Advanced Level Textbook
for Leaders of the Long-Term Care

Japan Welfare Education College
Keishin-Gakuen Educational Group(2017 Commissioned Project by the Ministry of
Education, Culture, Sports, Science and Technology)

This document, Advanced-Level Textbook for Leaders of the Long-Term Care is a deliverable
produced by the 2017 Project to Train Core Personnel for Regional Industry in Vocational Schools,
which was commissioned through Lifetime Education Promotion Project Funds from the Ministry of
Education, Culture, Sports, Science and Technology, and operated by Japan Welfare Education
College, Keishin-Gakuen Educational Group.

Advanced Level Textbook
for Leaders of the Long-Term Care― Contents ―INTRODUCTION WHAT IS ADVANCED LEVEL FOR LONG TERM/CARE WORKERS?�   1〈Personnel〉
1. ORGANIZATION/PERSONNEL MANAGEMENT
1-1. Organization/Team operations�����������������������   2
1-2. Personnel training�����������������������������

10

1-3. 	Gaining knowledge about the psychological stress of burnout syndrome inlong-term care and methods of how to handle it����������������

21〈Service〉
2. MAINTENANCE/ IMPROVEMENT OF SERVICE QUALITY
2-1. "Service" in a People-Oriented Job���������������������

33

2-2. Risk Management as Related to Long-Term Care���������������

38

2-3. 	Knowledge related to long-term care insurance systems, long-term care fees,
the services and supports for persons with disabilities act, medical andwelfare policies, etc����������������������������

44

2-4. Utilization of long-term care robots, AI, and ICT in long-term care��������

47〈Long-Term Care〉
3. BASIC PRINCIPLES OF LONG-TERM CARE
3-1. Basic principles of long-term care����������������������

64

3-2. Rights of the elderly/Maintaining their dignity/Support of self-sufficiency�����

71

4. COMMUNITY-BASED INTEGRATED CARE SYSTEMS
4-1. 	Systems to facilitate comfortable community lifestyles: Living assistance andcare management perspectives�����������������������

77

5. MULTI-DISCIPLINARY COOPERATION
5-1. Actively appealing to and cooperating with staff members of different disciplines��

78

5-2. Basic knowledge required for cooperation������������������

82

5-3. Proper behavior for other professionals from the long-term care standpoint����

85

6. ASSISTIVE SKILLS
6-1. 	Principles of evidence-based long-term care, and the implementation of
long-term care in support of self-sufficiency������������������

90

6-2. 	Basic knowledge on anatomical physiology, pathophysiology, symptoms,
illnesses, etc. necessary in long-term care������������������ 110
6-3. Evidence-based assistive skills as related to ADL and IADL����������� 116―i―

6-4. Skills related to consultative assistance������������������ 127

7. LONG-TERM CARE PROCESS
7-1. Guidance of staff in matters related to the long-term care process������� 134

8. DEMENTIA CARE
8-1. Guidance of staff in matters related to dementia��������������� 139

9. PALLIATIVE CARE/TERMINAL CARE
9-1. Guidance of staff in matters related to palliative care/terminal care������� 153― ii ―

INTRODUCTION

WHAT IS ADVANCED LEVEL FOR LONG TERM/CARE WORKERS?

The positioning of advanced level

Entry level：Training for the ones before starting care works and/or the ones doing
in‐home care
Basic level：Training for the ones who are going to work as care workers like those
who have completed the induction course for care worker
Standard level：Training for the core human resources in long term care like certifiedcare workers
Advanced level: Training for the ones in charge of long term care sites
This textbook targets advanced level care workers as the leaders providing
leadership and supervision for other staffs in long term care sites.
The definition of advanced level care workers is the followings：possessing
self‐decision‐making skills applying expert knowledge and technique based on
ethical standards and values as specialists of care and social service, improving
work efficiency, Solving problems, training their subordinates to improve thequality of care and taking responsibility for the consequences.

―1―1.ORGANIZATION/PERSONNELMANAGEMENT

1-1.Organization/Team operations

Learning Objectives and Target Achievements<Organization/Team Operations> Key Learning Points
The goal is to be able to understand the management philosophy of welfare
business, set your own goals and objectives for your organization, and lead efforts toimprove the quality of long-term care service through innovation and reform. Hereyou will learn learn how to conceptualize the corporate philosophy of the company
as the objective of the organization, set concrete goals and turn them into actionplans, and practical methods to solve expected future issues.
<Organization/Team Operations> Target Achievements
1. Be able to maintain a perspective in which you compare your own behavior inyour everyday work to the goal of the organization, and share this way of
thinking with other long-term care staff members.
2. Clarify the issues of the organization, and provide support for the process ofproposing measures to handle them.
3. As an advanced long-term care worker, support efforts towards improvement
and reform in the organization and lead these measures to success.

1) What is an Advanced Long-Term Staff Member?
 You, as an Advanced long-term care staff member, are expected to fulfill a varietyof roles. For instance, communicating management philosophy to long-term carestaff members, or encouraging long-term care staff members to work proactively
to improve long-term care services. What is required of you in these roles is yourability to be and behave like a leader.
 What do you think of when you think of a leader? It could be anybody—acelebrity, an athlete, a colleague?
 What aspects of this person do you think makes him/her a leader?
Successful people, people who lead their teams to victory, people who work hard
and achieve results. Different people will have a different image of what constitutes aleader. The word “leader” will perhaps bring to mind, for most people, a very specific
type of person who is charismatic, who draws people to them. As such, being a“leader” has come to be thought of over the years as a talent of sorts.
This idea has shifted somewhat, however, in modern society, into the belief that aleader is a role that anybody could fulfill, and leadership a skill that anybody could
have—not just the special people.
Understanding your role within a team, and working with other members to
produce results—this is something that everybody does, and this “working withothers” is a key ability, one that helps develop leadership skills. In other words,
everybody is a leader in some form or another. Being a leader is not somethingexclusive to certain people.

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1-1.Organization/Team operations

2) What does leadership mean to you?
“I can’t be like the type of leaders I see on TV.”
“I don’t have any of the qualities needed to be a leader.”There are many people who think in this way.
When you find yourself thinking these things, try “modeling.”
In “modeling,” you try to understand the ways of thinking and behaviors of the“leaders” you mentioned above, and imitate these behaviors in order to achieve
similar results. Of course, imitation does not always yield immediate results. The
important thing is to continue to engage in these thought processes andbehaviors.
If you have a manager or someone at your workplace who you would be able toconsider a “model,” try “becoming” them.
Look again at the examples you gave for 1), and try it out.

3) As Many Leadership Styles as There Are Advanced Long-Term Care
Workers[A1]“It’s hard for me to voice my opinions.” “I’m not good at leading meetings.” “I
don’t think I could manage people and tell them what to do...” There are many
people that have become Advanced long-term care workers who have felt
these kinds of worries.
 But even people who have these sort of worries are more than capable ofleadership.
The idea that leaders “lead,” “pull people along,” makes it seem like the act of
being a leader is inherently difficult.
In actuality, leaders themselves do not always have all the answers, or achieve allof the results. The true quality of an Advanced long-term care worker is the ability
to gain the trust of his/her team members.
 Current theories of leadership posit that there is no ideal way or method to bea leader. Instead, what is important is using the positive aspects of many
leadership styles (whether it be coach-style leadership, democratic leadership,etc.), depending on the situation.
In other words, there are as many leadership styles as there are Advanced
long-term care workers.


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4) Awareness as an Advanced Long-Term Care Worker Begins with an Image of the
Ideal State of the Organization
Answer the following questions.
Ⓠ What image do you have of the ideal workplace?
Ⓠ Why do you think this?
 Think about what any occasions, triggers, or experiences have led to
you thinking this way.
Ⓠ Write down your image of the ideal workplace, imagining this time that you
are presenting this information to those at your workplace.









What did you write? Perhaps some of you thought back to when you firstbegan your job, or about your companies’ philosophies, or what you would
consider your ideal image of welfare.
Why did you choose this job in the first place? What was the image you had ofyourself back then, when you thought of yourself in this job?
Most likely, your feelings have not changed since then, even now that you havebecome an Advanced long-term care worker.
Awareness as an Advanced long-term care worker starts when you envision
the ideal image of the team's organization you are leading. This ideal should
also align with the goal of the company and of the facility.
Perhaps some of you have never thought about this matter to this extent. But
look at the definitions ascribed to your facility through laws and regulations,and you should be able to discern what these ideals should be.

“Leadership means to consider thoroughly the missions of the organization, and to
exemplify these missions in very visible ways.” (P.F. Drucker, The Essential Drucker on
Individuals: To Perform, to Contribute, and to Achieve.)
You as an Advanced long-term care worker must be able to communicate yourorganization’s missions, in a way that is consistent no matter who or what situation
you are speaking in.

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1-1.Organization/Team operations5) Objectives and Goal
 As an Advanced long-term care worker, you have envisioned the ideal image ofthe organization you are leading.
 The next step is setting objectives and goal. “Objectives” and “goal” mean two
different things. Let’s break it down in detail.
① Objectives exist to accomplish the goal. “Objectives” are steps that must be
taken to achieve the “goal.” As such, objectives are the behaviors and/or
roadmap necessary to achieve the goal.
② Objectives are concrete, while the goal is abstract. The “goal” can beconceptual things, like “providing welfare for the elderly,” and can also serve
as decision-making standards in every long-term care staff member’s daily
work life. On the other hand, “objectives” are steps to achieve the goal, and somust be concrete, with concrete measures and methods for theirachievement.
③ Objectives are the process, and the goal the destination. When we achieve an
objective, we must find out how best to get to the goal, and tweak or change
our objectives accordingly as we strive towards the next objective.
④ There are multiple objectives, but only one goal. There is oftentimes morethan one objective that must be achieved to reach the goal. Objectives canalso branch out, and depending on the way the objectives are set, there may
be one larger objective, or many, smaller objectives.
⑤ Objectives can be changed, but goal cannot. There are times when achieving
an objective will not bring you any closer to achieving your goal. There areeven times when you should change an objective to get closer to the goal. But
as long as you do not lose sight of the goal, it is possible to set a different
objective to approach the goal in a different way.
Let’s try thinking about objectives and goal, using a vacation as an example. Fill inthe blanks.
Goal: Go to ________________ on vacation.
Objectives: Set concrete objectives in order to achieve this goal. List as many as you
want.
Objective ①: ___________________________________________
Objective ②: ___________________________________________
Objective ③: ___________________________________________
Now, think in more detail about a timeline to achieve these objectives. This is called
an action plan. List as many as you want.
・
・
・
・

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6) Think About Your Workplace So far, we have discussed goal and objectives. Next, let’s think about yourworkplace, and think about how to set action plans in addition to the goal andobjectives.
Fill in the following (you may write more/less than thebullet points allow)

Item
Goal of the Organization

・・
Setting Objectives

・
・
・

・
・
Action Plan to Achieve
・
Objectives
・・
It could be said that the role of the Advanced long-term care worker is to leadefforts to think of and implement concrete plans to achieve the organization’s goal.
As in the saying, “organizations obey strategies,” organizations move towards
objectives. This is another reason why it is so important to clarify goal andobjectives.
Meaning Behind the Existence of
Welfare Businesses

福
祉
事
業
の
存
在
意
義

Mission with respect to users
社会や利用者に対して果た
and society, what behaviors to
す使命やどのような行動を価
value, etc.
値とするかを示すもの。

Philosophy

理念

What you imagine to be the ideal image at
理念に基づいて、将来のある
some point in the future, the goal, etc.,
時点までにこうなりたいというbased on the organization’s philosophy
将来像や目的

Goal (Ideal

目的
Image)
あるべき姿

Roadmap, methods, etc. to
目的を実現するための、手achieve objectives
段や道筋

Objectives

目標

Plan
計画

Plan
計画

Plan
計画

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7) Directing the Team So far, we have discussed the “ideal image” that is to be the goal of yourorganization, and have set objectives as a roadmap for how to get there.
Here, we will actually begin to direct the team.
Ⓠ Use the bullet points from your action plan on the previous page to fill in thischart title. (Each action plan will produce one chart.)
Your Action Plan
Who
What
When (Until When)
Where
Why
How
How Many (Much)This chart divides the action plan into 5W2H. This framework allows you tocommunicate information thoroughly and accurately. *The 5W1H framework ismore common, but we have added an H and made it 2H for a morequantitative understanding
Leaving any of the 5W2H categories blank in an action plan leaves room forinterpretation and decision-making amongst the team, and can cause
misunderstandings. This can lead to results that differ from your original
intentions.
Who
What
When
Where
Why
How
How Many (Much)

 This framework allows every member of the team to see what they aresupposed to do. Using this framework as an entire team also allows teammembers to communicate information (report, contact, discuss, etc.) in athorough and accurate way.

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1-1.Organization/Team operations8) Handle Issues Expected in the Future You as an Advanced long-term care worker have set objectives towards theorganization’s goal, and have used the 5W2H framework to delineate inconcrete terms what must be done in the action plan.
 In the real world, this kind of action plan is created through communication inmeetings and discussions with team members. (We will discuss more on
communication in the “Personnel Training” section.) Additionally, the method we have described thus far only encapsulates theimplementation of objectives that every member of the team can understand,and the solving of issues that already exist in the workplace. An Advanced
long-term care worker should take a broader view of the organization as awhole, and work to handle future issues before they arise, to improve theorganization. For instance, issues like, “there aren’t enough new college
graduates that apply to work for the facility, despite efforts at recruitment.”“There’s only two years until the repair period for the equipment in the facility.”“How do we adapt to new long-term care fee policies?” These issues may not beurgent time-wise, but tend to be very important.
 Though members of the team are aware of these issues, they tend to prioritize
their everyday work, and put these issues on the back burner. As an Advanced
long-term care worker, another one of your roles is to lead efforts to solve theseless urgent issues as well.
Think of of some issues that you expect to crop up in your organization in the
future.
Trigger
Expected Issues
Changes inEx) Decrease in revenue due to revision of long-term carepolitics/law
fees・・Changes in theEx) Increase in labor costs due to labor shortage
economy・・
Changes in societyEx) Increased demands/requests due to the increase in
the number of elderly・・
Changes inEx) Changes in work due to the implementation of IT
technology
・・Changes inEx) Large-scale restructuring of facility in two years
management
・
・


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Reference: For Those Who Wish to Know More About Organization/Team
Operations
 Ways of thinking related to management: Management, P.F. Drucker Theories of management (case studies, etc.): Fundamentals of Management:
Essential Concepts and Applications, Stephen P. Robbins
 How to be a leader, etc.: The Essential Drucker on Individuals: To Perform, toContribute, and to Achieve, P.F. Drucker―9―

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Learning Objectives and Target Achievements<Personnel Training> Key Learning Points
Understand the types of communication methods that exist in the workplace, anduse them to motivate ad supervise individuals, to better support the training of
long-term care staff members.
In order to achieve this goal, we will introduce theories of motivation andcoaching while also applying them to the daily work conducted by Advanced
long-term care workers, so that you can use this knowledge in practical ways.
<Personnel Training> Target Achievements
1. Gain an understanding of the necessary communication skills and be able touse the right communication methods at the right times.
2. Gain an understanding of the skills to support the growth of long-term carestaff members, and use these to support them.
3. Be able to display the leadership it takes to encourage growth in individuals
and organizations.

1) Communication Skills as a Factor in Personnel TrainingOrganizations are made up of a number of long-term care staff members.
Each of these members have different perspectives in the organization, fromtheir roles and positions to their motivations for their jobs.
Leaders must begin by understanding the differences between each long-termcare staff member’s perspective, as this is where team management begins.

For instance, let’s say you ask an experienced long-term care staff member to train
a new staff member, but this caregiver is happy with just completing his own tasks,
and doesn’t want to take on the responsibility of educating someone else—thetraining will most likely not go well due to the differences in opinion. And asking
experienced staff members to conduct training can sometimes even backfire if theylack the motivation to conduct the training, as they may try to teach new staff
members difficult methods and skills that go over their head, forcing them to lose
motivation.
Advanced long-term care workers must communicate with others and learn tosee matters from their perspective.
When you do so, you must eliminate all preconceptions or biases that you havefor or against that person, listen to what they tell you in its entirety, and use theways of thinking and theories you will learn below to understand theirperspective.

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2) Maslow’s Hierarchy of Needs


People interpret and think about matters from their very own perspectives.
Their needs also change depending on the situation they are in.

Self-Actualization
The need to develop one’s own abilities and reach one’s fullest

Growth needs

potential as a human being

Psychological Needs

EsteemThe need to be accepted, valued, and respected by others

Love/Belonging
The need to feel a sense of belonging and acceptance among socialgroups, and feel that one fulfills a role or purpose in society

SafetyDeficiency-needs

The need to acquire physical safety, financial security, good health, agood way of life, and other conditions for stability and order in life

Physical Needs

PhysiologicalBase/primitive needs like food, sleep, excretion of body waste, etc.

