents (Arras, 1995). For
example, patients who wander into others’ rooms, rummage
through others’ belongings, dip their hands into other diners’
plates, make yelling noises, or display combativeness disrupt
the quality of life of other residents. To deal with such conflicts
in an institutional setting, the facility must try to achieve an
appropriate balance among the needs and rights of different
groups. In a social environment, no one patient’s interests are
legitimately outweighed by the competing interests of other
patients. Hence, appropriate interventions and compromises
often become necessary.
Nursing Home Organization
An organizational chart showing the main service departments
in a typical skilled nursing facility is illustrated in Figure 7–2.

In midsized facilities, each of these services is managed by a
midlevel department head who reports directly to the
administrator.
Figure 7–2 Organizational Chart of a Typical Skilled Nursing
Facility
The various support services are adjuncts to the central nursing
care process and interface with clinical care using a
multidisciplinary approach that works across the various
departments. Building a multidisciplinary team requires the
administrator’s involvement, and the administrator must
develop an organizational culture of interdepartmental
communication and cooperation to address patient needs in a
holistic system of care.
In an integrated multidisciplinary approach to patient care,
professionals who provide medical, nursing, social services,
recreational activities, and dietary services share their
observations, discuss clinical goals, and develop interventions
in which a variety of services interface. Professionals in each
discipline are aware of what others are doing to address the
multifaceted needs of each patient. Using an individualized plan
of care for each patient, the overarching goal is to address all
aspects of a patient’s needs without duplicating or disregarding
any needs.
Clinical Set-Up
The vast majority of nursing homes use a traditional clinical
set-up. Many newer facilities that are being built use innovative
design concepts to tone down the clinical organization.
Nursing Units
A nursing unit or wing is a section of a facility that consists of
a certain number of patient rooms served by a nursing station.
Depending on its size, a facility may have clinically distinct
nursing units, each providing a somewhat distinct level of care,
such as rehabilitation, dementia care, or specialized care.
Distinct nursing units can also be designated according to the
type of certification. To achieve staff efficiency, most clinical

units are self-contained, having their own bathing rooms, linen
closets, dining or feeding rooms, and lounges for patients and
visitors. An enclosed area or a hallway nook for depositing
soiled linens is located in the unit, with marked containers to
ease sorting and to separate lightly soiled and heavily soiled
linens. When utility closets are easily accessible to staff,
hallways are kept free of clutter, and odors are kept to a
minimum. An enclosed soiled utility area, rather than a nook in
the hallway, is ideal because it can be equipped with a rinse tub
to eliminate heavy wastes. Modern ventilation and waste-
elimination systems are designed to keep odors to a minimum.
Also, staff members should be trained in sanitation and odor
control methods. Chemical deodorizers should not be used to
mask odors.
When a facility has more than one nursing unit, it can segregate
patients on the basis of clinical criteria. However, neatly
categorizing patients in terms of their needs for care is not
always practical. Comorbidities often present a challenge to
LTC clinicians about where a patient with given health
conditions can be best accommodated. Yet, facilities must give
due consideration to each patient’s clinical needs as well as
quality of life. Distinctly separate specialized care units are
often provided for subacute care or Alzheimer’s care. Such
specialized units allow the facility to match staff skills to
special patient needs. Rehabilitation aides (paraprofessionals
who follow up on rehabilitation therapies), for instance, are
most appropriately stationed in the skilled nursing facility unit
where most of the Medicare patients are located. A separate
nursing unit, however, is not generally feasible for every type
of specialization. Several clinically complex services such as
ventilator care, head trauma care, care for spinal injuries, and
treatment for pressure ulcers and wounds can be located on one
unit that is served by the same nursing station.
Nursing Station
The hub of clinical care is an appropriately located, adequately
staffed, and well-furnished nursing station. This station can be

regarded as a service center from where all nursing care is
delivered to a certain number of patients, generally on an entire
nursing unit.
Location of Nursing Stations
A nursing station should be centrally located to enable the
nursing staff to observe and supervise a certain number of
patient rooms and to respond effectively to patient needs. As a
general rule, a separate nursing station serves each clinical unit
or wing in a facility.
Adjacent to the nursing station are rooms for bathing and
showering, special dining areas to accommodate patients who
need assistance with eating, and patient lounges, including any
lounges designated for smokers. Of course, not all patient
dining rooms and lounges need to be in the vicinity of a nursing
station—only those where supervision from staff is necessary.
Nursing Station Furnishings
The layout and furnishing of a nursing station should enhance
staff effectiveness. The station itself is an enclosed area, with a
counter behind which nurses and other staff members perform
administrative tasks. To protect the confidentiality of patient-
related information, no one but authorized staff members should
have access to the area behind the counter. Among other things,
a nursing station’s furnishings must include three important
components: a nurse call system, medical records, and a
pharmaceuticals room.
Nurse Call Systems A call system connects devices at all
patient bedsides and in toilets to the nursing station and to
pocket pagers carried by individual caregivers assigned to those
patients. It should also connect the station to the bathing and
shower rooms, dining areas, and lounges located on a given
nursing unit. The system enables the patients themselves and
staff members working with patients to summon help when
needed. The most commonly used systems have audiovisual as
well as voice capabilities. A patient uses a sensory device—
such as a call button—that sets off the audiovisual signal at the
nursing station. A voice or “talk-back” feature allows the staff

member attending to a patient to communicate with staff
members located at the station; this device saves time that
otherwise will be spent walking back and forth from the nursing
station. Modern wireless communication devices such as
portable pagers have eliminated the need for buzzing sounds at
nursing stations and frequent overhead paging, which make the
environment noisy and stressful.
Medical Records Located at the nursing station, there must be
a separate medical chart for every patient on the unit. Medical
records are increasingly being automated by implementing
electronic health records. Automation can greatly facilitate the
tasks of keeping records up to date and retrieving them quickly.
Privacy practices must comply with HIPAA standards.
Pharmaceuticals Room The pharmaceuticals room, or
medication room, as it is commonly called, should be quickly
accessible from the nursing station. This room is locked to
safeguard all medications. The pharmaceuticals room is also
used to store nursing treatment supplies and a first-aid box.
Socioresidential Environment
A nursing facility is a community in which the social and
residential elements are closely intertwined. The environment
itself should promote the healing of the body, mind, and spirit.
A healing environment relieves the clinical infrastructure of
pressures that might otherwise be imposed on it from social
conflict or individual ill-adjustment. As mentioned earlier,
segregating patients with severe dementia and those with
behavioral problems reduces stresses in an environment that can
otherwise be disruptive from commotion and confusion. The
facility’s set-up should also make it easier for patients to
explore their compatibilities with others and engage in social
interactions in accordance with personal preferences. The
socioresidential environment should emphasize both personal
and public domains.
Personal Domain
At a personal level, the main concerns people have are security,
safety, wayfinding, autonomy, and privacy. To adequately cope

with change, individuals need opportunities for introspection, a
sense of personal space, and support from professionals.
Security
Security is a basic human need. It entails physical safety and
psychological peace of mind. It includes a variety of conditions
that contribute to freedom from risk, danger, anxiety, or doubt
(Schwarz, 1996). A nursing facility is responsible for its
residents’ personal security and the safekeeping of their
belongings and private funds if the latter are deposited in a
resident’s trust account that the facility manages. Security
considerations often vary from one patient to another. A patient
may have a tendency to wander out unnoticed and compromise
his or her safety. But if this same person can wander out into a
protective environment, such as a fenced-in walkway
surrounded with plants and flowers, it can have a therapeutic
effect. Another may insist on wearing expensive jewelry that
someone could remove or that could get lost. Another may
hallucinate and imagine that someone is assaulting her.
Not all nursing homes are located in safe neighborhoods,
particularly in large cities. The administrator must evaluate both
external and internal security concerns, which include
protecting residents and their property from intruders. To the
extent that patients feel safe and secure, they can choose to
spend time indoors and outdoors.
Safety
Building design is primarily governed by federal, state, and
local codes and regulations. Among these, the Life Safety
Code® provides the most comprehensive set of rules. However,
creation of a safe environment goes beyond compliance with
the Life Safety Code®. In 2009, an environment that was not
free of accident hazards was the most cited deficiency
nationally (Harrington et al., 2010). Hence, several
considerations are important in creating a safe environment:
• The elderly are particularly vulnerable to falls. Great caution
and vigilance needs to be exercised around wet floors, power
cords, and throw rugs.

• Potential hazards should be eliminated or closely monitored.
Access to products such as drugs, lotions, and ointments on
medication and treatment carts should be adequately supervised.
Patients could also gain access to other unattended toxic
substances, such as cleaning chemicals left unattended on
housekeeping carts, or sharp objects, such as certain
maintenance tools.
• Access to areas such as the kitchen, mechanical rooms, and
laundry are generally prohibited. However, with some
supervision, cooking/baking or laundry activities can provide
stimulating and meaningful engagement for some patients,
including those with mild to moderate dementia. For this
purpose, small household-style kitchens can be included in the
facility’s design.
• All major safety concerns should be incorporated into the
patient’s plan of care. The patient may require therapeutic
intervention from trained staff. For example, a person’s
medications may need to be reviewed or behavior modification
may be necessary.
Wayfinding
Wayfinding refers to features that can help people find their
way through a large institution with relative ease. Residents in
nursing homes are often susceptible to disorientation because of
a decline of various senses. Sameness and repetition—similar
layouts, regular pattern of doors, and similar furniture
throughout a facility—are the common sources of disorientation
(Drew, 1992). Orientation involves much more than use of
signs. In addition to clear and readable signage, wayfinding can
be facilitated by using a variety of means such as employing
different color schemes; change of patterns in different sections
of the facility; color-coded handrails; varying furniture styles;
varying layout and arrangement; and use of pictures, tapestry,
hanging quilts, and window displays. On the other hand, doors
leading to utility rooms and areas not meant for residents should
be painted to blend with the adjacent walls.
Autonomy

Autonomy can be defined as “a cluster of notions including
self-determination, freedom, independence, and liberty of
choice and action. In its most general terms, autonomy signifies
control of decision making by the individual. It refers to human
agency free of outside intervention and interference” (Collopy,
1988). Because health care by its very nature creates
dependency, caregivers must make deliberate efforts to
maximize the preservation of patient autonomy. On the other
hand, a patient’s autonomy cannot be taken to an extent that it
infringes on the rights of others or exposes the patient to
serious harm.
Autonomy for patients also requires that they be allowed to
personalize their rooms with familiar things, including such
personal items as radios, small television sets, family pictures,
mementos, artifacts, plants, music, personal furniture, and bed
accessories. Emotions and memories from past experiences and
events often stimulate conversation and social interaction.
Although space is almost always limited, a display shelf in each
room can help people personalize their space by displaying
memorabilia and other items. On the other hand, certain
personal belongings may pose safety concerns. For instance, too
many electrical gadgets may overload the circuits and create a
fire hazard. Long extension cords and floor rugs pose a tripping
hazard.
Autonomy also means that a patient must be able to make
informed choices. Although the nursing facility must encourage
informed choice, it also has the responsibility to do what is in
the patient’s best interest. Occasionally, conflicts may arise
between a patient’s autonomy and the facility’s duty toward the
patient. Such conflicts should be resolved by taking into
consideration legal requirements, regulatory constraints, and
ethics.
Privacy
Almost all individuals require some privacy in terms of space,
time, and person.
Privacy of Space In a health care facility, privacy of space is