You can see from this hierarchy that those who have a motivation for their jobs
and who are actively in charge of their own lives have fulfilled the“self-actualization” need, as well as everything from the “esteem” need to the“physiological” need.
What about a new staff member on the first day of their job? Perhaps their“safety” need has been fulfilled, but they have yet to feel a sense of belonging or
purpose in their workplace.
These five stages act as a barometer for each individual’s fluctuating needs.
According to this way of thinking, in order for people to behave in ways that are
conducive to their own growth, their needs must be fulfilled all the way to the levelof “esteem.”Then, think about concrete actions/behaviors that you think could fill the needfor esteem in long-term care staff members, and see whether theseactions/behaviors are being implemented.
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4) What Are the Factors that Lead People to Resistance?
It is oftentimes necessary in an organization for Advanced long-term care
workers to instigate change. However, there are some people who will express
resistance to the idea of changing something that they are used to, or
introducing something new.
 Resistance can be expressed in many ways, from passive resistance (pretending
to agree but secretly going against the measure), to being uncooperative,
protesting proposals, and even announcing one’s intention to resign. There arereasons for each and every one of these forms of resistance.
 Though it may seem at first glance as if staff members are simply unmotivated,
they almost always have legitimate reasons for thinking and behaving in theseways. Understanding this as an Advanced long-term care worker allows you to
be more open and empathetic to their situation and get to the root of the cause,
which will help move the organization gradually towards a better direction.
 Defensive Behaviors
Practice excessive adherence to existing standards, shift
Avoid desired
responsibility to others, pretend ignorance, drag out their
behavior
work, cover up undesirable behaviors
Avoid being
Do more than what is necessary, take precautions, rationalize
criticized
their own behavior, set up a scapegoat, submit false reports
Obstruct reform, self-defense, give reasons why they cannot
Avoid reform
implement reform These defensive behaviors can occur as a result of changes to work methods andcommunication styles that members of the organization have grownaccustomed to, whether it be personnel changes, restructuring of theorganization, the addition of a new kind of work, etc.
 Work in welfare environments has the tendency to settle into routine, as staff
members often engage in the same work with the same methods, amidst fairly
static human relationships. These staff members often come to believe that
their methods are the best methods.
 As these long-term care staff members believe that their methods are needed
and that they are the best way, they will not understand why change/reform isnecessary if you come into their workplace and attempt to implement change
and reform.
 It is difficult to get long-term care staff members to understand issues that you
are perhaps able to see as an Advanced long-term care worker. The job of aleader is to try to understand what is at the root of their resistance andunderstand their perspectives, all the while resolving issues and moving steadily(however slow the process may be) towards the goal. If you do this right, youwill notice that resistance will begin to wane.
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5) Communication Methods






Communication is the best tool that an Advanced long-term care worker can use
to bring drive and energy into an organization.
Lead your team with an understanding of the methods and characteristics ofdifferent forms of communication.
Communication in the workplace occurs in various forms, including
lectures/presentations given by the chairman, meetings, in-house reports, PRmagazines, morning assembly, etc. These fulfill various objectives, fromdiscussing current issues, to conveying information and introducing facility
events/functions.
Advanced long-term care workers must use these forms of communication in
effective ways.

Ⓠ Write down the forms of communication at your workplace, as well as theirfrequency and objectives.
Hosted byParticipantsFrequency
Method
Ex: Morning Facility
All staff
Every morning Assembly
assembly
director
memberspresentNormally, “workplace communication” brings to mind things that aresystematized, like briefings, meetings, daily reports, committees, etc. However,communication also includes things like discussions/planning of facility
philosophy, business operations, and activities, as well as casual conversationand study sessions amongst members, that help build a foundation of sharedgoal within the team. It also includes yet more casual forms of communication,
like small talk, casual conversation, and drinking parties, that help strengthen
relationships between members of the team.
Regardless, Advanced long-term care workers must use these various
opportunities for communication to gain an understanding of the othermembers of the team.

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6) Running a Meeting

Meetings are effective communication methods where all related members of
the team gather together to make decisions on certain matters/issues.
If not managed properly, however, meetings can actually decrease themotivation of its participants and devolve into a time sink.
Let’s think in depth about meetings, which are indispensable to Advanced
long-term care workers accomplishing their targets.

Ⓠ Conduct a self-evaluation of the meetings for one form of communication thatyou conduct.
 You communicate the time, location, participants, content, etc. of themeeting to the organization before the meeting You prepare outlines for meetings
 Meetings start and end on time There are clear points of discussion for each meeting Meetings begin with friendly greetings
 There are set rules for meetings
 There is tea, snacks, etc. prepared for meetings
 Seating arrangement is conducive to participation
 For meetings with a large number of participants or when people have a lot
to say, you prepare things like sticky notes and white boards to make iteasier for everyone to give their opinion
 There are more positive remarks than negative remarks
 All participants are encouraged to participate the same amount, and they
do so
 Participants interpret others’ opinions in logical/rational ways
 The meetings make clear who should do what, and what should be done bywhat time, for any leftover issues or points of discussion
 Reports of the meeting are provided to managers and those who wereabsent There is a set way to store meeting records
 There is a set method for long-term care staff members to be able to view
meeting records (even for those with authority limits)You will most likely be unable to implement all of these things immediately.
However, as long as you take these points into account, team members will findit easier to voice their opinions in these meetings, and there will come to be
more communication between participants. This should help instigate
day-to-day communication as well, and help create an open and transparent
organizational culture.

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7) Wrapping Up a MeetingMeetings are the most effective communication method to improve openness
and transparency in an organization.
Work to make the meetings you facilitate more effective for the organization asa whole.

Ⓠ What is your conception of a meeting facilitator?
 Facilitators must be good at talking.
 Facilitators must always have the correct answers to issues discussed in themeeting.
 You ask for opinions, but there are very few people that speak up.
 You are worried that meetings end up being biased towards the people who
speak up the most.
Meetings are places for people, specifically those related to the matters inquestion, to discuss and make decisions on issues. It is not the facilitator that makes
the decisions—it is all the participants. Your job as a facilitator is simply to support
the discussion.
Prepare an Agenda: Prepare all necessary documents, including outlining theissues, start/end times, timeline of the discussion and materials, and hand themout in advance to make it easier for the participants to understand the meetingas a whole.
 Clarify Meeting Objective: At the beginning of the meeting, clarify to theparticipants the points of the discussion and objective of the meeting. If theobjective of the meeting is made clear, the meeting will stay focused andon-topic.
 Decide on the Rules: For instance, anyone who speaks must start with theirconclusion first and speak for a maximum of one minute. Don’t outright denysomeone else’s opinion. Managers must take on listening roles. The last fiveminutes are to be used to look back on the meeting, etc. Announcing the rules
at the beginning of the meeting is a good strategy to make sure the meeting
goes smoothly. Try to think of the appropriate rules according to the participantsof the meeting and its goal(s).
 Conclude Meeting with Action Plan: Go over the action plan to fulfill theobjectives announced at the beginning of the meeting, through the 5W2H
framework.



Depending on the circumstances, it can be an effective strategy to have a newer
staff member act as facilitator. Newer staff members may hesitate to speak undernormal circumstances due to their relative inexperience and/or differences inworkplace roles, so this experience managing a meeting can serve as valuable
leadership training.

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8) Training for Long-Term Care Staff Member

One of the jobs of an Advanced long-term care staff member is to train personnel.

The goal of training personnel is to develop and utilize the abilities of the “individuals”
that are the driving force behind an organization achieving its goal.

On the other hand, each individual has their own ways of thinking and development
goals. No amount of expensive external training can be effective if these do not align atleast somewhat with the direction of the organization.



The Will/Skill Matrix offers 4 approaches depending on the individual’s level of will andskill. Personnel training can be made more effective by using these different approaches
for different types of long-term care staff members.

The most effective means of training for those with high levels of both will and skill is todelegate them with more responsibilities. On the other hand, those with high will but
low skill should be guided first to acquire the appropriate skills.

Those with high skill but low will must be motivated (excited) in some way to work
harder, or it will be a waste of talent. Those with both low will and skill must be directed
through orders. It is dangerous, however, to decide early on that someone is“unmotivated,” as the individual in question may simply have hidden issues withrespect to their ways of thinking, their beliefs, motivations, sense of purpose,
self-image, etc., or there may just be a gap between their wishes and the wishes of theorganization. Knowing the individual is the most important aspect of personnel
training.
High Will
やる気（Will）高い

委任する
Delegate

）
低
い

能
力
（

High
Skill
Skill

SkillSkill
Low

能
力
（

指導する
Guide

命令する
Direct

着火する
ExciteLow Will
やる気（Will）低い― 16 ―）高い1.ORGANIZATION/PERSONNELMANAGEMENT

1-2.Personnel training

9) Keeping Your Eye on the Individual
As we have seen so far, individuals express different attitudes depending on
where they are in their hierarchy of needs (Maslow’s Hierarchy of Needs), andeach hold different sets of values. Though individuals are sometimes not evenaware of these attitudes and values, they express themselves stronger or
weaker depending on the circumstances in which they find themselves. If you
can figure out what individuals truly cares about with respect to their job, it
can aid greatly in helping them develop their career, in personnel transfers ingeneral, as well as in their education/training and motivation.
 A career anchor is something that remains fairly static throughout anindividual’s life and shapes significantly an individual’s decisions with regards totheir jobs.
 Awareness of your career anchor can help you develop your career, and evenhelp you reevaluate your own behaviors. Being aware of the career anchors ofyour long-term care staff members can also help, not only in terms of training,but in motivating them in their work as well.
 There are, however, people who have multiple career anchors, or whose careeranchors have not been fully established yet, and it can be dangerous to makedecisions due to specific circumstances.
Career Anchor
Content
I want to use my professional abilities in a field that suits
Professional Ability
my strengths
Business
I want to manage an organization effectively and meet theAdministrationneeds of the organization
I don’t like change, and want to work in a stable/steadyStabilitymanner
I’m not afraid of risk, and want to create new things, like
Creativity
an entrepreneur
I want to be able to work at my own pace and discretion
Independence
without the rules and boundaries of an organization
I want to make positive contributions to society and assist
Social Contribution
others through my work
I want to live a life that balances work, my household, andBalanced Life
my self-actualization
I want to challenge myself to solve difficult problems, beat
Challenge
the competition, etc.
 Particularly important when discussing an individual’s future career withhim/her is whether a certain path will fulfill all three elements of“Will/Can/Must,” as this will allow them to challenge themselves and feel themost sense of purpose. Make sure you remember to do so in your interviews
with long-term care staff members. (Chart below is an example.)
What Will You Do? What Can You Do? What Must You
Do?
Acquire a certain〇×△
certification
Coaching〇△〇― 17 ―

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1-2.Personnel training

10) Coaching
Coaching, in addition to guidance and advice, is an effective strategy for
Advanced long-term care workers to encourage team members to engage incertain behaviors.
 Coaching is a method in which you speak to the team member, encourage themto make some sort of change to their behavior, and support their achievementof this goal. It can help in situations where team members have learned what to
do but don’t know exactly how to act, and fill in the gaps in their understanding
through interactive communications between Advanced long-term care workers
and individuals.
 The most well-known technique is the GROW model, in which leaders
encourage the action towards achievement of goals through a 5-step model.
This method also helps in establishing a concrete action plan.
 For instance, if a more experienced staff member needs advice on training a
newer member, ask them, “what kind of worker do you want this new staff
member to be?” and set goals accordingly. Next, ask them “what are the issues
to solve?” to help them clarify the current reality, and then, “are there any
cases of successful training in the past?” to aid them in discovering resources.
Next, help them to come up with options by asking them, “what kind of
methods have you not tried yet?” Finally, ask “which one will we begin with?”and verify their will towards concrete action.
GROW
Examples of Questions
G: GoalWhat is the thing you need to accomplish the most right now?
What kind of result is desired?
R: Current
Where are you in achieving this goal?
Reality
What would be three issues obstructing you from reaching thisgoal?
R：Discovery of What kind of support do you need to move forward?
Resources
Have there been any successful cases in the past?
O: Options
Is there a new method that hasn’t been tried before?
What kind of methods have not been tried yet?
W: Will
Which issues have the highest priority?
“By when,” “who,” and “how” will you accomplish this goal?
What is important in coaching is to move slowly through the discussion, and notrush through the steps to get to the “W: Will” stage. Take creative efforts todeepen the conversation gradually and gain a more thorough understanding of
their standpoint, using the 5W2H framework, asking them to clarify what theysaid (“so you mean __________?”), or pressing them for details (“give me aconcrete example”), turning a difficult, more open-ended question into a yes/noquestion, and tweaking the way you ask questions in general.

― 18 ―

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1-2.Personnel training

11) What the Advanced Long-Term Care Worker GainsAs a leader, you are given the opportunity to lead your team towards your ideal
image of welfare and the ideal image of your facility. To achieve this goal, youhave at your disposal methods and ways of thinking like communication
methods, meeting management, personnel training, coaching, and more, thatyou can use on your team.
 Your role in the organization is to use these various tools to lead the rest of yourteam. To achieve goals, plan actions, implement these actions, monitor andevaluate the status of these implementations through meetings etc., and make
improvements as necessary. This cycle (known as PDCA) is powered by the
Advanced long-term care worker, which serves as its engine. A measure that you
may have been alone in calling for in the beginning may gain traction as theresults become more obvious, and more and more team members join theeffort to keep the cycle going. Part of the joy of being an Advanced long-termcare worker is being able to create this kind of dynamism.
 Finally, we will introduce common traits that define the behaviors of Advanced
long-term care workers who have successfully learned how to build trust in theirrelationships.

① Open-Minded② Fair
③ Verbally
Expresses
Emotions④ Tells the Truth⑤ Be Consistent⑥ Keep Promises⑦ Keep Secrets⑧ Use Abilities

Communicates the reasons why they made a certain
decision. Discusses issues honestly and openly. Discloses
all related information.
Engages in objective and fair work evaluations.
Depending on circumstance, will speak honestly andopenly about their own feelings, not just the facts. Letting
their emotions take over them and becoming angry,
however, must be avoided.
Long-term care staff members would prefer if you tellthem the truth, however unpleasant it may be, over lying
to them.
Consistent in their decision-making, which is based on
their values and principles as Advanced long-term care
workers.
Makes sure to keep promises and pledges.
Does not tell people about others’ secrets.
Refines their communication, negotiation, and dialogueskills over their professional knowledge, and uses them in
effective ways.

― 19 ―

1.ORGANIZATION/PERSONNELMANAGEMENT

1-2.Personnel training

Reference: For Those Who Wish to Know More

For those who wish to learn more about the topics we’ve discussed:

About Maslow’s Hierarchy of Needs: Motivation and Personality, Maslow onManagement, Abraham Maslow
About career anchors: Career Anchors and Career Survival, Edgar H. Schein
Individual behavior in an organization (factors that cause resistance, etc.): Essentialsof Organizational Behaviors, Stephen P. Robbins
About coaching: Coaching for Performance: GROWing Human Potential and Purpose– The Principles and Practice of Coaching and Leadership, John Whitmore― 20 ―

1. ORGANIZATION/PERSONNELMANAGEMENT

1-3.Gaining knowledge about the psychological stress ofburnout syndrome in long-term care and methods of how tohandle it

Learning Objectives and Target Achievements<Learning Objective>
Learn the background behind “burnout” syndrome, and the perspectives andmethods needed to prevent it. The goal is for Advanced long-term care staff
members to be able to “care for those who care.”<Achievement Targets>(1) Gain an understanding of the factors behind “burnout” (burnout syndrome).
(2) Gain an understanding about emotional regulations in emotional labor.
(3) Gain an understanding of the concept of resilience.
(4) Be able to support long-term care staff members in ascribing meaning to theirexperiences to turn them into learning experiences.
(5) Gain an understanding of the systems related to mental health care.

Does any of the following apply to you?
1
2
3
4
5
6

I feel my work is emotionally draining
I feel it takes an immense amount of energy to deal with people
all day for work
I feel like my work is slowly breaking me down
I am frustrated/dissatisfied with my work
I feel I am trying too hard at my work
I feel like I am both physically and emotionally exhausted

The checklist above was extracted from the MBI (Maslach Burnout Inventory), ameasure for evaluating “burnout” (burnout syndrome).

― 21 ―

1. ORGANIZATION/PERSONNELMANAGEMENT

1-3.Gaining knowledge about the psychological stress ofburnout syndrome in long-term care and methods of how tohandle it(1) What is Burnout Syndrome?
1) Summary of Burnout Syndrome
Burnout as a concept was first proposed by Freudenberger in 1974. In Japan, it iscommonly known as “moetsuki shokogun,” or “burnout syndrome.”“Burnout” (burnout syndrome) is defined by three symptoms: “emotional
exhaustion,” “depersonalization,” and a “diminished sense of personal
accomplishment” (Kubo, 2007). It is a situation wherein a previously motivatedindividual loses all of this motivation, as if burnt out, and becomes unable to handle
the demands of his/her work.
Though there are many causes of burnout, the main cause, if we were to put it
simply, would be “stress.”
Stress accumulates through various situations and occurrences in the workplace,and is a burden on both mind and body.
Once stress accumulates over a certain threshold, it can cause burnout.
For this reason, the most effective way to prevent “burnout” (burnout
syndrome) is to learn how to handle everyday stress.
2) The Characteristics of People Who Experience “Burnout” (Burnout Syndrome)in the Human Care Service Field
Many people who experience “burnout” (burnout syndrome) are idealists, whowork towards a very specific ideal in their everyday work and who devote
themselves each day to making their users’ lives better.
These people are indispensable to a long-term care workplace, as they engage intheir work with a strong sense of purpose and ethics.
For this reason, it is particularly necessary for us to support these people andprevent “burnout” (burnout syndrome).