first determined by the type of accommodation: private or
shared. Many facilities maintain a small number of private
rooms for single accommodation. As a general rule, however,
occupying a private room is considered a luxury for which
someone has to pay more. Unless a medically determined need
exists for private accommodation, public as well as private
insurers do not cover it. So, in most instances, a patient must
spend out-of-pocket funds if a private room is desired. Hence,
for most patients, shared accommodation is the norm, which in
most facilities constitutes double occupancy (rather than triple
or quadruple accommodation). In these circumstances, privacy
rests on how much physical space each individual has, including
closet and storage space. Privacy also entails the need for
intimacy (Westin, 1967). Intimacy refers to a person’s privacy
during visits with family, friends, and legal or spiritual
counselors. Residents can also express their sexuality in a
private environment. Because privacy is generally compromised
in a multiple-occupancy setting, the facility should provide
secluded areas that may be used for intimate dining experiences
with family and friends, for private visits, or for sexual
intimacy.
Privacy of Time Privacy of time is often compromised by
clinical routines that are established for the sake of staff
efficiency or convenience. However, such routines tend to make
patients’ lives regimented. In many nursing homes, wake-up and
morning hygiene chores must be completed before breakfast.
Because assigning staff members to every resident at the same
time is not possible, certain residents must wake up before
others, and there may be little provision for patients to sleep
late. Meal hours are also generally fixed. Bathing and shower
routines are scheduled ahead of time. Yet, within the parameters
of such scheduled routines, patients’ individual preferences
should be accommodated whenever possible. Privacy of time
also includes the need for personal reclusion, that is, have time
for oneself and be free from unwanted intrusion, to be alone for
quiet reflection. For this purpose, quiet and secluded spaces

such as small libraries and chapels are highly desirable.
Privacy of Person Privacy of person can be equated with
dignity. A basic rule for facilities to follow is to treat every
person with dignity, regardless of whether he or she can
perceive indignities (Kane, 2001). Knocking at the door before
entering a patient’s room, closing the door for a patient while
that patient is using the toilet, drawing privacy curtains during
treatment, providing appropriate personal covering for a trip to
the common bathing and shower area, providing proper
grooming during a trip to the therapy room or dining room, and
giving lap robes to female residents in wheelchairs are examples
of how personal privacy is respected to preserve individual
dignity.
Public Domain
Loneliness and isolation are common concerns among the
elderly. Unless a person chooses to remain alone, opportunities
must be provided for wholesome social interaction. The range of
opportunities depends on how well a nursing facility functions
as a social community. The three most important experiences
from this perspective are compatibility, the dining experience,
and socializing.
Compatibility
Social interactions in the public domain are primarily driven by
compatibility because compatible relationships are something
people naturally seek. The issue of compatibility first arises
when a new patient is admitted to the facility and has to share a
room with another resident who is a complete stranger. Gender
compatibility has been a long-established practice. Room
sharing by two individuals of the opposite sex is permitted only
in the case of legitimate couples. Apart from such obvious types
of compatibility, the main consideration in assigning a room to
two people is how well the two individuals are likely to get
along and engage in a meaningful social exchange.
Compatibility is also an important consideration in other
situations requiring social groupings, such as dining at the same
table or participating in social and recreational events.

Relationship building and bonding can be facilitated in several
ways. Some nursing home residents assist other residents with
simple tasks, such as escorting a friend to the dining room or
assisting someone in a wheelchair. People who have disabilities
of their own can find meaning in being helpful to others; it
builds their own self-esteem. Nursing home residents can also
develop appropriate relationships with volunteers and staff
members.
Dining
Meal time should be an enjoyable experience. Seating
arrangements should be such that they create opportunities for
those who can socially interact. Of course, a patient’s clinical
condition will determine to what extent interaction is possible.
For patients who require feeding assistance or who may have
other special needs, dining may become a clinical event, but
staff interaction can still help make it a social event. To the
extent possible, clinical dining areas for those who cannot eat
on their own should be separated from social dining areas so
that those who are able to dine in a social setting can enjoy the
dining experience without interruption or distraction.
The dining environment should be relaxed. Comfortable chairs,
tablecloths, placemats, cloth napkins, table centerpieces, and
soft music contribute to a relaxed and enjoyable experience. A
facility should also have some special tables to accommodate
wheelchairs, but ambulatory and wheelchair patients can sit and
dine together.
Socializing
The facility must schedule programs that offer numerous daily
opportunities for residents to socialize according to their
personal interests. Social events also enable patients with
dementia and other limitations to receive sensory stimulation by
just being present. Events should be held in both interior and
exterior spaces.
Interior spaces include lounges, dining areas, craft and game
rooms, and chapels. Some modern facilities also have spaces
such as mini malls, ice cream parlors, and barber and beauty

shops where residents can enjoy some of the social activities
they once pursued. One example of modern architectural
designs for senior care environments includes the concept of
“main street,” in which a common area opens into large interior
volume spaces that have façades with exterior building
appearances (see Figure 7–3). In some designs, a chapel can
have the look of a church, a meeting space can appear as a town
hall, and food service operations can look like a sidewalk café.
Such features can give residents the feeling of going out to
dinner, church, or other event (M. Milligan, personal
communication, March 19, 2014).
Exterior spaces include courtyards, patios, balconies, terraces,
vegetable and flower patches, gazebos, and spaces around bird
feeders and fountains. The building’s design should permit all
residents easy access to the exterior. The outdoor spaces should
have appropriate seating arrangements so that the residents can
spend time relaxing, socializing, and simply enjoying the
surroundings.
Figure 7–3 Illustration of the “Main Street” Concept. Towne
Center Community Campus, Avon, Ohio
Reproduced with permission from JMM Architects, Inc.,
Columbus, Ohio. Courtesy of Mike Milligan.
Modern Architectural Designs
The average size of a nursing facility increased by 44% from 75
beds in 1973 to 108 beds in 2006 (National Center for Health
Statistics, 2007). Although the larger size creates operational
efficiencies, it detracts from a residential environment. In
response, some architects have created innovative facility
designs that strike a balance between the clinical and
socioresidential factors. Increasingly, in new constructions,
private rather than shared rooms are in vogue to give patients
more personal space. In addition, current architectural designs
no longer feature the traditional long corridors that are lined
with rooms on both sides, which often get cluttered with all
kinds of barrels and carts and create an institutional look and

feel. High-pitched roofs, creation of neighborhoods rather than
hallways, use of natural light, installation of fireplaces in
lounges, and the connection of indoor to outdoor spaces can
make a building seem more like a home than an institution. In
some cases, the medical character of the facility can be
deemphasized by even eliminating the traditional nursing
station. In large institutions, some smaller self-contained units
can be created, each with its own household-style (family)
kitchen and a common room that can serve as a multipurpose
room for dining, activities, and socializing.
Neighborhood Design
Also referred to as a cluster design, it places decentralized self-
contained neighborhoods, or “household clusters,” within the
larger clinical units, creating relatively small residential
groupings. Each neighborhood may have its own living and
dining spaces, and may also include a “family kitchen.” Cluster
designs practically eliminate the traditional long corridors, and
offer better flexibility in segregating residents than traditional
layouts do. For instance, patients requiring heavy care could be
accommodated in the same cluster. Small groupings of residents
are also desirable in short-term rehabilitation units and
dementia units. Neighborhoods allow food service to be more
personalized with small serving kitchens adjacent to dining
spaces. Food can be served on plates rather than trays, and
allows caregivers to accommodate individual requests quickly
and easily (M. Milligan, personal communication, March 19,
2014).
Figure 7–4 illustrates adjoining 12 to 13 bed neighborhoods.
High construction costs for clusters present a major challenge to
facilities, although better functional efficiencies are often
gained. By decentralizing staff and services and giving
associates quick access to utilities, a cluster layout can make
associates more productive and the delivery of care can be
improved. In some arrangements, small nursing assistant (nurse
aide) stations—generally no more than a desk and chair—enable
the staff to be in close proximity to residents, allowing for

prompt attention to their needs. The self-contained clusters also
have their own bathing rooms, linen closets, and soiled utility
closets. Associates can function more efficiently because this
arrangement shortens walking distances and saves time.
Services are brought to each cluster instead of transporting
residents to the nursing station, dining room, or therapy room.
A group of permanent caregivers assigned to each cluster can
also provide opportunities for interaction and bonding between
caregivers and residents.
Figure 7–4 Adjoining Neighborhoods in a Cluster Arrangement.
Vrable Healthcare Center, Dublin, Ohio
Reproduced with permission from JMM Architects, Inc.,
Columbus, Ohio. Courtesy of Mike Milligan.
Nested Single-Room Design
To counter the high construction costs of private rooms, the
architectural firm of Engelbrecht & Griffin (now named EGA,
PC) pioneered the design of nested single rooms. Cost is
conserved by efficient use of space. Although nested rooms are
much smaller than regular rooms, they are self-contained
bedrooms with their own private half-bathrooms that have a
toilet and a sink (Figure 7–5). Nested single rooms offer
privacy, and when they are placed in a cluster setting, they can
also provide opportunities for socializing through
“neighborhood living” arrangements (Figure 7–6). Easy access
to common lounge areas in the vicinity of the rooms encourages
residents to get out of their rooms to meet and converse with
familiar neighbors and provides a comfortable setting for
visiting with family and friends.
Figure 7–5 Overhead One-Point Interior Perspective of Nested
Rooms
Reproduced with permission from EGA, P.C. “Designs for
Living.”
Aesthetics
Aesthetics are necessary to promote a sense of well-being. Light

and color, for example, influence patients’ sleep, wakefulness,
emotions, and health. Use of lighting, color, and furnishings
create an environment that is both aesthetically appealing and
comfortable. Institutions are often noisy places where conscious
efforts must be made to reduce noise levels. The physical
environment can also affect social behavior and certain clinical
outcomes.
Lighting
Vision impairment increases with age. Compared with
community-dwelling elders, nursing home residents suffer from
far greater visual impairment (West et al., 2003). Inadequate
lighting can promote depressive symptoms, and can cause falls
that can otherwise be prevented. Glare can lead to agitation,
confusion, anger, and falls. Lighting issues in LTC facilities
should be addressed by (1) raising light levels substantially, (2)
balancing natural light and electric light to achieve even light
levels, and (3) eliminating direct as well as reflected glare
(Brawley & Noell-Waggoner, n.d.). As a rule of thumb, lighting
for seniors should be 25 to 50% higher than normal.
Consistency in lighting is also important. An even level of
lighting from wall to wall, from floor to ceiling, and from
corridor to public and private rooms reduces glare and decreases
shadows (Moller, 2008).
Figure 7–6 Partial Floor Plan of Cluster Scheme
Reproduced with permission from EGA, P.C. “Designs for
Living.”
Natural sunlight has positive effects on overall health. Facility
design should incorporate as much natural lighting as possible
while also incorporating artificial light. Chandeliers, wall
sconces, recessed lighting, table lamps, floor lamps, and other
light fixtures can be incorporated to improve lighting, reduce
glare, and enhance the homelike feel. Patios and porches enable
residents to enjoy fresh air as well as direct sunlight. Windows,
skylights, atriums, and greenhouse windows can be used to
bring some of the natural daylight indoors. Low windows in