― 22 ―

1. ORGANIZATION/PERSONNELMANAGEMENT

1-3.Gaining knowledge about the psychological stress ofburnout syndrome in long-term care and methods of how tohandle it3) The Factors Behind “Burnout” (Burnout Syndrome)
Here we will discuss the factors behind “burnout” (burnout syndrome), from two
perspectives: the environment of long-term care work and the characteristics oflong-term care work in general.
The environment of long-term care work
1. More Diverse and Complex Long-Term Care Needs
In modern society, more and more people are living different kinds of lifestyles.
This means that there are differences in values and ways of thinking. This isexacerbated also by the fact that many of these people wish to maintain the lifestylethey are accustomed to, and remain true to themselves, even when they come torequire long-term care.
Long-term care services must be provided in individually tailored ways that meetthese diverse needs.
2. More Severe Conditions in People Who Require Long-Term Care
For instance, elderly long-term care facilities. In order to enter an intensive carehome for the elderly, people must be classified Long-Term Care Requirement Grade
3 or above, and many of these people have dementia.
High-level long-term care is required, as the Long-Term Care Requirement Gradefor people entering the facilities is higher, and the amount of long-term care thatmust be provided has increased.
3. More Complex Work Due to Multi-Disciplinary Cooperation
It is impossible for caregivers on their own to support a user’s entire lifestyle.
Currently, there is a need for a team approach to long-term care that requires
cooperation with those of other disciplines. Multi-disciplinary cooperation requires alevel of operational ability to be able to handle differences in opinions atconferences, the sharing of information, communication in general, reports, etc.
4. Cooperation with a Diverse Group of Long-Term Care Workers
People who work in the long-term care workplace are of different genders andages. There are people who have undergone the government’s Beginner’s Training
Program and Practice Training Program before acquiring their caregiver certification,and there are those who learned their caregiving skills at a vocational school.
In recent years, there are also many foreigners who are working as long-termcare workers. Working in a team with this kind of diversity can give rise to stress due
to issues caused by differences in life history and values.

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1. ORGANIZATION/PERSONNELMANAGEMENT

1-3.Gaining knowledge about the psychological stress ofburnout syndrome in long-term care and methods of how tohandle it

The Characteristics of Long-Term Care Work
Human care service professionals are particularly prone to “burnout” (burnout
syndrome). The reason for this tendency can be explained by a concept called“emotional labor,” proposed by Arlie Hochschild.
Mitsui1 explains emotional labor in the following way: “[emotional labor is] theconcept wherein an individual feels an emotion that is different from the emotionthat would be expected of them in a given situation, and attempts to manage theiremotions in order to fit the mold. This is thought of as emotional labor when thisemotional management is part of one’s job.”
In other words, people who are under the burden of emotional labor are
expected to act and behave in ways that express only the emotions appropriate totheir situations. These situations require them to express emotions that are
different from the ones they actually feel, and when they occur often, theemotional management can lead to fatigue.
What kind of emotion is “appropriate to their situation” is not usually describedin concrete terms. They may be, for instance, communicated from the moreexperienced people to the less experienced, from manager to subordinate, etc.
Reference: 1) Sayo Mitsui. “Kaigoshoku ni Okeru Kanjorodo (‘Emotional Labor in
Nursing Occupations’),” Journal of Ohara Institute for Social
Research: No. 567 (2006).

Exercise 1: “What is your ideal image of a long-term care worker?” Come up
with as many ideas as you can.

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1. ORGANIZATION/PERSONNELMANAGEMENT

1-3.Gaining knowledge about the psychological stress ofburnout syndrome in long-term care and methods of how tohandle it(2) Emotional Regulations
What you all would consider the ideal conduct and behavior of a care worker

What is the ideal image of a care worker as envisioned by human care service
professionals?
“Always calm,” “smiling,” “bright, active energy,” “give users energy,” “give users
the hope to live”

1) How the Ideal Image of a Human Care Service Professional is CreatedEducation at
SchoolTV and Books

Workplace

Individual Values,

Philosophy, Policies

Perspectives― 25 ―

1. ORGANIZATION/PERSONNELMANAGEMENT

1-3.Gaining knowledge about the psychological stress ofburnout syndrome in long-term care and methods of how tohandle it2) The Emotional Regulations of Long-Term Care Workers
Emotional regulations as it relates to long-term care workers refer to the“appropriate behavior and actions” of idealized vision of a human care service
professional.
Long-term care workers also evaluate their own everyday communication andbehaviors against an internalized set of emotional regulations.
These emotional regulations do have the effect of heightening workers’ awarenessas to the specialized nature of their work, as well as their sense of ethics, guiding
their behavioral policies and principles. However, they are also an important factor incausing burnout.

3) The Effects of Emotional Regulations
Case Study:
Ms. A (25 years old) works as a caregiver at an intensive-care home for the elderly.
She has worked as a long-term care worker for 5 years.
Recently, Ms. B (83 years old), a resident of the care home who has dementia, hastaken to accusing Ms. A of stealing her money 3 to 4 times a day. So far, Ms. A has
been patient in handling the accusations, but Ms. B’s suspicion of her has now led
her to reject Ms. A’s long-term care efforts, and Ms. A is exhausted.
Ms. A begins to wish that Ms. B be moved to a different facility, and the mere
sight of Ms. B begins to make her feel frustrated. Her frustration shows in her facial
expression as she communicates with Ms. B.
This frustration towards Ms. B makes Ms. A even more frustrated with herself
about her inability to behave appropriately as a long-term care worker.

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1. ORGANIZATION/PERSONNELMANAGEMENT

1-3.Gaining knowledge about the psychological stress ofburnout syndrome in long-term care and methods of how tohandle it4) The Burnout Process as Seen Through Emotional Regulations

Feeling negative emotions like mental conflict, anger, etc.

Denying and repressing your negative emotions
Emotional fatigue, quitting job
Earlier, we mentioned that long-term care workers evaluate their own everyday
communication and behaviors against an internalized set of emotional regulations.
When there is a discrepancy between their emotional regulations and their actual
communication and behavior, they begin to think that they are not fit for the role oflong-term care worker.
They continue trying to communicate and behave in the ideal ways, but will soon
redevelop their negative emotions towards certain users, making them feel evenmore frustrated about feeling these negative emotions, and ultimately increasing
emotional fatigue. The result is burnout.

(3) Resilience
Let’s use the concept of resilience to pick up some tips on how to prevent burnout
due to emotional labor.
1) What is Resilience?
Resilience is the ability to “bounce back,” “recover quickly,” and “spring backinto shape.”
People with high resilience are said to have three abilities.
① The ability to recover from setbacks and difficulties② The ability to buffer oneself, and deal with intense stress through a more flexible
mentality③ The ability to adapt to new environments and unexpected change
Source: “Leadership Monthly,” Nihon Kantokushi Kyokai (‘Japan Supervisor
Association’): No. 713 (2016).

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1. ORGANIZATION/PERSONNELMANAGEMENT

1-3.Gaining knowledge about the psychological stress ofburnout syndrome in long-term care and methods of how tohandle it2) An Example of Problem-Solving with a Person with High Resilience
They do not consider an issue to be an insurmountable, even if the issue is miredin high levels of risk and stress.
After making a mistake, they look for opportunities for self-discovery.
They set realistic goals and work towards these goals.
They maintain an optimistic outlook, expect good things, and visualize their hope.
(Reference: “The Road to Resilience,” American Psychiatric Association)

Exercise 2:
Think of a failure you experienced in your career as a long-term worker that you
will never forget.
Then share your experiences amongst each other.
Make sure to convey your feelings when you experienced this failure, and yourfeelings now as you look back on this experience.

Exercise-Based Discussion
What kind of differences exist between your feelings when you first experienced
the failure and your feelings now looking back on it?
First, let us just say that you all who have experienced failure have overcome thisfailure.
This means that you all are highly resilient individuals.
Many of you probably said that when you experienced your failure, that it was
painful or sad. But how do you feel looking back on that experience now? Many ofyou would probably see it now as a learning experience.
This way of handling a failure the way highly resilient individual handle
failures—by looking for opportunities for self-discovery after a mistake, and notconsidering an issue to be insurmountable even if it is mired in stress and risk.

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1. ORGANIZATION/PERSONNELMANAGEMENT

1-3.Gaining knowledge about the psychological stress ofburnout syndrome in long-term care and methods of how tohandle it(4) Handling Stress by Ascribing Meaning
Here we will discuss how to apply the factors of resilience (“after making a
mistake, look for opportunities for self-discovery,” and “do not consider an issue
to be insurmountable even if it is mired in risk and stress”) in a more concreteway.
1) Ascribing Meaning to Experiences for Learning
As we mentioned earlier, we go through our whole lives “interpreting” things.
These interpretations are influenced by your circumstances, your knowledge, andyour values at the time. For this reason, the way we understand an experiencechanges as time passes, as it is filtered through newly acquired knowledge andexperiences. In other words, the way we interpret experiences is subjective. If weare able to interpret “bad experiences” in a way that gives them meaning, we canchange the way we feel about these experiences.
For instance, a long-term care worker who currently sees an experience as
being painful can ascribe meaning to the experience in such a way as to change
the way they interpret it.

Ascribe meaning to experienceby interpreting it as a learning
experience

Painfulexperience

Good experience that helped
my personal growth2) Thought Process Behind Interpreting Experiences to be Learning Experiences
When we use words like “ascribe meaning” and “interpret as a learning
experience,” we make it sound more difficult than it is. Try to think, “what does thispainful experience (situation) teach me?” In doing so, you will be able to think ofyour own situation from a different perspective, and be able to handle it in a morepositive way.

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1. ORGANIZATION/PERSONNELMANAGEMENT

1-3.Gaining knowledge about the psychological stress ofburnout syndrome in long-term care and methods of how tohandle it3) Supporting the Ascribing of Meaning for Long-Term Care Staff Members
Advanced long-term care staff members, in addition to being able to turn theirown difficult experiences and setbacks into learning experiences, must also beable to support other long-term care staff members when they are in a difficult
situation, and work with them to turn what may be bad experiences into learning
experiences.
This also requires that Advanced long-term care staff members engage inday-to-day communication with the staff members and maintain a relationshipthat allows for honest communication.

(5) Compassion Fatigue and Self-Care
Compassion fatigue is when you become exhausted from the stress of wanting
to and/or actually helping others who are suffering or in pain (Figley, 1995).
Human care service professionals, like long-term care workers, are said to beparticularly prone to this fatigue.
For this reason, it is important that Advanced long-term care workers remainaware of the importance of “caring for those who care.”
It is, of course, unrealistic to expect to be able to keep up with everyone’s
emotional needs all the time. As such, it is important for Advanced long-term care
workers to educate others as to self-care methods and how best to deal withstress.
Here, we will introduce some simple self-care methods on how to “care forthose who care.”・ Think about concrete ways you can try to be more positive.
・ Think about whether you can try to increase how you feel positive emotions.
・ Instead of trying to avoid negativity, try to increase the time you spend on
thinking positively.
・ Accept your emotions.

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1. ORGANIZATION/PERSONNELMANAGEMENT

1-3.Gaining knowledge about the psychological stress ofburnout syndrome in long-term care and methods of how tohandle it(6) Basic Systems Related to Mental Health
Here you will gain an understanding of the basic systems related to mental health,which you can use to help preserve the mental health of long-term care staff
members.
1) Industrial Safety and Health Act
The Industrial Safety and Health Act (hereafter “the Act”) is a law that aims topreserve the safety and health of workers with respect to the workplace, andencourage the creation of comfortable work environments. The Act defines safety
and health management systems, measures to protect workers from danger andhealth impairment, regulations for machines, hazardous materials, and harmful
substances, safety and health education systems, and measures to preserve andadvance worker health, and comprehensively regulates matters related to safety
and health in the workplace. (The Japan Institute for Labour Policy and Training)

1 Industrial Physicians
Any workplace that regularly employs more than 50 workers are required toappoint an industrial physician (Article 5, Order for Enforcement of Industrial
Safety and Health Act).
2 Health Committees and Health Managers
The Act requires workplaces to appoint health managers. It also requires
workplaces of certain industries that regularly employ more than 100
workers (for certain special industries, more than 50 workers) to establish asafety committee, and workplaces of all industries that regularly employ
more than 50 workers to establish a health committee.
3 Stress Check Systems
A stress check system is required for workplaces that regularly employ morethan 50 workers.

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1. ORGANIZATION/PERSONNELMANAGEMENT

1-3.Gaining knowledge about the psychological stress ofburnout syndrome in long-term care and methods of how tohandle it2) Mental Health Care Support Systems
1 Examples of Various Support Websites
・“Minna no Mentaru Herusu (‘People’s Comprehensive Site on Mental Health’),”Ministry of Health, Labour and Welfare [http://www.mhlw.go.jp/kokoro/]
・ “Akarui Shokuba Oendan (‘Joyful Workplace Support Group’), Ministry of Health,Labour and Welfare [http://www.no-pawahara.mhlw.go.jp/]
・ “Kokoro no Mimi (‘Ears of the Soul’), Ministry of Health, Labour and Welfare[https://kokoro.mhlw.go.jp/worker/]・ “Federation of Inochi no Denwa” [http://www.inochinodenwa.org/lifeline.php]
2

Various Support Institutions

・
・
・
・

Health centers
Health and welfare centers
Free consultations at city halls
Medical institutions (psychiatry, psychosomatic medicine)(7) Supporting the Mental Health of Long-Term Care Workers
1) Use of Checklists
With respect to the mental health of long-term care workers, it is important tobe able to sense the early signs and handle them immediately. Early signs that along-term care worker is experiencing an unbalanced mental state are often
symptoms like “feeling frustrated,” “feeling anxious,” and “being unable toconcentrate.”
For this reason, it is necessary for those in the workplace to utilize check sheets
to measure the accumulation of fatigue for those of different job types, anddecide which early signs they should pay particular attention to.
The Tokyo Labor Consultation Center has created a checklist that could be agreat point of reference when creating accumulation of fatigue checklists.
http://www.kenkouhataraku.metro.tokyo.jp/mental/self_care/check.html― 32 ―

2. MAINTENANCE/ IMPROVEMENT
OF SERVICE QUALITY

2-1. "Service" in a People-Oriented Job

Learning Objectives and Target Achievements● Key Learning Points
Deepen understanding of service.
● Target Achievements
Be able to handle issues related to long-term care and user service.

① Service (What is "Service" in a People-Oriented Job?)
The long-term care insurance system, established in 2000 (Heisei 12), changed
long-term care from a government measure applied to users as a welfare service, tosomething that the users themselves could choose, choosing to establish contracts
with businesses that are coordinated with welfare services.

“From measure to contract”
The conceptualization of users has shifted accordingly, from simply receivers of agovernment measure to customers that are using a service. For this reason, as well as
the competition between businesses, there has been a need to reevaluate service as
it applies to long-term care.

― 33 ―

2. MAINTENANCE/ IMPROVEMENT
OF SERVICE QUALITY

2-1. "Service" in a People-Oriented Job<Exercise 1>
There are various kinds of customer service jobs. Think of one, and think about
what you need to consider in your work for this job.
* Think individually, then organize your ideas within the group, grouping thesimilar ideas together, and discuss how these kinds of jobs differ from that oflong-term care work.

What kind of service are contractually obligated to provide in the long-term care
workplace? Think about it.

Contract― 34 ―

2. MAINTENANCE/ IMPROVEMENT
OF SERVICE QUALITY

2-1. "Service" in a People-Oriented Job

In long-term care, there must first be a focus on “preserving dignity.” As is
described in the Long-Term Care Insurance Act, we must first provide an environment
where users can live true to themselves, regardless of the type of service. We must,
additionally, provide the kind of service that empowers the user from the perspectiveof self-sufficiency.
Service in this kind of environment does not necessarily mean listening to every
request by the user or their family, and providing what could amount to excessive
service. An important aspect of service is to help increase the number of things that auser is capable of doing in the current situation.
As such, it is important to remember that excessive service can have negative
effects on both users’ physical abilities and daily motivation. Service as it relates tolong-term care must be provided in such a way as to maintain what users are
currently capable of doing, physically and emotionally—not too much and not too
little. It is important to gain the understanding of the user and their family withregards to this conceptualization of service.

② User-Oriented Long-Term Care Services/Empowering the Family<Exercise 2>
Ms. A (80 years old) has been living at home. Think of possible things (people,
organizations, environment, etc.) that she could be involved in her life.
* You do not need to think of whether she is using a welfare service or not.
* Think individually, then discuss in groups.

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2. MAINTENANCE/ IMPROVEMENT
OF SERVICE QUALITY

2-1. "Service" in a People-Oriented Job

In order for users to maintain their at-home lifestyle, and depending on theirsituation, there is a need for them to be involved in more than their welfare service.
Amongst these other involvements that a user may have, nearby people are perhaps
one of the most important. For instance, a long-time friend who lives nearby, fellow
members of a neighborhood association, their siblings and family, etc.
The cooperation of the family is indispensable in maintaining an at-home lifestylefor elderly users that require long-term care. Even if the user is employing at-homelong-term care service, the time that the long-term care worker spends in their home
is limited, and the empowerment of the user’s nearby people becomes very
important.
In order to build a support relationship with the user’s nearby people, and be able
to communicate with them, we must maintain a perspective of assessment for thethese people as well.

③ Case Study of Family-Related Troubles, Their Causes, and How to
Handle/Solve Them
Risk management is necessary in an organization to reduce and avoid loss. One
risk that must be managed is complaints. Upon receiving a complaint, we must not
only look into the direct cause of the complaint, but the cause of the cause, and soon.
Complaints are also oftentimes an expression of client wishes and desires. As
such, we must take them seriously as an organization and use them as opportunities
to brush up or improve the quality of our service—not of each individual long-termcare worker, but of the organization as a whole.

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2-1. "Service" in a People-Oriented Job<Case Study>
Mr. A (80 years old; one month into admission), who lives in a senior home, isvisited by family member Ms. B (his oldest son’s wife). The next day, the facility
receives a call from family member Mr. C (his oldest son; key person), who says, “you
don’t seem to be taking care of my father at all—what do you think you’re doing,
abandoning the elderly?”
When long-term care worker Ms. D (2 years into employment) receiving the callasks him what had happened, Mr. C tells her that Mr. A had complained to Ms. B, “I
have to walk and change and do everything by myself here, and I’m tired.” Ms. D loses
her confidence as a long-term care worker and begins to not show up to work.
Think about the causes of this issue and how you could handle them.
Additionally, think of how you could support long-term care worker Ms. D in thissituation.
* Imagine you are in a position to manage the long-term care staff members.