patient rooms, lounges, and corridors allow residents to see the
exterior grounds from their beds and wheelchairs. Window
treatments should be used to regulate sunlight and minimize
glare. Horizontal miniblinds are generally preferable to vertical
blinds, but light-filtering pleated shades are considered even
better. Valances can enhance the overall décor.
In resident rooms, night-lights are essential. Along with clear
pathways to the toilet, night-lights can facilitate safe trips to the
bathroom and help prevent falls (Brawley, 1997).
Color
Colors used in health care settings have changed dramatically in
recent years. Traditional colors such as white, bold yellow,
beige, and green are no longer considered appropriate. More
pleasing and stimulating colors, applied in judicious
combination, have now become popular. Such colors include
soft apricot, peach, salmon, coral, soft yellow-orange, light
cinnamon, and a variety of earth-colored tones. Patterns and
colors in wall coverings and decorative borders can liven up
some otherwise unexciting areas. Bedrooms, bathrooms, dining
rooms, living rooms, and alcoves are all appropriate places
where wall coverings can enhance residential quality. Coated
wall coverings can be used in areas such as hallways, where
soiling is a serious problem. Handrails are necessary in
hallways and other areas, but a natural wood finish can help
maintain the residential look.
Colors can be used to promote wayfinding and safety. Aging
reduces a person’s ability to distinguish colors, such as blue,
which may appear grey (Moller, 2008). To compensate for this
reduced visual function, high-contrast colors should be used.
For example, the color of grab bars in the toilet should contrast
sharply with the color of the wall, to ensure maximum
visibility. Countertop colors should stand out strongly from
those of floors. For many nursing home residents, being able to
use the toilet may depend on being able to locate it. In a totally
white bathroom, some patients will find it difficult to
distinguish the toilet from the floor or the adjacent wall.

Colored toilet seats create visible contrasts against the
surroundings and can facilitate locating the toilet. Conversely, a
colored wall can provide visual contrast against a white toilet.
Noise
Unpleasant noise jars, disrupts, and upsets because it lacks
meaning and sense (Picker, 2003). Noise reduction may appear
to be a matter of common sense, but when caregivers are busy
with heavy workloads and numerous demands on their time,
common sense may not become so common. Hence, nursing
homes need to engage in a conscious noise-reduction program.
Bharathan and colleagues (2007) found that noise levels in U.S.
nursing homes were in the range of 55–70 decibels (dBs). The
Environmental Protection Agency recommends noise levels
below 45 dB during daytime and 35 dB at night (Bharathan et
al., 2007). Benbow (2013) has suggested a number of measures
to reduce noise. Noise mitigating design features can include
acoustical ceiling and wall products that reduce echoes, sound
proofing resident rooms, and ventilation and heating systems
with sound reduction. Other techniques include use of lined
drapes, wall hung quilts or sound-absorbing panels, place mats
on dining tables, and rubber tips under table and chair legs. Use
of alarm and overhead paging systems should be confined to
emergencies. Fire drills can be conducted silently, without the
use of alarms. Visitors can be asked not to use cell phones
inside the facility. Staff can be trained to use lower speaking
voices. Closing of doors is one of the most effective methods to
reduce noise.
Furnishings
Carpeting adds warmth and softens sounds. It also provides
cushioning against falls and can prevent serious fractures of the
hip or wrist. Today’s high-performance carpets, which are
resistant to stains and odors, are also cost effective. New
carpets are treated with a vinyl moisture barrier and an
antimicrobial coating (Yarme & Yarme, 2001). Proper
installation and regular maintenance can make carpeting last for
several years. Of course, carpeting is not appropriate for all

areas in the building. Slip-resistant tile is by far the most
widely used flooring material. Resilient flooring with low sheen
can be used in certain high-use areas without creating an
institutional appearance. For example, these hard-surface
floorings also come in beautiful wood-grain patterns that add a
homelike touch. Also available are new soft-surface floorings
that are made of easy-to-maintain sheet vinyl material with a
dense, soft, carpet-like surface and a cushioned backing. These
materials have been tested to ensure that they reduce injuries
from falls (Yarme & Yarme, 2001). Highly polished and buffed
surfaces are not recommended for the elderly because they
produce glare, appear wet or slick, and can be a source of
anxiety and confusion.
A variety of furniture is available that is specifically designed
for LTC facilities. Lounge chairs, sofas, and rocking chairs can
add charm and variety as well as comfort. Use of upholstered
furniture has actually become quite common. Some
manufacturers are producing foam cushions that are soft enough
to be comfortable and yet firm enough for residents to rise
easily from chairs and sofas (Child, 1999). Brawley (1997)
commented on several enhancements in high-tech finishing of
upholstery fabrics. These include soil- and stain-resistant
finishes, lamination with vinyl, fluid barriers, and antimicrobial
finishes. For nursing home use, these fabrics must also be flame
retardant. “Super fabrics,” such as Crypton, have built-in stain
and moisture resistance and have been tested for fire and
microbial resistance. These new fabrics have replaced vinyl
coverings for chairs and sofas, and a range of colors, textures,
and patterns are now available to enhance the residential
environment in nursing facilities.
Enriched Environments
The environment is viewed as a “silent partner” in caregiving
because it contributes to the healing process (Noell,
1995). Enriched environments (or enhanced environments) are
physically and psychologically supportive environments that
promote positive feelings, harmony, and thriving. They also

reduce boredom and stress.
Theoretical Foundations
Creation of enriched environments finds support in two
complementary theories: biophilia framework and theory of
thriving.
Biophilia Framework
E.O. Wilson, a biologist, coined the term biophilia for the
human propensity to affiliate with other life forms. In short, it
describes the human tendency to pay attention to, affiliate with,
and respond positively to nature (Wilson, 1984). People not
only have an inborn biophiliac tendency to relate to animals and
to natural settings, but people’s relationship with nature is
essential to their thriving. Plants, animals, water, and soil are
the most common elements of the natural environment
(Wohlwill, 1983). Based on an integrative review of the
literature, Jones and Haight (2002) reported consistent findings
that interactions with the natural environment, which can be
experienced both indoors and outdoors, produce beneficial
effects in human beings, such as positive mood and mental as
well as physical restoration. For instance, a study of
hospitalized patients recovering from an appendectomy showed
that patients with plants in their rooms had a significantly lower
need for pain medication, had lower blood pressure and heart
rates, and had less anxiety and fatigue than their counterparts in
the control group with no plants in their rooms (Park &
Mattson, 2008).
Theory of Thriving
Thriving means living life to the full. It is also a growth process
that occurs as a result of humans interacting in a symbiotic
relationship with their environments to enhance their physical,
mental, social, and spiritual well-being. According to Haight et
al. (2002), the integrative model of thriving includes three
elements: (1) the person; (2) the human environment comprising
family, friends, caregivers, and others; and (3) the nonhuman
environment comprising the physical and ecological
surroundings of the person. Thriving occurs when the

relationship among the three entities is mutually engaging,
supportive, and harmonious. Conversely, a failure to thrive
occurs when discordance exists among the person, the human
environment, and the nonhuman environment. When thriving
occurs, certain critical attributes are noticeable in the person:
social connectedness, finding meaning in life, adaptation, and
positive cognitive/affective function.
Principles of Enrichment
Enriched environments are created by incorporating three main
principles:
• All three elements of person-centered care (clinical care,
socioresidential elements of the physical environment, and
overarching human factors) must be integrated, as discussed
earlier. In a person-centered environment, care delivery is
congruent with the values, needs, and preferences of care
recipients (Eales et al., 2001). Health care professionals
empower residents to assert their rights and preferences. This
empowerment is achieved through a bonding between residents
and caregivers who place supreme value on listening to the
individual’s preferences while offering professional advice and
instruction on the risks and benefits of the choices the resident
wants to make. The resident’s freedom to take some risks is
respected, but it calls for greater staff vigilance.
• The environment provides a moderate degree of positive
stimulation and distraction. Prolonged exposure to low levels of
environmental stimulation can lead to boredom, negative
feelings, and depression. In the absence of positive distractions,
patients begin to focus on their own problems and end up
increasing their level of stress. Positive distractions elicit good
feelings, hold attention, and generate interest. Happy faces,
laughter, people passing by, pets, fish in aquariums, birds,
flowers, trees, plants, water, pleasant aromas, and soothing
music can all be positive distractions. Negative distractions, on
the other hand, are stressors. They simply assert their unwanted
presence because it is difficult to ignore them. Visual
stimulation from pictures, artwork, and television watching can

be positive for patients, but abstract art and uncontrolled loud
noise from television are negative distractions.
• Thriving is not entirely a function of external stimulus.
Thriving also requires solitude, reflection, introspection,
spiritual contemplation, study, and a sense of one’s
individuality and self-worth. Contemplation and inner reflection
often occur in a passive relationship with serene natural
surroundings. On the other hand, thriving also requires active
engagement in meaningful social relationships, caring for live
plants or animals, lending a helping hand to a fellow patient,
playing with children, or working on hobbies such as gardening
or woodworking. In its ultimate sense, thriving is achieved
when a person feels a deep sense of belonging to and connection
with the physical environment comprised of people and things,
and also feels closeness to a Supreme Being in accordance with
one’s own belief system.
Culture Change
The ideas presented in this chapter are at the heart of what has
been loosely referred to as “culture change.” As a working
definition, culture change refers to a gradual transformation of
the traditional nursing home environments and care processes
driven by the sick-role model to the ones that promote person-
centered care in enriched environments. Culture change affects
all organizational levels of the nursing home, including
residents, direct care staff, management, and the physical
environment (Shier et al., 2014).
Culture change is achieved mainly by blending three key
factors. The first two listed here have already been discussed
earlier:
1. In newer and older facilities alike, culture change begins
by integrating the three elements of person-centered care
(see Figure 7–1). For example, in the traditional nursing home
culture, the resident must comply with schedules and routines
preset by the organization. Through culture change, residents
and staff design schedules that reflect the residents’ personal
needs and desires. For instance, within reason, residents can

decide whether they prefer a shower or a bath in the morning or
in the evening (Andreoli et al., 2007).
2. Creating an enriched environment that offers opportunities
for positive stimulation and distraction, minimizes negative
distractions and stressors, and also enables residents to find
times and places for solitude and reflection.
3. Empowerment of associates is the third key element.
Culture change requires a new mindset on the part of both
management and associates. Empowerment requires a change in
management philosophy and practice. As a guiding principle,
administrators and department managers start treating their
associates as they would want the associates to treat the elders.
There is no room for practices that devalue workers, most of
whom are women who typically earn just a little above the
federal minimum wage. Empowerment also requires a
decentralized management approach in which decision making
is taken back to the elders, the families, and caregivers; and
these stakeholders are given a voice in the elders’ daily routine
and life.
Advocates of culture change also recommend adopting the
practice of consistent assignment whereby caregivers are
assigned to the same residents. It is assumed that forming a
bond between residents and caregivers may bring increased
satisfaction to caregivers and lead to better quality for
residents. Consequently, a large number of nursing homes have
started to use consistent assignment (Doty et al., 2008).
However, research to date has shown inconsistent effects of
consistent assignment on quality outcomes (Roberts et al.,
2013). Caregiver and resident preferences regarding consistent
assignment have also shown mixed results (Rahman et al.,
2009). On the other hand, there is some preliminary evidence
that consistent assignment may help lower absenteeism and
turnover among caregivers (Castle, 2013).
Groundbreaking Work of the Pioneer Network
The Pioneer Network played a critical role in advocating culture
change in nursing homes. It began as a grassroots movement of