④ Case Study of User-Related Troubles<Case Study>
Ms. A (75 years old) lives in a private senior home with long-term care services.
She tells new staff member Ms. B, “I don’t like your attitude and you’re bad at yourjob, so don’t come care for me anymore,” and “I’ll leave this facility if you don’t leave.”
Ms. B has come to a manager (you) for advice.
Think about the causes of this issue and how you could handle them.
Additionally, think of how you could support long-term care worker Ms. B in thissituation.

― 37 ―

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2-2. Risk Management as Related to Long-Term Care

Learning Objectives and Target Achievements● Key Learning Points
Deepen understanding of risk management through case studies.
● Target Achievements
Be able to provide guidance on risk management.

① Labor Laws and Regulations

What is the Labor Standards Act?
“To labor” is to establish a contract between employer and worker. The Labor
Standards Act exists to protect workers from injustice and disadvantage by setting
minimum standards that all workplaces must adhere to.
The fundamental idea of this law is to protect workers (those in the weaker
position) from employers (those in the stronger position).

― 38 ―

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2-2. Risk Management as Related to Long-Term Care

① Labor Laws and Regulations

Regulations on Working Hours
1) Working hours must not exceed 8 hours per day, or 40 hours a week.
2) Employers must allow at least 45 minutes of rest for workers if their working
hours are to exceed 6 hours, and at least 1 hour of rest if working hours are to
exceed 8 hours.

① Labor Laws and Regulations<Case Study>
Long-term care staff member Ms. A, who works at a residential care home,consults you for advice.
“Last month, I worked 30 minutes or so of overtime every day, but I didn’t receive
any extra pay. This isn’t normal, right? I don’t have the time to talk to the chairman,
so could you tell me the reason why?”
How would you respond as a manager?
* Ms. A works from 9AM to 5PM.
* Ms. A works 5 days a week.
* Ms. A is allowed to take 1 hour of rest away from her work.

― 39 ―

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2-2. Risk Management as Related to Long-Term Care

② Heinrich's Law and "Close Calls"
Incident: Instances in which something happens or is done that is inappropriate
in a long-term care workplace, but without causing damage to the user.
Accident: Instances in which, for some reason or another, damage is caused tothe user.

<Case Study> Intensive Care Home for the Elderly
It is nighttime, and long-term care staff member Mr. A visits user Ms. B’s room.
Mr. A finds Ms. B sitting up in bed, holding onto the railings and trying to stand.
When Mr. A asks what her she is doing, she says she wants to go to the bathroom.
Mr. A gets her to sit in a wheelchair, guides her to the bathroom, and takes herback to her bed after she is done. Later, he returns to the staff room and creates a“close call report.”
A few days later, long-term care staff member Mr. A, an Advanced long-term care
worker, and two members of the Accident Prevention Committee (long-term care
workers) are to gather for a meeting to discuss future measures to prevent this kindof thing from happening again.
* Staff members have asked Ms. B to call a nurse when she wishes to go to thebathroom.
* Ms. B does feel the urge to go to the bathroom, she uses rehabilitation
underwear, and staff members use a wheelchair to take her to the bathroom.
* Ms. B’s knees tend to buckle when she stands due to the decrease in muscle
strength in her lower limbs, so a wheelchair is used to help her move, andrequires partial support to stand up.
* Similar close call reports have been submitted about Ms. B in the past, andlong-term care staff member Mr. A has said that he doesn’t know what to do,as he’s already explained this to her many times.
How would you, as an Advanced long-term care worker, conduct the meeting if
you were in the position of the manager, and what kind of measures would youtake?

― 40 ―

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2-2. Risk Management as Related to Long-Term Care

③ Standardization of Care Methods/Procedures that Utilize Care Cards, etc.
Currently, there is a particular focus on the quality of service provided by welfare
institutions. There exists currently a lack of standardization in the reasoning behind
long-term care. For instance, experienced long-term care workers who are asked
why they practice a certain support method often reply that they were simply
taught that way, and there is disparity in the methods used even in the samefacility.
In resolving this situation, it is important to use care cards and standardize thesupport and communication methods used by long-term care staff member.
For instance, when helping a user stand up, long-term care staff member Mr. A
may support their core, but Ms. B may support their knees and hips. These
differences in method can cause confusion for the user receiving the support as
well.
* Care cards are referred to as different things depending on the workplace(“support manual,” “support plan,” etc.)<Exercise>Create care cards to standardize the care method for changing clothes before
sleep.
* There is no set format.
* Make sure to include concrete details so that all long-term care staff members
can have the same understanding.
* Make sure to include specifics that must be standardized as well, like different
methods for changing clothes on the bed vs. while the user is sitting, etc.

― 41 ―

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2-2. Risk Management as Related to Long-Term Care

<Example of a Care Card>④ Hygiene Management and Risk Management
There are many risks inherent in the lives of elderly people who require long-termcare. In order to give them a sense of safety and security, it is necessary for us toengage in risk management—preventing accidents, taking safety measures, etc.
through the establishment of organizations like accident prevention committees,
infection control committees, and disaster management committees.
Particularly in the case of welfare facilities, however, it is not enough simply toestablish these organizations. In addition to safety measures in each of the user’s
rooms, we must check whether there are objects placed in front of theemergency exit, for instance, and ensure that routes of movement are clear
throughout the building itself. Risk management to prevent choking, errors inmedication, etc. are also necessary in welfare facilities.

― 42 ―

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2-2. Risk Management as Related to Long-Term Care

④ Hygiene Management and Risk Management<Exercise> 2F of Intensive Care Home for the Elderly (Unit-Type Facility)
2:00PM: In the cafeteria, you (an Advanced long-term care worker) and anotherlong-term care staff member are watching over ten users enjoying conversation
and reading newspapers. Suddenly, user Ms. A, who has been watching, begins
to vomit.
Discuss how you would handle this situation.
* There is a chance that Ms. A could be suffering from infectious gastroenteritis
due to the Norovirus.
* The 2F of this facility is divided into a North Unit (where Ms. A lives) and a South
Unit, with ten rooms each.
* Use infection control guidelines and documents from the infection control
committee at your facility as reference.

④ Hygiene Management and Risk Management<Exercise>
Risk management in a welfare facility also requires standardized measures for
emergencies and disasters (fire, earthquake, storm and flood damage, etc.). Lookback on the concrete plans that your workplace has established for emergencies anddisasters.
1) How does your facility communicate evacuation routes for emergencies?
2) Where does your facility store emergency provisions and disaster supplies?
3) How much emergency provisions do you have stored (for how many people forhow many days, etc.)?
4) How will you coordinate with community residents during an emergency and/or
disaster?
* It is important that all of the long-term care staff members at your workplace
understand each of these elements, not just you, so that they are able to handle
whatever situation that arises on their own as well. Discuss information sharing andtraining methods to accomplish this as well.

― 43 ―

2. MAINTENANCE/IMPROVEMENT 2-3. Knowledge related to long-term care insurance systems,
OF SERVICE QUALITY
long-term care fees, the services and supports for persons
with disabilities act, medical and welfare policies, etc.

Learning Objectives and Target Achievements<Learning Objectives>
In this training theme, you will learn knowledge on long-term care insurance
systems, long-term care fees, medical and welfare policies, etc. The long-term carebusiness exists on the basis of a variety of laws and regulations. You must
understand these laws and regulations, as well as the necessity of compliance, whatkind of influence and/or effects they will have on users and staff, and be able toutilize this knowledge to provide guidance.

<Target Achievements>● Be able to explain the objectives of long-term care/welfare laws andregulations, and the importance of compliance.
● Be able to provide guidance to others as to long-term care insurance systems
and how to utilize long-term care services.
● Understand revisions to long-term care insurance systems and long-term carefees, and be able to use this knowledge when providing service.
● Understand the Services and Supports for Persons with Disabilities Act andmedical and welfare policies, and be able to provide guidance to staff about them.

First…
Let’s think about the laws and regulations that are necessary for long-termcare/welfare work.
You are working in the midst of a variety of laws and regulations. It is important foryou to understand the types of laws and regulations, their content, and theirobjectives.
Compliance means to obey and adhere to the orders, regulations, rules,
standards, agreements, laws, ordinances, etc. established by laws and regulations.
Laws and regulations are established in order to create an ideal society. The
Constitution of Japan defines “respect for fundamental human rights” as one of its
principles, and long-term care/welfare laws and regulations are based on thisprinciple.

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2. MAINTENANCE/IMPROVEMENT 2-3. Knowledge related to long-term care insurance systems,
OF SERVICE QUALITY
long-term care fees, the services and supports for persons
with disabilities act, medical and welfare policies, etc.

1. Compliance with Long-Term Care/Welfare Laws and Regulations

The Social Welfare Act, Long-Term Care Insurance Act, and the Services andSupports for Persons with Disabilities Act, which you all should familiarize yourself
with as people involved in welfare, have the shared objectives of “preserving
dignity” and “supporting self-sufficiency.” “Preserving dignity” means to respect
people as human beings no matter their age or disability, ensure their fundamental
human rights, and to cherish all people. “Supporting self-sufficiency” means toallow people as much as possible to engage in their own decision-making and live
the life they want to live, and to support people in this endeavor.
Long-term care/welfare laws and regulations work to ensure a certain level ofservice so that users are not at a disadvantage. The long-term care business inparticular has more meaning to society as a social resource than the averagecompany, not to mention that much of their revenue derives from long-term carefees, which are sourced from insurance fees and taxes. This means that thisbusiness in particular must maintain particularly close compliance to laws andregulations.
We must understand the goals of these regulations, remain compliant to them,and provide appropriate services that adheres to workplace ethics. Managers oflong-term care workplaces in particular must behave in ethical ways (with regards tobusiness), and educate staff members as to the importance of ethics. 暮らしの実現を図ることである。

<What is Ethics?>

Ethics is when you adhere to standards, laws, and rules (in society, the workplace,etc.), follow social agreements with respect to human relationships, and think andbehave in a morally correct way as a human being. Ethics is an important factor inbeing compliant to laws and regulations.

<Workplace Ethics for Caregivers>

The preface of the Code of Ethics of the Japan Association of Certified Care
Workers (established on November 17, 1995) states, “we wish that all people withlong-term care/welfare needs are able to live with a sense of security in their very
own neighborhoods, and that our society becomes one where they can continue tolive in this way. For this reason, we of the Japan Association of Certified Care
Workers, as an association of caregiving professionals that wishes to support the richand meaningful lives of users in Japan, will hereby establish a code of ethics, anddedicate ourselves to providing the best possible caregiving services, armed with our
professional knowledge and techniques, and with an awareness of ethics.” It goes on
to define the following seven codes of conduct:① User-oriented/self-sufficiency support, ② Providing professional services, ③
Protecting privacy, ④ Providing comprehensive services and active
coordination/cooperation, ⑤ Representing users as to their needs, ⑥ Advancing
welfare in the region, and ⑦ Training the next generation― 45 ―

2. MAINTENANCE/IMPROVEMENT 2-3. Knowledge related to long-term care insurance systems,
OF SERVICE QUALITY
long-term care fees, the services and supports for persons
with disabilities act, medical and welfare policies, etc.

<Situations Where Compliance May Fail>〇

Workers do not have the proper knowledge of laws and regulations
 Workers do not understand the work necessary for compliance, andprovide service according to their own decisions and personal
circumstances. (I’m busy or having a hard time so I can’t do this orthat.)〇

Workers are too caught up in their everyday work tasks and the
management system is insufficient Decreased sense of mission and responsibility; issue withorganizational structure〇 Workers prioritize their own interests (improper charges, covering up
violations/accidents, not maintaining sufficient records)
 Decreased sense of ethics and morals: “this much can’t hurt” or “wecan’t make money unless we do this”
Without the right knowledge and the right awareness, people cannot
comply with laws and regulations.
There must be a strong will to “comply.”Ex) Are you following the rules of the road? Do you make sure to drive under the
speed limit?

― 46 ―

2. Maintenance/
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2-4.Utilization of long-term care robots, AI, and ICT in
long-term care

Learning Objectives and Target Achievements
 Gain an understanding of efforts and methods involving
long-term care robots, AI, and ICT in the latest long-term care,and be able to use them appropriately
 Learn how to utilize long-term care robots, AI, and ICT to
improve work and maintain/improve the quality of service
 Be able to provide long-term care service that meets changing
needs in the future

By 2025, the baby-boomer generation will be of late-stage elderly age, andcoupled with the declining population, we will reach a peak in our aging society. One
possible countermeasure that has been proposed to combat this issue, the chronic
shortage of long-term care workers, as well as the increasing workload on theseworkers, and has quickly gained traction in recent years, is the implementation of
long-term care robots and AI.

Living with robots will be absolutely
necessary, especially for the long-term careindustry and its shortage of workers.

― 47 ―

2. Maintenance/
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2-4.Utilization of long-term care robots, AI, and ICT in
long-term care

Revision of the “Priority Areas to Which Robot Technology is to be Introduced in
Nursing Care” (established November 2012; revised February 2014) by the Ministryof Economy, Trade and Industry and the Ministry of Health, Labour and Welfare
Here in Japan, businesses to advance the development and implementation of
long-term care robots began in 2013, and has since then focused on such fields as
the support of transfer and movement and support in the bathroom and withbathing, as well as monitoring and communication. The revision, however, defines
13 themes in 6 different fields, and places more importance on robots capable ofhigh-level yet precise movements, as well as equipment that can provide support for
long-term care work, with developments in these fields expected to pick up in the
future.

Revision of “Priority Areas to Which Robot Technology is to be Introduced in Nursing Care” (October, 2017)*Text in red are the revised (added) fields

Transfer Support

Movement Support

Bathroom Support

Monitoring/
Communication○ Installation○ Outdoors○ Waste Disposal○ Facility

Wearable robot technologythat provides power
assistance to long-term care
workers

Walking support device thatuses robot technology to assist
the elderly in their outdoor
activities and allows them totransport their things safely

Height-adjustable toilet thatuses robot technology todispose of waste

・Device platform that uses
robot technology to serve as asensor, external
communication device, etc. in
long-term care facilities○ Non-Installation○ Indoors○ Bathroom Guidance○ In-Home

Walking support device that uses robot
technology to assist the elderly in

Non-wearable device that uses
robot technology to assist
long-term care workers in
lifting movements

walking indoors, sitting standing, etc.
and particularly their trips to and fromthe bathroom, as well as helping
maintain their posture while using thebathroom.

・Device that uses robot
technology to predict thebathroom need of users, sothat caregivers can guide themto the bathroom○ Installation○ Action Support

Wearable mobility support
device that uses robot
technology to assist the elderlyin their outdoor activities,
providing support for walking
and preventing falls

・Device that uses robot
technology to provide support
for all bathroom actions, frompulling down the pants toactually using the bathroom.

・Device platform that uses
robot technology to serve as afall alert sensor, external
communication device, etc. inin-home long-term care

Bathing Support

・Devices that uses robot
technology to assist individuals
with all actions necessary to
get in and out of the bathtub

Support for Long-TermCare Work○ Lifestyle Support
・Device that uses robot technology tocollect/accumulate the data that comes

Lifestyle support device thatuses robot technology tocommunicate with the elderlywith long-term care—monitoring,
movement support, bathroom support,
etc., and allows workers to use thisdata to provide elderly with thenecessary support(Reference: Ministry of Health, Labour and Welfare.,Ministry of Economy, Trade and Industry. ”miraitoshikaigi”)

For the next revision of long-term care fees, the government has proposed areevaluation of personnel, equipment, and fees regarding the implementation of
long-term care robots, ICT, and AI.
For this reason, staff of the long-term care industry must continue to pay close
attention to the latest information, and continue to brush up their knowledge withrespect to the use and operation of these technologies.

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2. Maintenance/
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2-4.Utilization of long-term care robots, AI, and ICT in
long-term care

Survey Conducted by the Ministry of Health, Labour and Welfare (MHLW) on
the Percentage of Care Workers Who Feel Burdened by Certain Long-TermCare Tasks
In 2011, the MHLW conducted a survey of 220 facility managers/long-term carestaff as to whether they felt burdened by certain long-term care tasks.
Main Task Categories in Long-Term Care
Percentage (%) of people who feel it is a burden

Other

Sharing Information

Dementia Care

Monitoring

Bathing

Bathroom Support

Meals

Movement

Transfer

Standing Up(Source: “Report on Businesses to Support the Implementation of Assistive Technology andLong-Term Care Robots,” Ministry of Health, Labour and Welfare)

The use of Big Data, AI, and IoT (the Internet of Things) is indispensable to theoperation of long-term care robots, and the robot market is expected to expand
drastically, increasing to 5.3 trillion yen by 2025 and 9.7 trillion yen by 2035.
Market Forecast for the Robot Industry Leading Up to 2035
Manufacturing(100 million yen）
120,000

Robot Technology Products

9.7 trillion

Agriculture, Forestry, and Fisheries Field

100,000

Service Field

80,0005.3 trillion

60,00040,00020,0002.9 trillion
0.9 trillion
2012

1.6 trillion

2015

2020

2025

2035

Source: Ministry of Economy, Trade and Industry― 49 ―

2. Maintenance/
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2-4.Utilization of long-term care robots, AI, and ICT in
long-term care

*ICT is an abbreviation of “information and communication technology.” It refers
to technology that focuses on communication, and utilizes computers to advancevarious aspects of our lives. “IT,” a term that sounds similar, refers to technology thatcreates things, whereas “ICT” refers to the technology to use (communicate through)IT.
*AI is an abbreviation of “artificial intelligence.” It refers to technology that
attempts to artificially create human-level intelligence in computers and otherplatforms, and is gathering widespread attention as something that could solve
various societal issues and create new value.