caregivers, consumer advocates, and others who were concerned
about the quality of life in even some of the finest conventional
nursing homes. Beginning in 1997, nursing home professionals
and advocates, referred to as “pioneers,” began informal
meetings to define common areas of endeavor and opportunities
for bringing about a cultural change in nursing facilities. A few
nursing home professionals, who had already experimented with
some innovative approaches, were invited to share their
experiences with various stakeholders that included regulators,
nursing home administrators, directors of nursing, and social
workers. Subsequently, regular meetings of the pioneers led to
the formation in 2000 of a formal organization, named the
Pioneer Network. Since then, it has evolved into a growing
national movement with formal coalitions established in more
than 30 states. The network has continued to make a meaningful
impact in the areas of education and advocacy to influence
public policy.
The organization has worked tirelessly to partner with local and
state governments and the Centers for Medicare and Medicaid
Services (CMS), all of which have endorsed the principles of
culture change. Ongoing efforts are being made to find linkages
between creating a culture change and compliance with nursing
home regulations. As a result of these efforts, even changes to
the Interpretive Guidelines are being made in the State
Operations Manual used for surveying nursing facilities.
How to Bring About Culture Change
There is no single model of culture change because of several
variables involved. For example, leadership, ownership,
financial resources, and case-mix factors vary from facility to
facility, making it difficult to implement one standard model, if
one could be developed. Moreover, numerous possibilities of
arrangements exist to bring about culture change that can differ
rather substantially from one facility to another. Even at that, it
remains a work in progress. These same variations have made it
extremely difficulty to empirically test the outcomes of culture
change.

Even though there is no standard process to bring about culture
change, it is no longer a novelty or a fad. It is the wave of the
future that is unstoppable. Facilities that do not adopt this
growing movement will be left behind and find themselves in an
uncompetitive position, and perhaps out of business at some
point.
As a start, nursing home administrators and leaders need to
change their mindset established in the “old school” of nursing
home management. They can start working with one of the three
key factors mentioned earlier, and gradually, over time
incorporate elements from the other two. For example, a good
starting point will be to change management practices, which do
not require any capital outlays. Staff training in the principles
of culture change, training of managers in staff empowerment,
educating residents and their families and involving them as the
facility plans to make transitions toward culture change, and
joining a state-based Pioneer coalition to increase one’s
knowledge about culture change can certainly put the
organization on the right track. Gradual changes in the physical
environment can follow. The high cost of constructional
modifications could be a deterrent. Also, many of the older
buildings may present daunting challenges because of their
layout and lack of available space that must be devoted to
providing essential services such as nursing care and
rehabilitation. Yet, facilities can enrich their existing
environments, implement person-focused changes in the
processes of care delivery, and make quality improvement a top
priority. A facility built with a modern architectural design, but
providing impersonal care of poor quality will in time not be
able to compete against an older facility that excels in
delivering high-quality person-centered care and offers an
enriched environment in which the patients can thrive.
Doty et al. (2008) demonstrated that a greater degree of
adoption of culture change results in greater benefits in terms of
staff retention, higher occupancy rates, better competitive
position, and improved operational costs. It is also surmised

that, compared with previous generations, baby boomers
entering retirement will be more inclined to search for LTC
options that promote comfort and quality of life in an
environment comparable to their own homes (Ragsdale &
McDougall, 2008).
Contemporary Models of Culture Change
The Eden Alternative
In the early 1990s, Dr. William Thomas, while working as a
physician in nursing homes, undertook a pilot project sponsored
by the state of New York. Working with the staff in an 80-bed
nursing home, which served mostly patients with dementia,
Thomas developed some new ideas and a set of principles for
creating a garden-like environment. As an advocate for change,
Thomas explained:
I want an alternative to the institution. The best alternative I
can think of is a garden. I believe when we make a place that’s
worthy of our elders, we make a place that enriches all of our
lives—caregivers, family members, and elders alike. So the
Eden Alternative provides a reinter-pretation of the environment
elders live in, going from an institution to a garden … There are
kids running around and playing. There are dogs and cats and
birds, and there are gardens and plants. I want people to think
that this can’t be a nursing home. Which it isn’t—it’s an
alternative to a nursing home. … The future of caregiving
belongs to people and organizations who can dream new dreams
about how to care for our elders. (McLeod 2002, pp. 14–15)
Eden Alternative, a trademark of its founding organization,
entails viewing the surroundings in facilities as habitats for
human beings rather than as facilities for the frail and elderly,
as well as applying the lessons of nature in creating vibrant and
vigorous settings. It is based on the belief that the
companionship of pets, the opportunity to give meaningful care
to other living creatures, and the spontaneity that marks an
enlivened environment have therapeutic values (Eden
Alternative, 2002). One of the main objectives of Eden
Alternative is to banish from the lives of nursing home residents

the loneliness, helplessness, and boredom that Thomas called
“the three plagues of nursing homes” (Bruck, 1997). To
counteract these ills, residents need companionship, variety, and
a chance to feel needed (Stermer, 1998).
According to the 10 principles on which the Eden Alternative is
founded (Exhibit 7–1) the antidote to loneliness is meaningful
contact with plants, animals, and children, as well as easy
access to human and animal companionship; the remedy for
helplessness is giving as well as receiving care; and the cure for
boredom is unexpected and unpredictable interactions and
happenings in surroundings that deliver variety and spontaneity.
Among methods to build relationships between staff members
and residents, alternative means of healing such as massage
therapy and aromatherapy are suggested, based on the belief
that a back-rub or foot-rub may eliminate the need for sleep-
inducing medications, and the belief that the smell of lavender
or peppermint can have a calming effect.
Edenizing is the expression used for achieving culture change
by implementing the Eden principles. For a long time, many
nursing homes have, at least to some extent, involved their
residents in nature-oriented activities such as pet therapy,
gardening, and nature walks. Programs in collaboration with
local schools and day care centers have also been developed to
promote intergenerational companionship. Edenizing more fully
incorporates the concepts of biophilia. It promotes surroundings
rich in plants, animals, and children. Involving the residents in
the care of plants and animals, and in interaction with children
enriches everyone’s lives. A facility can have an on-site child
day care center, providing opportunities to integrate child care
with the care of the elderly. Children playing with toys in the
facility’s living room, or playing outdoors on a swing and slide
set add to variety and spontaneity. But edenizing goes beyond
these steps. It also incorporates other aspects of culture change,
such as resident and caregiver empowerment.
Exhibit 7–1 The Eden Alternative Principles
1. The three plagues of loneliness, helplessness, and boredom