The Use of Long-Term Care Robots and AI in the Long-Term Care Workplace
Currently, development, verification, and implementation is underway forlong-term care robots and AI for a variety of long-term care task categories, including
those that provide transportation/movement support, bathroom support, bathing
support, monitoring/communication services, etc. Here, however, we will focus on
examples from the Silverwing Social Welfare Corporation, a company working to
implement long-term care robots in order to ensure user safety and decrease theburden of long-term care work.

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long-term care

Examples of Long-Term Care Robot Implementation in Facilities(Silverwing Social Welfare Corporation)
Since 2013, we have focused on the following points in order to advance theimplementation of long-term care robots, making sure we can use them in safe yet
effective ways, in order to improve employment environment and in particularimprove the physical health of our staff.
・Ensure user safety, improve functional training effectiveness, improve ADL
scores, improve QOL
・Decrease long-term care worker workloads, and make long-term care work more
efficient
Incorporated long-term care robots from five categories:
1

Transfer Aid System

Muscle Suit

2

Mobility Device

scalamobil

3

Status Monitoring Device

OWLSIGHT, Nemuri SCAN

4

Communication Robot

PALRO, Pepper

5

Labor-Saving System

Smart Suit

I. Long-Term Care Robot
1. Transfer Aid System(1) Muscle Suit (Innophys)
Uses air pressure to generate power for lifting/lowering movements, forinstance when transferring a person from a bed to a wheelchair, a bathtub to a bed
and vice versa, thereby decreasing the amount of hip stress on long-term care staff
members. It generates about 30kgf of power and can reduce hip stress by up to
two-thirds.

Muscle Suit

When Worn (Front)― 51 ―

When Worn (Back)2. Maintenance/
Improvement of Service Quality

2-4.Utilization of long-term care robots, AI, and ICT in
long-term care(2) Resyone (Panasonic)
A sit-up assistance bed that allows long-term care workers to safely, easily, andsmoothly transfer intensive-care users from bed to wheelchair without having to lift
him/her up on their own. A revolutionary new kind of long-term care robot thatcombines electric care beds and reclining electric wheelchairs. Part of the bed
separates from the whole to become a reclining electric wheelchair, making transferfrom bed to wheelchair safe and stress-free for both long-term care worker anduser.

電動ケアベッド状態

Electric Care Bed State

Wheelchair Part Separates

Wheelchair State

2. Mobility Device(1) scalamobil (Alber Japan)
Electric stair device designed to transport users up and down the stairs whilestill in their wheelchairs, and small and lightweight enough to be stowed easily incars. Developed in Germany, it has received international patents from 13
countries throughout the world. The device greatly reduces the burden on
caretakers in taking users up and down the stairs, and is relatively low-costcompared to elevators and lifts.
We use this device when picking up/dropping off users that live in housing
complexes with no elevator.

scalamobil― 52 ―

2. Maintenance/
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2-4.Utilization of long-term care robots, AI, and ICT in
long-term care

3. Status Monitoring Device(1) OWLSIGHT (Ideaquest)
A bed monitoring device that can recognize anything from changes in a user’s
posture (standing up, leaning against the railings) to smaller movements (writhing
movements, trembling).
An AI processes the information collected through an infrared sensor placed
above the user’s head, and notifies you if it decides that the user may be at risk.
The device is also capable of storing three month’s worth of a user’s conditions
and risk assessments, so you can look back on a timeline of user risk at any time
during the storage period.

OWLSIGHT Device

Risk Alert Notification(2) Nemuri SCAN (PARAMOUNT BED)
When laid under a mattress, the Nemuri SCAN will record a daily sleep log thatkeeps track of when users sleep, when they wake up, and when they get out ofbed. This allows you to be aware of user sleep conditions to take better care ofthem, and also to see what kind of impact sleep conditions have on different
users. The device also provides alerts via computer if a user’s status changes. Thisnot only allows you to provide effective emergency help, but also gives you theopportunity to recognize user patterns through an archive of past data, allowing
you to structure more efficient night patrols and decrease the staff’s psychologicalstress.

Nemuri SCAN

Sleep Log

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2-4.Utilization of long-term care robots, AI, and ICT in
long-term care

4.Communication Robot(1) PALRO (FUJISOFT)
PALRO is used for recreational purposes. This small
robot is packed full of various recreational activities
for the elderly, including games, physical stretches,quizzes, music, etc. Passes the Ministry of Health,Labour and Welfare’s standards on long-termcare prevention.
(2) Pepper (SoftBank)
Pepper not only senses human emotion throughpeople’s voices and facial expressions, but has its
own feelings as well, developed through an
original emotion system, through which it behaves.
Because Pepper can be connected to the Internet
at all times, it can tell users at any time about thenews or the weather by accessing information on theInternet.

5. Labor-Saving System(1) Smart Suit (Smart Support Technologies)
Labor-saving suit that makes use of the tension of the elastic (rubber band) tostabilize the core and support the muscles when bent over, decreasing the stress andfatigue on the lower back. Provides support for the human body via a simple elastic(rubber material), thereby decreasing the risk for lower back pain.
Pulls the bodyup

Tightens thecore

Smart Suit

― 54 ―

2. Maintenance/
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2-4.Utilization of long-term care robots, AI, and ICT in
long-term care

In addition, we have also worked to implement functional training (rehabilitation)
robots such as walking assistance rehabilitation robots and random-pattern electric
stimulation devices for long-term care users.
Ⅱ Functional Training Robot
1. Walking Assistance Rehabilitation Robot(1) Weight-Reduction-Type Lift POPO (Daiwa House)
POPO’s lift function allows users to stand up safely, and its weight-reduction
function allows them to walk without causing as much stress to their bodies.

(2) Walking Rehabilitation Support Tool Tree (Leaf)
Walking training robot designed for those rendered hemiplegic by
cerebrovascular disease. Foot pressure measurements allow for precise weightbalance training, and allow them to engage in step training and rhythmic walking
training

See the ideal foot position
See where the user's actual foot is
See when the user steps

Left

Audio

Right

Start

（3）Walking Assist (Honda)
Walking training device based on “Inverted
Pendulum Model,” for effective support.
Helps guide the pendulum movement of
the legs caused by the bending of the
hip joint, as well as the swing of the legs
after they straighten.
Hip Frame
Motor
Thigh Frames― 55 ―

2. Maintenance/
Improvement of Service Quality

2-4.Utilization of long-term care robots, AI, and ICT in
long-term care

2. Random-Pattern Electric-Stimulation Devices for Long-Term Care Users(1) IVES (OG Wellness)
Device used in the arm/leg rehabilitation of stroke patients and those withmotor system diseases.

(2) Leg Rehabilitation Tool LR2 (YASKAWA Electric)
Device used to coordinate action movement amongst the three major joints(hips, knees, ankles).

介護ロボットや ICT などの導入に関して、政府は次の介護報酬の改定に向けて、人員や設備、報酬の見直しを俎上にのせることも提言しています。そのような意味から、今後、介護分野で働く職員も、最新の情報に目を向けてそれらの活用方法を学んでいく姿勢が求められてくるでしょう。
3. Other(1) AEROBIKE 2100R
Device used to combat reduced lower limb-muscle strength, improve thelower-limp muscle strength of those with low physical fitness, improve physicalfitness, maintain a healthy weight through aerobic exercise, improve lower-limb
range of motion, and conduct muscle contraction/relaxation training (which leads
to the ability to walk).
*Information on these systems/devices are based on public information and are
published with the approval of the companies involved.

― 56 ―

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2-4.Utilization of long-term care robots, AI, and ICT in
long-term care

In addition to the examples we just described, there are also assistive
technologies like GP shoes, etc. as well as ICT technologies meant to simplify records
and share data, that are already being implemented in the long-term care
workplace. Let’s do some research on the latest long-term care robots, ICT devices,and AI devices that could be used in the long-term care workplace.
Transfer Support

Movement Support

Eating Support

Bathroom Support

Bathing Support

Status Monitoring

Communication

Simplification of
Work/Information-Sharing― 57 ―

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2-4.Utilization of long-term care robots, AI, and ICT in
long-term care

The Future of Healthcare and Long-Term Care
The Ministry of Internal Affairs and Communication is currently deliberating how
long-term users should manage and utilize information on their health, healthcare,and long-term care, and how the latest ICT services like mobile devices and 8K
resolution should be utilized, in order to maintain citizens’ health for even longer
and to realize a society that is capable of providing high-quality health, healthcare,and long-term care services.
In more concrete terms, the Ministry in FY2016 began a three-year plan, the“Personal Health Record (PHR) Utilization Project” as a research project through theJapan Agency for Medical Research and Development (AMED), aimed at developing
a PHR service model adapted to four life stages, providing support for ①
pregnancy, childbirth, and childcare, ② prevention of disease and long-term care,③ prevention of progression of lifestyle-related diseases, ④ healthcare andlong-term care coordination. The Ministry has also established the basic
technologies necessary to allow individuals to maintain comprehensive
management over a wide variety of information.
<PHR Model Creation Project>
Insurers (Health Insurance Companies, National Health

Local Government

Insurance, etc.)

EHR (Through Medical
Institutions/Welfare Facilities)

Disasters/Emergencies
Can provide treatments based on an individual’s
past medical history, current allergies, etc.
Visiting New Medical Institutions, etc. After aMove
Doctors can evaluate you based on the
medical information on your records as wellMother andChild
Handbook

SchoolCheckup App

HealthManagement
AppLong-Term

Lifestyle-Based

Care

Disease Handbook

Prevention

App

Primary Care
Doctor
HandbookApp

Private Insurance Companies
Create new services that can set
things like insurance prices
according to each individual’s healthcondition, lifestyle, etc.

Data collected throughindividual approval

Use of DataApp

PHR BusinessDistribute

Verification/View

Individual
Download apps in accordance with
their own life stage

High Added Value Health Care
Service
Provides a comprehensive
analysis of health checks, medical
examinations, etc. to provide an
individually-tailored, high-quality
disease prevention/healthadvancement program
Clinical Research Institutions, etc.
Make collected data anonymousand analyze/utilize

Secondary Useof Data

My Number Card

Collect/utilize information about individual health/healthcare in a timeline through apps

(Reference: “Advancement of ICT Utilization in the Healthcare, Long-Term Care, and Health Fields,”
Ministry of Internal Affairs and Communication)― 58 ―

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2-4.Utilization of long-term care robots, AI, and ICT in
long-term careLong-Term Care Robots and AI Can Reduce the Psychological Stress of Those
Receiving Care as Well
The use of robot technologies in long-term car workplaces is greatly anticipatedfor its effects in reducing the physical stress on long-term care workers, and theseeffects indeed have been verified in actual practice.
However, perhaps more surprisingly, robot technologies may reduce thepsychological burden of those receiving care as well.
In the future, more and more people in the baby boomer generation, or with
their diverse values and cultural backgrounds, will require long-term care. Amongst
them, there will be many who will feel they don’t want anyone taking care of them,that they’d prefer to have a robot help them than feel guilty being a burden toanyone else, or that they want to live at their own pace. For these kinds of users,
long-term care provided through robots and AI may be what it takes to preserve
their dignity.
(Reference)“Special Poll on Long-Term Care Robots,” Cabinet Office
In 2013, the Cabinet Office conducted a special poll of 3000 Japanese citizens 20
years of age or older through individual reviews. The results are as follows (61.4%
meaningful responses).
(1) Appeal of Long-Term Care Robots(Multiple Answers)

Reduces physical/emotional burden on
long-term care workers
Don’t have to feel guilt for needing care
Improves self-sufficiency
Prevents decreases in users’ physical/emotional
healthReduces fees associated with long-term care
Safer than long-term care by people
Can receive cutting-edge long-term care
Other
Nothing in particular
I don’t know

Total Number（N = 1,842 people; M.T. = 223.7%）(Source: “2013 Special Poll on Long-Term Care Robots,” Cabinet Office)― 59 ―

2. Maintenance/
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2-4.Utilization of long-term care robots, AI, and ICT in
long-term care(2) User Attitudes Towards Long-Term Care Robots

I do not want them to be used(subtotal)
29.3

I want them to be used (subtotal)
65.1

I want them to be
used

If I had to choose, I would
want them to be used

(Number of people)

I don’tknow

If I had tochoose, I
would notwant them tobe usedI do not wantthem to be
used

Total Number: 1,842 people(Source: “2013 Special Poll on Long-Term Care Robots,” Cabinet Office)Things to Consider When Implementing Long-Term Care Robots, etc.
In addition to the examples we just described, there are also assistive
technologies like GP shoes, etc. as well as ICT technologies meant to simplify records
and share data. However, when implementing robots and AI in the long-term care
workplace and using them in effective ways, it is very important for us to understandthe reasons why these technologies are being used, and understand their positives
and negatives for users and long-term care workers.
It is also important for us to first improve the quality of our overall work before
implementing these technologies, and not simply use them as ways to make up forthe labor shortage, or to decrease the burden of long-term care work. And after
implementation, it is also important to properly evaluate the effects of thetechnologies, to try to make better use of them in the future.

― 60 ―

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2-4.Utilization of long-term care robots, AI, and ICT in
long-term care

Discuss in your groups your opinions on these topics: “coexisting with long-termcare robots,” “reducing user psychological stress,” “making work more efficient,”
etc.

Task:
Choose one specific user you are currently in charge of in your workplace, andthink in concrete terms about how you would utilize long-term care robots and/or
AI in their care—which parts of your work would you use these technologies for,and which parts would you yourself provide support? Also think about the reason
why you would use these technologies for these specific situations, as well as theirpositives (expected effect) and negatives (cautionary points).
・Parts of work you chose・Explaining the robots/AI you chose・How you would use them・Positives (Expected Effects)

・User situation
・Reason for use

・Negatives (Cautionary Points)― 61 ―

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2-4.Utilization of long-term care robots, AI, and ICT in
long-term careYour Situations
User Condition

The Devices You
Will Use and How
You Will Use
Them

Reason for Use

Method of Use(When and How
Will You Use
Them?)

Positives(Expected Effects)
Negatives(Cautionary
Points)― 62 ―

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2-4.Utilization of long-term care robots, AI, and ICT in
long-term care

Purpose of Using Long-Term Care Robots, AI, and ICT
The purposes of using long-term care robots, AI, and ICT can be organized into
the following:
・Handling the shortage in long-term care personnel
・Reducing the burden of long-term care work
・Supporting user self-sufficiency
・Controlling long-term care fees
・Adapting to users’ changing values
・Developing new business (economic development)etc.

As we come to coexist with long-term care robots, etc. in the long-term care field,
it is important to remember that we are not necessarily being taken over by thesetechnologies—in fact, it is our job to utilize these technologies in effective ways toprovide high-quality long-term care services that are efficient and safe for both
long-term care workers and those being cared for.
To accomplish this, we must take a good long look at what makes us human, anddecide for ourselves which areas to use these technologies in, and which areas
long-term care staff will provide support for.
We must understand that we as humans are able to offer certain kinds ofsupport that long-term care robots cannot, and shift our specializations to theseareas in order to do our best work as long-term care workers.

― 63 ―

3. BASIC PRINCIPLES OF
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3-1.Basic principles of long-term care

Learning Objectives and Target Achievements: Be Able to…
◇1. Be able to (logically) explain the theoretical rationale behind the practice of“caregiving” through internationally recognized frameworks.
◇2. Be able to explain the differences between the work of “caregiving” and thework of other, similar fields, through a common theoretical basis.
◇3. Be able to explain in scientific terms the social and productive meaning in thepractice of “caregiving.”◇4. Be able to propose long-term care plans that are adapted to social changes inJapan (and the world), and that take into consideration the future outlook ofcaregiving systems.

◇5. Understand public long-term care policies in Japan, and be able touse the most appropriate legal systems depending on client needs.
<Learning Points>
To be an Advanced long-term care staff member that can supervise other staff members, youmust be able to do the above, be aware of the tremendous significance and meaning of
long-term care work, and be able to describe what makes the job interesting, as well as its future
outlook through a creative framework.
For this, it is necessary for you in your everyday work to provide professional care, maintaining
awareness and verifying the reasoning behind their care, including the long-term care plans ofeach client (person that requires long-term care). It is not enough to simply complete the tasks.
Below, we have organized the “basic principles of long-term care,” which will help structure
this process. Typical training for caregivers tends to gloss over this very important information,
focusing instead on the acquiring of day-to-day skills.
Look back on your own work and connect this information to it as we go through this section,and learn how to logically explain the rationale (be able to explain why it is done in that way)
behind each aspect of long-term care.

― 64 ―

3. BASIC PRINCIPLES OF
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3-1.Basic principles of long-term care1) Basic Principles of Long-Term Care (Division of Roles with Similar
Fields) as Defined by the WHO ICF
Long-Term Care and Similar Fields
Professional

Long-Term

介護領域
Care Field

Healthcare Field

Social Work Field

Long-Term Care
(Care Work)

Skill Level

看
Nursing
護

Social Work

Common Field forLong-Term
Care/Social Work

Common Field for
Nursing/Long-Term Care

Basic

Common Field for
Healthcare/Social Work for the
Elderly, Children, the Sick andWounded, and the Disabled
Body functions and structure←→

Activity←→Social participation

Basic Components of ICF Functioning and Impairment
Note: Fields 1-6 show the individual and common fields for nursing, long-term care, and social work.
Reference: Motoyuki Kawatei, “Kaigo Kyoiku Hohoron” (‘Methodology of Long-Term Care Education), Kaigo Fukushi Kyoiku no Zentaizo(‘Comprehensive View of Caregiving Education’) (Koubundou: 2008), pg. 7. Partially edited.
33◇1. Long-Term Care Handles Impairment of Day-to-Day Life as a Resultof Disability.

〇 According to the classifications of the WHO’s International Classification of Functioning,
Disability and Health (ICF), impairment of day-to-day life can be divided into three categories:“body function and structure,” “activities,” and “social participation.”〇 Long-term care handles ①, “activity.” Long-term care encourages various kinds of activities,
regardless of function or structure. This field is characterized by levels from the “basic” to the“professional” levels.
〇 The nursing/healthcare/rehabilitation handle ②, “body function and structure.” In this field,
people aim for recovery of impaired functioning and structure.
〇 Social work/social welfare/support handles ③, “social participation.”◇2. Professionalism and Mutual Cooperation of Each Field

Because fields ①②③ each developed out of the day-to-day behaviors of everyday life,
they each have different levels of professionalism, with the highest level deemed“professional” work. On the other hand, ⑥, which is basic level, is made up of activities thatanybody can do in their day-to-day lives (①: drink an energy drink; ②: carry someone’s
heavy luggage for them; ③: discuss your issues with friends)〇― 65 ―

3. BASIC PRINCIPLES OF
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3-1.Basic principles of long-term care

〇 As you go higher up in ①②③, the level of professionalism increases. Professionals in eachfield, however, cannot be content only to work within their own fields. They must be able tohave a holistic understanding of the issue of “impairment,” and work with other disciplines totake a more comprehensive approach to the issues. As in ⑥, they must be able to provide
certain levels of support from other fields as well.
〇 ④ is a field shared by nursing and long-term care. ⑤ is a field shared by long-term care andsocial work.

◇3. The “Long-Term Care” Field and Levels of Professionalism〇 Look at ④⑤⑥, and you will see that ①, the long-term care field, has more areas incommon with other disciplines than the other fields. Because of this, professionalism in thelong-term care field tends to be more difficult to define than for other fields〇 There are, of course, significant level differences in the content of ① versus ⑥. What wasconsidered long-term care in the past—“bathing, bathroom, and meal support”—would
actually be considered mid-level in area ⑥. Even without the levels in the chart, there is agreat range in the level of ADL activities that users need support for, whether it be cleaning,
laundry, cooking, or support for going outside. This shows the range of skill necessary topractice what is generally considered long-term care. In other words, professionalism withregards to long-term care is still stuck in the level of ⑥, with higher levels (like theprofessional content of ①; management of the long-term care process, etc.) still in theprocess of establishment.

◇2. ICF is an international classification system of “functioning,disability and health.”
The International Classification of Functioning, Disability and Health (ICF)〇 The concept of “health” has changed. Previously, “health” had been conceptualized as a stateof “complete physical, mental, and social well-being,” though it did acknowledge that “health”
was not simply the lack of disease and/or impairment.” Now focus has shifted to aconceptualization that emphasizes quality of life (QOL), and sees health and illness not as
separate things but two ends of the same spectrum.
〇 Through this perspective, the practice of long-term care becomes a professional framework
wherein care workers support clients in engaging in the everyday activities that everyone else
wants to engage in, regardless of their physical/mental function.

― 66 ―

3. BASIC PRINCIPLES OF
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3-1.Basic principles of long-term care2) Impairment as Seen by the WHO IC-IDH (Past)
ICIDH (First version of the ICIDH)

1980: International Classification of Impairments, Disabilities and Handicaps

The IC-IDH divided “impairment” into 3 categories.
〇 It was meaningful as an analysis of what “impairment” meant, but had several issues.
① Considered impairment to be “abnormal,” a “negative” state.
② Ignored environmental factors, and tended to reduce certain factors into individual issues.
③ Considered the three factors to be part of a cycle when they should be considered
independent factors.

3) Long-Term Care Issues in Aging/Aged Society (History)◇1. Elderly Who Have Lived in Communities〇 In villages and hamlets, elderly people enjoyed certain roles in their communities, taking careof their grandchildren and overseeing village rituals (communication of tradition).
〇 As a very small minority of the population, whose who lived long were well taken care of.
〇 Limits in food production meant there were limits to the population of these villages andhamlets. Once the population went over the limit, the elderly were made to disappear
through “ubasute” (the practice of carrying elderly or infirm members of the family to aremote, desolate place and leaving them to die).
〇 This was not a society where people who were disabled or sick could survive. (No such thing
as long-term care.)◇2. People Who Did Not Plan to Become “Elderly”〇 Of those from older generations, there are people who planned to simply work and live
without much planning, and die somewhere along the way. They did not expect to be able tolive this long, or for society to house so many elderly people that it would be considered an“aged society.”〇 It is difficult to provide long-term care for those who did not plan to live this long.
☆ Providing care for people who have completed all of their end-of-life procedures, and who are
waiting for (and anticipating) the end.

◇3. Why Did Long-Term Care (Work) Become Necessary?

〇 There became a public need for long-term care due to the increase of elderly people living on
their own and due to limits on the familial provision of long-term care.

― 67 ―

3. BASIC PRINCIPLES OF
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3-1.Basic principles of long-term care

◇4. Demand for the Socialization of “Long-Term Care”: Elderly
Healthcare and Issues of Long-Term Care

〇 There were a variety of issues in particular for families providing long-term care to elderly
people with dementia or some kind of impairment. Disuse syndrome and bedsores werecommon, and there were even cases of long-term-care-related murders by family members.
〇 The urbanization of society had given rise to a population of elderly people who were alone,
living in poverty, and unable to engage in ADL, and it became difficult for communities tohandle these individuals on their own.
〇 The increase in the number of the elderly led to an increase in terminal care expenses, andthere arose the need to separate a portion of elderly health care policies from general healthinsurance policies, to reduce the national burden caused by these costs.

◇5. People Who Enter the “Elderly Stage” of Their Life with
Knowledge, But Without Preparation〇 There is a need now to plan one’s life on the assumption that we will live to be 100 (perhaps
even 120 in the future).
〇 There are 3 issues expected: ① Daily life expenses, ② Health (long-term care) issues, ③Sense of purpose (meaning).
* “Caregiving” provides support mainly for ③ and part of ②
〇 Long-term care in its current state (long-term care that provides, in both the common/basic
fields) may not be fit for the people in the baby boomer generation, with their strong
tendencies towards self-sufficiency. There is a need for more professional, universal long-term
care.

4) Long-Term Care Issues in Aged Societies/Super-Aging Societies
How Do We Handle Long-Term Care, Robots and AI in the Mid-21st
Century?
◇1. Long-Term Care, a Universal Requirement for Human
Beings/Society〇 There is a need for long-term care that helps support self-sufficiency and the activities ofclients, and which is based on a framework of scientific theory based in empiricism. (Canwithstand changing times.)〇 It is also important to establish and define the professional nature of long-term carework—work that will be necessary all throughout history. (Needs leveling up.)
〇 It is important to engage in research and development to figure out long-term care needs
and skills as seen from the perspective of the users (clients).

◇2. Long-Term Care That Can Hold Its Own Internationally〇 If the need for long-term care is universal for all humans, irrespective of national borders andculture, then it is also an international need, in which case there must be a shared,
international framework for long-term care in general.
〇 This cannot be limited to us asking foreign personnel to assist us in long-term care in Japan.
We must work to contribute to long-term care in their countries as well, particularly if theirsocieties too are aging rapidly.

― 68 ―

3. BASIC PRINCIPLES OF
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3-1.Basic principles of long-term care

◇3. The First Half of the 21st Century, in the Midst of the 4th (5th)Industrial Revolution〇 The 4th industrial revolution (changes in communication tools, ICT, etc.) and the 5th industrial
revolution (changes in life sciences, etc.) are very likely to cause significant changes to ourdaily lives and social systems. (Common/basic field long-term care will most likely be
conducted by robots.)〇 With these industrial changes will come great changes to long-term care technologies. The
incorporation of robots in the three major long-term care task categories (bathroom, bathing
and mealtime) is currently limited only by time and money, and there have already beentechnologies developed that will come into actual practice. (Estimates say that by 2035, there
will be robots and houses capable of supporting the elderly and people with disabilities,
without the help of long-term care workers. [Source: “Tokyo no Mirai wa Donaru” (‘What is
the Future of Tokyo?’) (pg. 21), Nikkei BP Intelligence Group Report])〇 There is currently an urgent need for research on this kind of long-term care equipment. A
large-scale reform of the long-term care system is also expected. We are approaching the limit
of long-term care provided by humans, due to care workers quitting their jobs and causing aloss to society in general.
〇 Clients (users) are expected to live until 120 years old. People will require support to help
plan and realize a 120-year life (human relationships, academics, income, sense of purpose,etc.). The longer these individuals can contribute to society, the more society can reduce its
long-term care costs.
〇 Long-term care workers will have to help create these life plans, though it may be difficult,taking into account the maximum life expectancy of people in current and future society.

5) Long-Term Care (Insurance) Policies in Japan vs. Policies for the
Support of the Disabled/Elderly in the West and East Asia
◇1. Public Long-Term Care System as Part of a System that Ensures
Fundamental Human Rights〇 Operates on the basis of ensuring economic security〇 Ensures physical security, physical/psychological activity, social security, and maintenance oflifestyle (environmental factor = factors outside of the individual’s control)◇2. System of “Public Long-Term Care Insurance”〇 “Insurance,” “payment (allowance),” “assistance” policies〇 “Public long-term care insurance” and “private long-term care insurance”◇3. Policies for the Support of the Disabled/Elderly in the West
〇 Differing circumstances depending on country: Service systems (content), payment
standards, etc.

◇4. Policies for the Support of the Disabled/Elderly in East Asia

〇 How to engage in policy-making, using Japan as a precedent? Issues for 5 years, 10 years into
the future.

― 69 ―

3. BASIC PRINCIPLES OF
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3-1.Basic principles of long-term care

<reference>①“kokusaiseikatukinoubunrui-kokusaishougaibunruikaiteiban-”（nihongoban）
http://www.mhlw.go.jp/houdou/2002/08/h0805-1.html②Ookawa Yayoi cho“｢yokusurukaigo｣wozissensurutamenoICFnorikaitokatuyou”
chuuouhouki③Kawatei Motoyuki hencho“kaigokyouikuhouhouron”
koubundou④Ookawa Yayoi cho“seikatukinoutohananika-ICF:kokusaiseikatukinoubunruinorikaitokatuyou-”oukyoudaigakushuppan⑤Kurosawa Sadao hencho“ICF wotoriiretakaigokateinotenkai”
kenpakusha― 70 ―

3. BASIC PRINCIPLES OF
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3-2.Rights of the elderly/Maintaining their dignity/Support ofself-sufficiency

Learning Objectives and Target Achievements◇1. What kind of “value” do the elderly/disabled have?
Be able to provide your own answer to this question. There is no correct
answer.
◇ 2. What kind of support do we have to give in order to help the elderly/disabled
realize their inherent “value”? Be able to provide your own answer to thisquestion.
◇3. Be able to explain how these ways of thinking and support methods areconnected to legal systems related to human rights.
◇4. Be able to conduct measures to prevent the abuse of disadvantaged people,
including the elderly/disabled, by long-term care staff members.

<Things to Remember/Points of Issue>〇 Despite the significant efforts by many people involved in long-term care, there is no end tocases of client (user) abuse in the long-term care workplace. Abusing clients that are paying fortheir services would be unthinkable in any other industry. However, abuses of the“disadvantaged” (those who receive the service) by the “advantaged” (those who provide theservice) unfortunately remains fairly common in the long-term care workplace, as well as inother service institutions like welfare agencies, schools, and government offices.
〇 As an Advanced staff member, it is important for you to be aware of the “human value” ofthe disabled/elderly. With this knowledge, you must help other staff members advance client(user) self-fulfillment (realizing human rights), and take measures to prevent injustices likeabuse.
〇 In order to do so, there is a need to put standards in place for everyone to recognize the“human value” of the “disadvantaged” in the long-term care workplace. As you think about
taking these active measures, it is also necessary to make sure you understand why they arenecessary, including the legal reasoning behind them.
〇 Currently, the training of long-term care workers tends to focus on acquiring the skills
necessary for day-to-day work, with not as much focus on the human value of theelderly/disabled. With the lack of regard for the human value of long-term care staff members
also an issue, the reality is that it can be difficult to consider the value of the users (as clients) inaddition to it all. Learn the following with an understanding of this reality, as basic knowledge to
use when thinking of comprehensive measures.

― 71 ―

3. BASIC PRINCIPLES OF
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3-2.Rights of the elderly/Maintaining their dignity/Support ofself-sufficiency

1) Human Dignity/What is Independence?/Rights of Disadvantaged
People◇1. Principles Related to Long-Term Care Services for the Elderly“United Nations Principles for Older Persons”: Towards a Society for All Ages
Independence/Participation/Care/Self-Fulfillment/Dignity (All five of these principles must
be implemented.)◇2. What is “Independence” for the Elderly?

・Reference: “United Nations Principles for Older Persons”
・Older persons should have access to adequate food, water, shelter, clothing and health carethrough the provision of income, family and community support and self-help
・Older persons should have the opportunity to work or to have access to otherincome-generating opportunities.
・Older persons should be able to participate in determining when and at what pace withdrawal
from the labour force takes place.
・Older persons should have access to appropriate educational and training programs.
・Older persons should be able to reside at home for as long as possible.
☆ Support for the elderly must help them establish what kind of life they wish to live, how best
to handle their current situation and set goals, figure out what is needed to accomplish thesetasks, and establish the necessary environments. (Long-term care takes on a central role in thisprocess.)◇3. What is “Participation” for the Elderly? (“UN Principles for Older Persons”)
・Older persons should remain integrated in society, participate actively in the formulation andimplementation of policies that directly affect their well-being and share their knowledge andskills with younger generations.
・Older persons should be able to seek and develop opportunities for service to the community
and to serve as volunteers in positions appropriate to their interests and capabilities.
・Older persons should be able to form movements or associations of older persons.

◇4. What is “Care” for the Elderly? (“UN Principles for Older Persons”)

・Older persons should benefit from family and community care and protection.
・Older persons should have access to health care to help them to maintain or regain the optimum
level of physical, mental and emotional well-being and to prevent or delay the onset of illness.
・Older persons should be able to utilize appropriate levels of institutional care providing
protection, rehabilitation and social and mental stimulation in a humane and secureenvironment.
・Older persons should have access to social and legal services to enhance their autonomy,
protection and care.
・Older persons should be able to enjoy human rights and fundamental freedoms when residing inany shelter, care or treatment facility, including full respect for their dignity, beliefs, needs andprivacy and for the right to make decisions about their care and the quality of their lives.

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3. BASIC PRINCIPLES OF
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3-2.Rights of the elderly/Maintaining their dignity/Support ofself-sufficiency◇5. What is “Self-Fulfillment” for the Elderly? (“UN Principles for Older

Persons”)
・Older persons should be able to pursue opportunities for the full development of theirpotential. (Maslow/self-actualization)・Older persons should have access to the educational, cultural, spiritual and recreational
resources of society.
◇6. What is “Dignity” for the Elderly? (“UN Principles for Older Persons”)
・Older persons should be able to live in dignity and security and be free of exploitation andphysical or mental abuse.
・Older persons should be treated fairly regardless of age, gender, racial or ethnic background,disability or other status, and be valued independently of their economic contribution.

◇7. Human Dignity/What is Independence?/Human Rights of
Disadvantaged People

・ “People who require long-term care” are, first and foremost, “human beings” before they are“long-term care users.”“Human being” = Someone who has had their very own life history, and who is trying to live ina way that is true to themselves.
“Human being” = Someone whose life will remain in their control, except in the case of special
circumstances.
・To give long-term care is to support the life activities of this “human being.”
To provide long-term care is to provide support. The care cannot be provided on the terms of
the provider.

2) Accepting Multi-culturalism/Multi-Dimensional Understandings of
Human Beings/Long-Term Care for Foreigners◇1. Multi-Dimensional Understanding of Human Beings〇 The same person can have different values and ways of thinking depending on various factors
like time, place, relationships, physical circumstances, life history, social standing, etc.
〇 Because the elderly will have lived longer life histories, individual differences in this age
group tend to be even more pronounced than in other age groups. (Ex: There are cases where
a 70-year old has aged more than a 90-year old.)〇 In the long-term care workplace, each of these people are considered individual humanbeings. You must not lump them together.
〇 You must understand the differences between each individual, gain insights from thesedifferences, and use them to come up with new ideas.

◇2. Accepting Multi-Culturalism/Diversity〇 You will find that individual differences in ways of thinking stem from various environmental
differences such as nationality/ethnicity, generation, gender, and region. These differences
should all be accepted.
◇3. Long-Term Care for Foreigners *Does not refer to long-term care byforeigners〇 Long-term care for people who have grown up in different cultures are becoming increasingly
necessary. Korean, Brazilian, etc.

― 73 ―

3. BASIC PRINCIPLES OF
LONG-TERM CARE

3-2.Rights of the elderly/Maintaining their dignity/Support ofself-sufficiency

3) Discussing the Human Rights of the Elderly (and Disabled)◇1. The Fundamental Question: How Do We Think of Human Rights(the Value Inherent in a Person)?