account for the bulk of suffering among our Elders.
2. An Elder-centered community commits to creating a
Human Habitat where life revolves around close and continuing
contact with plants, animals, and children. It is these
relationships that provide the young and old alike with a
pathway to a life worth living.
3. Loving companionship is the antidote to loneliness. Elders
deserve easy access to human and animal companionship.
4. An Elder-centered community creates opportunity to give
as well as receive care. This is the antidote to helplessness.
5. An Elder-centered community imbues daily life with
variety and spontaneity by creating an environment in which
unexpected and unpredictable interactions and happenings can
take place. This is the antidote to boredom.
6. Meaningless activity corrodes the human spirit. The
opportunity to do things that we find meaningful is essential to
human health.
7. Medical treatment should be the servant of genuine human
caring, never its master.
8. An Elder-centered community honors its Elders by
deemphasizing top-down bureaucratic authority, seeking instead
to place the maximum possible decision-making authority into
the hands of the Elders or into the hands of those closest to
them.
9. Creating an Elder-centered community is a never-ending
process. Human growth must never be separated from human
life.
10. Wise leadership is the lifeblood of any struggle against the
three plagues. For it, there can be no substitute.
Courtesy of Eden Alternative. Available
at: http://www.edenalt.org/about-the-eden-alternative/mission-
vision-values.
Eden Alternative has become an international organization. Its
philosophy has been adopted in some 20 different countries that
include Canada, the United Kingdom, Australia, New Zealand,
and several European nations.

Edenizing may pose some risks in the form of allergies,
injuries, and illnesses. Zoonosis is the transmittal of infections
from vertebrate animals to humans. Examples of zoonotic
diseases include dermatophytosis, psittacosis, bartonellosis,
toxocariasis, pasturellosis, Q fever, and leptospirosis (Guay,
2001). However, potential problems can be managed with
appropriate veterinary care and infection-control practices.
Proponents of Eden Alternative explain that their approach is
not a quick fix for serious problems. Not every facility should
embark on making such changes. Acceptance of the Eden
Alternative by staff members and their training are necessary
prerequisites because, right off the bat, questions come up about
the staff’s extra responsibilities of caring for the pets and
cleaning up after them. Particularly in unionized facilities
where union–management contracts prescribe tasks and duties
of staff members, edenizing can be challenging. Costs of
training and implementation may be another deterrent. Also, the
quality of life in long-term care facilities can be improved in
ways other than edenizing. Changing an organization’s culture
takes time, effort, and leadership skills. Implementing the Eden
principles can take an estimated 3 to 5 years (Hannan &
Schaeffer, n.d.).
The Green House Project
An outgrowth of Eden Alternative, and also a brainchild of Dr.
Thomas, the Green House Project takes edenizing a step further
by revolutionizing the way in which nursing home services are
organized and delivered in small-scale settings. In the New
York State pilot project described earlier, Thomas experimented
with restructuring the caregiving staff into permanent care
teams designed to serve a particular “neighborhood” of elders
according to their special needs. The teams—consisting of
nurses, social workers, housekeepers, dietary employees, and
members of the activities staff—tried to adapt the traditional
largescale caregiving approach for smaller groups of residents.
Each team participated in extensive training in communication,
teamwork, and problem solving. In the Green House model,

these organizational ideas are applied to physically distinct
small-neighborhood architectural units. Also, unlike edenizing a
large institutional structure, the Green House model relies more
on natural outdoor activities, such as watching and feeding
birds and squirrels, and less on indoor pets because the small
design of the buildings allows ready access to the outdoors (J.
Rabig, personal communication, September 25, 2003).
The term Green House stands for architectural renderings of
small freestanding cottages, each designed to house just 10 to
12 residents who live together in a homelike setting (Figure 7–
7). The freestanding cottages are spread across a campus
(Figure 7–8). The first Green House project in Tupelo,
Mississippi, opened its doors in June 2003. Since then the
model has been adopted by a number of nursing home
organizations across the nation.
Figure 7–7 Ten-Bed Skilled Nursing Green House (Methodist
Senior Services, Tupelo, Mississippi)
Reproduced with permission from The McCarty Company,
Tupelo, Mississippi. Courtesy of Stephen Ladd.
Each Green House has self-contained private rooms that include
a commode, a sink, and a shower. To accommodate even the
frailest elders, rooms are equipped with ceiling lifts for
transferring. The lift operates on a ceiling track that runs from
the bed to the bathroom sink and commode. The residential
units are connected by short hallways to a central hearth room,
open kitchen, and dining area. Other amenities include a spa
room, laundry room, alcove, and storage space. The small size
eliminates the need for nursing stations and medication carts.
The nurse call system is wireless, using silent pagers that can be
activated from pendants worn by the residents (Rabig &
Thomas, 2003). In all aspects, the Green Houses fully comply
with Life Safety Code® and other building and safety standards
(National Fire Protection Association, 2009).
Figure 7–8 Overhead Perspective of Green Houses (Small
Residential Structures Spread Across a Campus)

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