〇 Value to society: “Konokora wo yo no hikari ni (‘These people light up our society’)” (slogan
meant to convey the value of disabled people/children to Japanese society)〇 Value to the economy: “All people have the talent to contribute to society”〇 Value to friends and family: “Loved one—people you love (unconditionally)”〇 Value to long-term care workers: “Someone to learn from,” who has lived a life different fromthemselves (a “privilege” only long-term care workers get to experience)◇2. The Constitution of Japan, Chapter 3: Rights and Duties of thePeople〇 Right to life, liberty, and the pursuit of happiness (Article 13): All of the people shall be
respected as individuals. Their right to life, liberty, and the pursuit of happiness shall […] be thesupreme consideration in legislation and in other governmental affairs.
〇 Right to standard of living (Article 25): All people have the right to maintain the minimum
standards of wholesome and cultured living.
〇 Right to work (Article 27): All people shall have the right and the obligation to work.
〇 Right to education (Article 26): All people shall have the right to receive an equal education
correspondent to their ability, as provided by law.

◇3. International Covenants on Human Rights (international resolution
adopted in 1976)〇 The fundamental document on human rights, composed of two parts: the International
Covenant on Economic, Social and Cultural Rights, and the International Covenant on Civil andPolitical Rights.
◇4. Declaration on the Rights of Disabled Persons (1976 UN Resolution)〇 Declaration (no legal authority) on the rights of persons with disabilities, which reaffirms
their right to live free from discrimination and identifies areas where adaptations have to bemade (medicine, economic security, education, training, etc.).
〇 This declaration paved the way for further measures for people with disabilities, including
the International Year of Disabled Persons (1981), the International Classification of
Impairments, Disabilities and Handicaps (1980).

◇5. How to Realize Laws and Declarations〇 Duty of citizens, the duty of human care service professionals (Article 12): The freedoms andrights guaranteed to the people by this Constitution shall be maintained by the constantendeavor of the people.
〇 Long-term care staff members must be particularly aware of this duty, and make sure torespect the user’s “will to live” (right as a human being to pursue self-fulfillment).
〇 Special support must be given to those who have, for one reason or another, lost their "willto live.”― 74 ―

3. BASIC PRINCIPLES OF
LONG-TERM CARE

3-2.Rights of the elderly/Maintaining their dignity/Support ofself-sufficiency

4) How Should We Think of QOL? How Do We Improve It?
◇1. How Do We Improve QOL?

〇 QOL = “(A certain) quality of life (activities/ADL)”〇 Support must be given to help those in question realize the quality of life/activity they wish
to have, not just the bare minimum◇2. How Do We Implement Normalization?

〇 Eliminating "discrimination" refers to all kinds of discrimination, including discrimination on
the basis of gender, class, race, disability, sexual minorities, economic status. "Normalization,"
however, is particularly central to the elimination of discrimination based on disability. People
with disabilities have the same rights as those without disabilities.
〇 “Normalization” as a way of thinking also helped advance this movement from simply
emphasizing the equal rights of people with disabilities, to seeing their disabilities as a uniquecharacteristic that they could utilize in society, in the form of social activities, etc.

◇3. How Do We Implement Empowerment?

〇 A method/way of thinking to support and empower people who are at disadvantaged
positions in society.
〇 It requires information (learning), supporters (support system), and the awareness of thepeople in question as to their own rights.

◇4. How Do We Implement Informed Consent?

〇 A way of thinking/method centered on the respect of “human beings (human rights),”
conceived in the medical field as a reaction to human rights violations, like humanexperiments, that so severely violated the idea of the value inherent in each human being〇 As a method of respecting the wishes of those in question, it requires that medical
professionals provide information on various treatment methods, and allow the person
themselves to make the ultimate decision on their treatment.
〇 Even after this way of thinking was established on an international scale in the 1960s, there
were some (mainly doctors) who prioritized the decision-making of the doctor over that of theperson in question. In recent years, however, the proliferation of information on the Internet
has made it easier for anyone to access the information they need, and decision-making is
generally in the hands of the person themselves.

◇5. Concepts and Methods, Not as “Philosophy” But as “Challenges to
be Tackled”〇 "Philosophies” and “goals” are meaningless if they cannot actually be realized.
〇 In order to do this, you must gain knowledge of the methods and skills necessary to realizethem.
〇 Necessary methods and skills include a course of action (a step-by-step process thatorganizes everything you have to do), as well as the necessary resources (including tools), theskills to convey information (communication skills), and the skills to evaluate the content you areto convey.

― 75 ―

3. BASIC PRINCIPLES OF
LONG-TERM CARE

3-2.Rights of the elderly/Maintaining their dignity/Support ofself-sufficiency

5) The Causes of Elder Abuse and How to Handle Them
◇1. Awareness of “Human Rights” of People Who Require Long-Term Care. Way ofLife. Self-Understanding.
〇 An important factor in preventing elder abuse is whether the person who requires long-term carehas the will to live, and/or their own personal understanding of how they wish to live their life.
〇 There are more than a few people who have lived their whole life with no choice but to obey
others (or have been taught in this way), and who do not have the will to live in a way that feels true
to themselves〇 However, starting with the generations of people who received their human rights education
under the new 1945 constitution, people have increasingly lived lives that are their own. (Accordingly,
the way of thinking of people who require long-term care will change greatly in the future.)〇 We must remain particularly vigilant for people whose wills and wishes may be unclear, such as
people with severe dementia, as “unclear” does not point to a complete lack of will. <Advocacy, adultguardians, etc.>◇2. How Long-Term Care Workers Should Understand Users: Understanding Their
Value as Human Beings〇 Long-term care workers must maintain a way of thinking that sees people who require long-termcare (“clients”) as people with their own wishes and ways of thinking, that are equal to them. Not
having this sort of mindset increases the possibility of abuse.
〇 It is very important to remember this, as there is a natural tendency for those that are advantaged
to inadvertently manipulate the disadvantaged.

◇3. Self-Understanding of Long-Term Care Workers: How Do They Feel About
Providing Care?

〇 Providing long-term care is a valuable experience that allows you to learn a lot from the lives ofothers. The possibility of abuse increases, however, if the long-term care workers themselves do not
feel a sense of meaning or pride in what they do.
〇 There is a need for appropriate training/education so that long-term care workers are able tothink in these ways.

◇4. Is the Long-Term Care Environment Sufficient? Financial Issues, Issues with
Facility Equipment, etc.

〇 The possibility of abuse increases if the environment for long-term care is insufficient, andlong-term care workers are not able to maintain living environments conducive to their jobs, and/or
the appropriate care tools, as this forces them to work in difficult conditions (the proper financial
standard to maintain conditions).
〇 The possibility of abuse also increases if long-term care workers do not have enough time tospend on each user (people who require long-term care tend to need a lot of time to move), or if they
do not have the proper support in their work.

◇5. Abuse of the Elderly/Disabled Can, Except in Special Cases, Be Prevented〇 People live life in the midst of their relationships with others, and it is these relationships that are
the source of issues of “human rights” and “rights” in general. “Abuse,” the most severe violation ofhuman rights, also occurs through these relationships.
〇 We must establish various standards to prevent these relationships from turning abusive,
including managing the mentalities of both those who require care and those who give care.

― 76 ―

4. COMMUNITY-BASEDINTEGRATED CARESYSTEMS

4-1.Systems to facilitate comfortable community
lifestyles: Living assistance and care management
perspectives<The Role of Caregivers in Care Management>
1) Think of Their Lives as a Whole
Many people conceive of caregivers as professionals that provide support forthings like eating, going to the bathroom, and bathing. However, is this really all weare? Think of your own lives—our lives are made up of so many little activities like,for instance, making a phone call to a friend, impulse shopping, or placing a flower ina vase next to the front door. Our role as caregivers, as lifestyle support
professionals, is to think about how each individual has lived their lives so far, andhow we can help them to maintain these lifestyles.
It is important for caregivers, as workers supporting users’ daily lives, to assess
what is necessary for each individual to continue living the life they’ve had, and to
give the appropriate advice to workers of other disciplines.
2) Taking Note of Connections to Society
Our lives supported by the various connections we have to society. For instance,even people who stay at home all day will interact with others to eat. Furthermore,
the connections we have to society are not necessarily always with welfare-related
institutions, facilities, and organizations. In fact, most of our connections will beoutside of these categories.
Thus, to live is to need social resources outside of welfare-related institutions.
Using these resources in organic ways is what will allow us to continue living in theareas we are accustomed to.
3) Work Towards Using Wider Variety of Resources in Care Plans
Long-term care insurance systems dictate that care plan drafts (in-home serviceplan) are created by long-term care professionals. These care plans can be
integrated with informal resources/services, but are generally centered aroundlong-term care insurance services.
Furthermore, care professionals are discouraged from using services offeredexclusively by the same company that provides the in-home long-term care support.
However, this can be difficult to accomplish depending on regional circumstances.
Though in the future, increasing numbers of people will come into the elderly age
bracket, it is as of yet unclear whether the number of long-term care insurance
service providers will increase accordingly.
For this reason, it is important not to become overly reliant on long-term careinsurance services, and instead learn to make effective use of the various resources
available in each region.
Exercise (Group Work):
Discuss with your group examples of the use of societal resources.

― 77 ―

5. MULTI-DISCIPLINARY
COOPERATION

5-1.Actively appealing to and cooperating with staff

members of different disciplines

Learning Objectives and Target Achievements“Key Learning Points”: Goals and Summary◇1. The role of long-term care workers and policies for informationtransmission◇2. Handling of personal information that comes with coordinating withfamilies“Target Achievements”● With this knowledge, be able to maintain an awareness of one’s leading role inthe cooperation required to provide effective service, and actually be able totake on this role.

* Fill in the blanks with the correct terms as you move through thissection.

1) The Role of Long-Term Care Workers and Policies for Information Transmission.
(1) Verify the role of a long-term care worker.

Think of your role as being a professional of long-term care—a “caregiver.”
Caregivers provide support for people whose ability to live their daily lives isimpaired in some way, as well as their families and those who care for them, sothat they may live in a way that is ①______________________.
The role of a caregiver is broad, encompassing all matters of a person’s daily life
in order to guide them to self-sufficiency.
☝₁ Fill in blank ① with the correct term(s).

(2) Transmission Methods and Skills
Can long-term care workers on their own provide the appropriate level of care
to people whose ability to live their daily lives is impaired, as well as theirfamilies, and provide support for their entire lifestyle? 𑠀
There is a need to cooperate with those of related disciplines.
In doing so, we must ② _____________ the ③____________ information.
☝₂

Fill in blank ② and ③ with the correct term(s).

― 78 ―

5. MULTI-DISCIPLINARY
COOPERATION

5-1.Actively appealing to and cooperating with staff

members of different disciplines(3) Proper Method of Communicating Each Type of Information
What kind of communication methods are available to use in our lives? Discuss
the characteristics of each of the communication methods and fill in the following
chart.
MethodCharacteristics

Meeting In Person
FAX
Email
Phone
Video Call
Letters* Group Work

伝達する相手に分かってもらうためには表現を工夫する必要があります。
(4)
Creating Environments Conducive to Care
画像を入れ過ぎる。電子メールにサイズの大きな貼付ファイルを付けるとThe
Ministry of Health, Labour and Welfare is encouraging the implementation
受け手の負担になります。
of “community-based integrated care systems,” in a shift towards“region-contained” systems wherein communities work as a whole to provide
support for long-term care in their region. “Information sharing” amongst
various disciplines is very important in this kind of system, along with the quick
and effective provision of medical/long-term care services. The use of ICT(information and communication technology) has been made possible throughthe establishment of Internet networks throughout the country.
“Policy Direction for Future ICT Implementation in the Medical and Health Care Fields” (December2013), The Ministry of Health, Labour and Welfare
http://www.kantei.go.jp/jp/singi/it2/senmon_bunka/iryou/dai2/siryou3.pdf#search― 79 ―

5. MULTI-DISCIPLINARY
COOPERATION

5-1.Actively appealing to and cooperating with staff

members of different disciplines

Image of a Community-Based Integrated Care System
If you get sick…

If you require long-term care…

Medicine・Acute phase・Chronic phase
・Recovery phase

Long-Term Care
Outpatient/inpatient

medical care
Medicine in Daily Life・Primary care doctor/Medical
clinics with beds
・Partner hospitals in region
・Dental care/Pharmacies■ At-Home Services:

Outpatient/inpatient ・In-home long-term care/In-homelong-term care nursing care/Outpatient long-term care・Multifunctional long-term care in asmall group home・Short-term inpatient lifestyle care
・24-hour-system in-home care service
・Combination of services(Multifunctional long-term care in asmall group home + in-home nursing
care, etc.)

Residence・Community-based
integrated care center
・Care managers■ Long-Term Care Prevention Services
People with dementia

Provides consultative
assistance and coordinates
services.

・Home・Elderly-oriented residenceswith services
To live with joy for as long as possible…

Lifestyle support and long-term careprevention■ Facility/Residential
Services・Elderly long-term carewelfare facilities
・Elderly healthcare
long-term care facilities
・Community-based
long-term care for thosewith dementia
・Lifestyle care for special
long-term care users, etc.

* A “community” in a community-based
integrated care system constitutes an area(sphere of life) where the necessary services
can all be provided within 30 minutes (middle
school districts, in more concrete terms)

Senior clubs, residents’ associations, volunteering, NPO, etc.

2) Handling of Personal Information that Comes with Coordinating with Families(1) The following efforts are necessary with respect to the handling of personal
information by long-term care workers and those of other disciplines.
Type of Effort
Example① Collection/use ofSpecify the purpose(s) of use, and use personal
personal
information only for those purposes.
information
Communicate or make public the purpose(s) of use.
② Storage ofStore personal information securely so as to prevent
personal
leaks, etc.
information
Ensure high standards of security by staff members
and contractors as well.
③ Provision ofGain prior approval of the people in question when
personal
providing their personal information to a third party.
information to a
Record certain kinds of information whenthird party
providing/receiving personal information to/from athird party.
④ Handling requests Handle the situation accordingly when a person asks
for the disclosurefor disclosure of their own personal information.
of stored personal Handle complaints, etc. swiftly and appropriately.
information― 80 ―

5. MULTI-DISCIPLINARY
COOPERATION

5-1.Actively appealing to and cooperating with staff

members of different disciplines(2) Ways of thinking with regards to the security of personal information come toshift with changes in ④________________ and the awareness of users, etc.
For this reason, those of disciplines related to long-term care must engage inappropriate handling of personal information, and make efforts towards
constant ⑤________________ and ⑥________________.
☝3

Fill in blanks ④-⑥ with the correct term(s).

“Q&A for the ‘Guidelines for the Appropriate Handling of Personal Information by Medical- andLong-Term Care-Related Businesses’ (Case Studies)” (May 30, 2017), Personal Information
Protection Commission Secretariat, The Ministry of Health, Labour and Welfare
http://www.mhlw.go.jp/file/06-Seisakujouhou-12600000Seisakutoukatsukan/0000166287.pdf#search― 81 ―

5. MULTI-DISCIPLINARY
COOPERATION

5-2.Basic knowledge required for cooperation

Learning Objectives and Target Achievements“Key Learning Points”: Goal and Summary◇ Understand the specialization and area of activity for each discipline“Achievement Targets”* With this knowledge, be able to maintain an awareness of one’s leading role inthe cooperation required to provide effective service, and actually be able totake on this role.
1) Specialization and Areas of Activity for Each Discipline(1) Let’s check out the roles and tasks of the specialists you will work with.

Nationally

Tasks/Roles

CertifiedLegally
Qualified
DoctorEngages in treatment and urges recovery; makes diagnoses andgives instructions accordingly; deathbed attendance as ahome-visit family doctor or home doctor; gives instructions as
to medicine, prescribes medicine; fills out the “⑦ _________”
portion of long-term care requirement authorization forms.

DentistWorks to prevent and treat cavities and periodontal disease;provides dental care as a visiting dentist; provides
consultations for eating and swallowing and provides
assistancePharmacist⑧1― 82 ―

5. MULTI-DISCIPLINARY
COOPERATION

5-2.Basic knowledge required for cooperation

Nurse

⑨

Registered
Dietitian⑩

Nutritionist

Provides nutritional advice and food management services,
generally for healthy individuals.

SocialProvides consultations and support for those who have trouble

Workerliving their daily lives, whether due to physical and/or mental
disability or circumstantial reasons; coordinating andcommunicating with healthcare professionals

Caregiver

Provides long-term care for individuals who have trouble living
their everyday lives, whether due to physical and/or mental
disability, according to their individual physical and emotional
need; provides long-term care advice with respect to theindividual’s overall lifestyle; supports efforts towards
self-sufficiency

PhysicalConducts rehabilitation, under the direction of a doctor, for

Therapist

individuals with physical disability or elderly individuals with
reduced physical functioning; provides support for the recovery
of athletic ability; works to prevent the need for long-term care2

― 83 ―

5. MULTI-DISCIPLINARY
COOPERATION

5-2.Basic knowledge required for cooperation

Occupational
Therapist

Works towards physical recovery and improvement of mental
state through activities like handicraft, craftwork, andhousework; works towards the recovery of social adaptability

SpeechTherapist

Provides training for individuals who have trouble with speaking,language, hearing, etc. and/or have dysphagia; runs thenecessary tests and gives advice; supports individuals’ return tosociety

CareCommunicates with various channels to provide appropriate

Manager

service, depending on the physical and emotional needs of eachlong-term care/support user, that aligns with the desires ofthese individuals☝4

Fill in “⑦__________” with the correct word.

☝5

Fill out the empty spaces for ⑧ - ⑩.

― 84 ―

5. MULTI-DISCIPLINARY
COOPERATION

5-3.Proper behavior for other professionals from the long-termcare standpoint

Learning Objectives and Target Achievements“Key Learning Points”: Goals and Summary◇ How to operate care conferences and the necessary skills◇ Communicating with those of various other disciplines from the long-termcare perspective“Target Achievements”● With this knowledge, be able to maintain an awareness of one’s leading role inthe cooperation required to provide effective service, and actually be able totake on this role.

1）How to Operate a Care Conference and the Necessary Skills（1) Understand the Care Conference☝6

What is a “care conference”?

⑪― 85 ―

5. MULTI-DISCIPLINARY
COOPERATION☝7

5-3.Proper behavior for other professionals from the long-termcare standpoint

What is a “service personnel meeting”?
⑫● Make sure you are able to explain the difference between care
conferences and service personnel meetings.

― 86 ―

5. MULTI-DISCIPLINARY
COOPERATION

5-3.Proper behavior for other professionals from the long-termcare standpoint(2) How to Operate a Care Conference and the Necessary Skills
Think about the process of operating a care conference for outpatient long-termcare, in-home long-term care, etc., and about what kind of skills would benecessary.
Processルグルー
プーCharacteristics

プワーク Preparation
Advance

Setting a Time
Beginning of Meeting
Attitude/Directionality
During Meeting
Organizing Discussion
Content
Clarifying Discussion
Content
End of Meeting2) Communicating with Those of Various Other Disciplines from the Perspectiveof Long-Term Care
(1) Case Study: “In-Home Terminal Care”
Case Study
Mr. T (93 years old; long-term care requirement category 4), who lives on his own,
is receiving outpatient long-term care (4 days/week), in-home long-term care (6days/week; morning and evening; support during meals, in the bathroom, etc.), andin-home nursing care (1 day/week) in his home, for which he is the owner. Due to a
cerebral infarction 20 years ago, he suffers from left hemiplegia and some cardiac
insufficiency, and uses a wheelchair. Having run his own company, he is financiallywell off. His niece, Ms. M (76 years old) is his only remaining family. Ms. M is a very
important person in Mr. T’s life, but has since 2 years ago shown signs of dementia,
which has started making it difficult for her to provide long-term care for Mr. T andmake financial decisions on his behalf. As a result, Mr. T has begun asking a lawyer
who worked with him in his company to manage his finances.
The lawyer, worried about Mr. T, whose advanced age has caused a decline in his
physical and emotional health, is strongly encouraging him to enter a private seniorhome. Mr. T, however, wishes strongly to remain at home, and has been discussing
his own long-term care and terminal care with Staff Member S at his outpatientlong-term care facility (day service), as well as Staff Member Y from his in-homelong-term care (home-help service), which he has used for the past 3 years.

― 87 ―

5. MULTI-DISCIPLINARY
COOPERATION

5-3.Proper behavior for other professionals from the long-termcare standpoint(2) Let’s look at this from each of the care worker’s perspectives, and think
about what they should communicate to staff members of different fields,
taking ① - ④ into account.
Staff Member S from the Outpatient Long-Term Care Facility (Day Service)① What kind of other staff members you would expect to be involved, given
the information in the case study② What regional/societal resources could be used (people, things, programs)③ What kind of information and analyses (ICF, PDCA, Maslow) would beneeded to gain their understanding and cooperation④ How to communicate Mr. T’s main complaints

Staff Member Y, Who Conducts In-Home Long-Term Care (Home Help Service)① What kind of other staff members you would expect to be involved, given
the information in the case study② What regional/societal resources could be used (people, things, programs)③ What kind of information and analyses (ICF, PDCA, Maslow) would beneeded to gain their understanding and cooperation④ How to communicate Mr. T’s main complaints― 88 ―

5. MULTI-DISCIPLINARY
COOPERATION

5-3.Proper behavior for other professionals from the long-termcare standpoint● To allow Mr. T to fulfill his wish: living his life in a way where hefeels like himself.
● Speak on users’ behalf as a long-term care professional.
● Communicate with those of other fields as the professional
closest to the users.
● Propose long-term care/support that is based in evidence.
● Maintain transparency and be ready to explain anything.

☝Make sure long-term care staff members understand these points.

― 89 ―

6.ASSISTIVE SKILLS

6-1.Principles of evidence-based long-term care, and theimplementation of long-term care in support of self-sufficiency

Learning Objectives and Target Achievements● Be able to educate long-term care staff as to the importance ofevidence-based long-term care and its principles.
● Be able to explain to users, their families, and others why a certain
long-term care method was chosen, and be able to back it up withevidence.
● Be able to share with others in the workplace the importance oflong-term care that supports self-sufficiency, and educate them as toits methods.

1. Evidence-Based Care (EBC)
Recently, the idea of “scientifically-supported long-term care” is seeing morewidespread recognition. But first, what exactly constitutes evidence-based care
(EBC)? Discuss what you think in your groups.

― 90 ―

6.ASSISTIVE SKILLS

6-1.Principles of evidence-based long-term care, and theimplementation of long-term care in support of self-sufficiency(Exercise)
Think about the following situations and fill out the chart with the actual long-termcare methods you use for a specific user, why it is necessary for you to use thesemethods, and the decision-making reasoning (evidence) behind it. (Each category
can be about a different user.)
Situation

MethodWaking the userup
Communication

Transfer support

Bathroom
supportBathing support

Recreation

Oral/swallowing
exercises
Recordingfood/water
intakeParticipating in
events― 91 ―

Evidence

6.ASSISTIVE SKILLS

6-1.Principles of evidence-based long-term care, and theimplementation of long-term care in support of self-sufficiency

What kind of things did you come up with?
Long-term care is not something that should be based only on feel, intuition, or
past experience. It is necessary to think about and be able to explain the evidence,or the reasoning, behind why this user needs this specific kind of long-term care,and why the care must be given in this specific way. It is not enough to talk to andsupport users just as part of the flow of your workday—you must be able to back up
your care with evidence.
But why? Think about the reasons why evidence-based long-term care isnecessary.
● The necessity of evidence-based long-term care

● How should you educate long-term care staff members as to the necessity ofevidence-based long-term care so that they understand its importance? Think aboutit.

― 92 ―

6.ASSISTIVE SKILLS

6-1.Principles of evidence-based long-term care, and theimplementation of long-term care in support of self-sufficiency

Evidence-based long-term care is necessary for a wide variety of reasons—to
alleviate the issue of long-term care fees, the shortage of long-term care workers,
the burden on these workers, etc. With regards to actually providing long-termcare, however, the following are the main reasons.
1) To be able to provide consistent, objective long-term care as a facility
regardless of the specific long-term care worker in charge, in order to solve
user issues and improve their QOL.
2) To be able to provide, as a professional, objective observations to medical
professionals involved in the process through multi-disciplinary cooperation,and share with them common goals.
3) Evidence-based care can be verified (what actual effects did this long-termcare method have on the user?), and long-term care methods verified in thismanner can later be applied not only to this individual, but to others as well(data accumulation).
4) Case studies, though also important with regards to the long-term care
workplace, work only to show, “we did this, and then that happened” In thespecific situation. It is unclear whether using this same long-term care method
in other cases would have the same effect. In that sense, evidence-based
long-term care is also necessary in refining the professional skills of long-termcare workers.
5) As professionals, long-term care workers have a responsibility to explain tousers, their families, and other related institutions why certain long-term caremethods are being used. Muddling through is unacceptable—you must be able
to give evidence to back up these explanations.
6) When educating long-term care staff members, it will also be difficult forthem to understand why they are doing what they are doing without evidence
to back up your explanations. They will have a harder time thinking andbehaving for themselves, as they have only been taught to complete tasks andare not aware of the meaning behind these tasks.
7) When long-term care personnel are under training, it is important that they
be able to measure concrete results: “I used this evidence-based type of careand the user’s life changed in these specific ways.” This helps build up theirsense of accomplishment and joy, making them feel their job is moremeaningful and allowing them to grow as long-term care workers.

― 93 ―

6.ASSISTIVE SKILLS

6-1.Principles of evidence-based long-term care, and theimplementation of long-term care in support of self-sufficiency

2. The Science of Long-Term Care
It is difficult, if not impossible, to explain all of the work of long-term care work inscientific terms.
However, the more we are able to measure the effects of evidence-based
long-term care and accumulate verified data, the more we will be able to apply
these methods to the other users in general. This will also lead to advancement in
the field of long-term care studies.
In the long-term care of the future, it is important that you do not rely on
intuition and experience, and instead seek out the science that backs up your work.
Any discoveries as to the science behind long-term care work accumulate as
evidence, and allow long-term care workers in the future to choose and practicecare that is based in logic.

Currently, with regards to “Growth Strategy” (*), the government is discussing
efforts to focus on “scientific long-term care," implementing it in such ways as tosupport self-sufficiency and prevent worsening of existing ailments. Discussions arealso underway to evaluate the effectiveness of certain methods to support
self-sufficiency, in preparation for the next revision of long-term care fee policies in
FY2021.
The goal of this strategy is to make clear what kind of long-term care is needed to
improve self-sufficiency for which kinds of conditions, and build a database togather and analyze the necessary data to establish the evidence-based long-termcare that is scientifically proven to have beneficial effects.
The plan is to create care categorization algorithms, etc. for data collection by theend of this fiscal year, begin constructing the database in FY2018, run test
operations in FY2019, and begin official operation of the database in FY2020. The
government is also discussing incentives for self-sufficiency support, with regards to
its 2018 revision of long-term care fee policies.
(From the main text of “Growth Strategy 2017”)― 94 ―

6.ASSISTIVE SKILLS

6-1.Principles of evidence-based long-term care, and theimplementation of long-term care in support of self-sufficiency* What is “Growth Strategy”?

“Growth Strategy” is a strategic blueprint established by thegovernment towards to realize the dream of “Society 5.0” of solving avariety of social issues through the widespread incorporation of IoT, AI,
robots, the sharing economy, etc. across industries and social life. It is thefruit of ten “Growth Strategy Meetings” that were held from September
2016 to June 2017, and was approved by the cabinet on June 9, 2017.
The name of this blueprint, “Society 5.0,” comes from the idea that weare now in the 5th era of civilization, after the (1) hunter-gatherer, (2)agricultural, (3) industrial, and (4) information societies.

Clarifying the Evidence Behind Long-Term Care and Providing ScientificLong-Term Care
● The important elements are “evaluation” and the “long-term care process”
・Collecting precise yet multi-dimensional data
・Clarifying the issue
・Clarifying why support is necessary
・Deciding long-term care direction
・Establishing a long-term care plan for solving issues
・Making evaluations through the lens of ICF● “Explainable Long-Term Care”
・Why is this kind of long-term care necessary?
・Why are you using this specific method of long-term care?
・What results are expected from these kinds of care?

― 95 ―

6.ASSISTIVE SKILLS

6-1.Principles of evidence-based long-term care, and theimplementation of long-term care in support of self-sufficiency

As professionals, long-term care workers must be able to back up everything
they say and do, and provide meaningful service.
Advanced staff members in charge of educating others must be particularly awareof their responsibilities and should, additionally, study the legal foundation (laws,
regulations, and standards on long-term care insurance) that supports jobs at
long-term facilities and offices.

3. Long-Term Care for the Support of Self-Sufficiency
The goal of the Long-Term Care Insurance Act, as delineated in Article 1, is“self-sufficiency support.” And indeed, we as long-term care workers work hard
every day to provide long-term care that supports user self-sufficiency. But what
exactly does it mean to support self-sufficiency? Let’s look back on our experience inthe long-term care workplace and think about what it means.
Long-Term Care Insurance Act (Article 1, Paragraph 1)
The purposes of this Act are to improve health and medical care and to enhance
the welfare of citizens. With regard to people who are under condition of need forlong-term care due to disease, etc., as a result of physical or emotional changes
caused by aging, and who require care such as for bathing, bodily wasteelimination, meals, etc., and require the functional training, nursing, managementof medical treatment, and other medical care, these purposes are to beaccomplished by establishing a long-term care insurance system based on theprinciple of the cooperation of citizens, solidarity, and determining necessary
matters concerning related insurance benefits, etc., in order to provide benefits
pertaining to necessary health and medical services and public aid services so thatthese people are able to maintain dignity and an independent daily life routine
according to each person’s own level of abilities.

― 96 ―

6.ASSISTIVE SKILLS

6-1.Principles of evidence-based long-term care, and theimplementation of long-term care in support of self-sufficiency

What is “self-sufficiency” or “self-sufficiency support” as it applies to the elderly?
Think of concrete examples.
・Self-sufficiency is…

・Self-sufficiency support is…

Discuss your concrete examples with your group and separate them into
different categories of “self-sufficiency.”― 97 ―

6.ASSISTIVE SKILLS

6-1.Principles of evidence-based long-term care, and theimplementation of long-term care in support of self-sufficiency

What is Self-Sufficiency and Support of Self-Sufficiency?
By 2025, we will be in an era where the baby boomer generation will haveentered the latter-stage elderly age bracket, and the values of those requiringlong-term care will have diversified in the near future. As society undergoes
massive tectonic shifts, it is important in the user's self-efficiency to consider, in
addition to things like ADL (Activities of Daily Living) and IADL (Instrumental
Activities of Daily Living), the following five points as well.
・Changes in values
・Extension of average lifespan, with a maximum life expectancy of 120 years
・Reason to live, education, social contributions
・The rapidly changing nature of the 21st century
・Lifestyle, life design

Clarify What Self-Sufficiency Means for Each User, and The Goal(s) in
Supporting Their Self-Sufficiency“Self-sufficiency support” in long-term care means to support users’ abilities totake control of their daily lives and life in general by themselves. Instead of looking
at it solely from the perspective of long-term care workers, it is important to think
about what self-sufficiency means for that specific user, and tailor support for themaccording to this conceptualization.
For example, there may be female users who have been housewives for many years
and who previously felt as if their roles in their households gave their life meaning. If
these users were able to improve their ability to engage in household chores andreclaim some of that role in the household, their range of activity would expand, andthey could become more self-sufficient. On the other hand, male users who havedevoted their life to earn a living for their family may be energized and driven to work if
the facility rewards them for some of the work they do in the facility, leading them toimprove physical and mental self-sufficiency.

It is important to view each user’s situation from the ICF perspective, draw out
their latent abilities, and work with them towards self-sufficiency if we are to
realize their dreams of making their current lives better, making themselves usefulto others, and living true to themselves― 98 ―

6.ASSISTIVE SKILLS

6-1.Principles of evidence-based long-term care, and theimplementation of long-term care in support of self-sufficiency

For Long-Term Care with Self-Sufficiency Support
1. Maintain an awareness of the need for “self-sufficiency support” in thefacility/office as a whole.
Though it seems as if companies are aware of the need for self-sufficiency support,
the way each staff member think about it is actually different.

2. Conduct regular training programs to educate workers on the practicalities ofself-sufficiency support.
use.

Train them with specific guidelines as to what theories and methods they should

3. Engage in these efforts with multi-disciplinary cooperation.
Share these ways of thinking across disciplines, implement the measures together,and share information about their effects as well.

4. Maintaining the motivation of staff members is also important for providing
continuous self-sufficiency support.
In order to advance efforts for self-sufficiency support, it is important for
facilities/offices as a whole to maintain an awareness of its importance, and work toheighten the motivations of the staff members.
In long-term care environments, however, long-term care workers areoccasionally met with users' heartless words and selfish attitudes. As these kinds ofsituations continue, these workers may find it difficult to remain empathetic to theusers, think for the users, or maintain the motivation to provide patient andconsiderate care.
In these kinds of circumstances, what kind of guidance/advice could you givethese workers to heighten their motivation as a leader? Discuss in groups.

How would you solve their troubles?

― 99 ―

6.ASSISTIVE SKILLS

6-1.Principles of evidence-based long-term care, and theimplementation of long-term care in support of self-sufficiency

4. Self-Sufficiency Assessment
What kind of assessments are necessary to support user self-sufficiency?
If our goal is to realize self-sufficiency as it applies to each specific user, we haveto do more than assess them by the same standards. We must take into accountthe following as well.
○ The kinds of criteria required to assess the self-sufficiency support○ The details of the criteria○ Assessment levels:
・Beginner (novices, volunteers, etc.)
・Qualified (new staff members, etc. who are able to maintain a certain levelof work)・Independent (staff members who can work completely independently)
・Advanced (able to handle special cases, circumstances, etc.)<Standard Assessment Criteria>① Health condition, ② ADL, ③ IADL, ④ Cognitive ability, ⑤ Communication
skills, ⑥ Societal involvement, ⑦ Urination/defecation ability, ⑧ Bedsores, skinissues, ⑨ Oral hygiene, ⑩ Meal intake, ⑪ Problematic behavior (behavioral
disorders), ⑫ Long-term care ability of workers, ⑬ Living environment, ⑭Special circumstances― 100 ―

6-1.Principles of evidence-based long-term care, and theimplementation of long-term care in support of self-sufficiency

6.ASSISTIVE SKILLS

Think of one user you are currently in charge of and fill out this chart with whatkinds of assessments you believe are necessary for what kinds of criteria, in order toprovide the user with the self-sufficiency support. Imagine also that you are training
other staff members as to these assessments, and think of level-adjusted criteria forthese assessments.
Assessment

Explanation

Level 1

Level 2

Level 3

Level 4

Criteria

of Criteria

Beginner

QualifiedIndependent

Advanced― 101 ―

6-1.Principles of evidence-based long-term care, and theimplementation of long-term care in support of self-sufficiency

6.ASSISTIVE SKILLS

Important Perspective with Regards to Assessments
It is important in self-sufficiency assessments to clarify “current actions,” “possible
actions,” and “future actions” from the ICF perspective, and evaluate accordingly. If theevaluations are arbitrary, it becomes impossible to decide at which level a user has
achieved self-sufficiency, and the user will have a hard time maintaining motivation
towards becoming self-sufficient.
→ “Current Actions”

Actions they perform in daily life

Abilities upon evaluation/practice→“Possible Actions”

Actions they wish to perform→“Future Actions”

Goal(Example)

Criteria

Goal

Actions They Perform

Abilities Upon

(Future Actions)in Daily Life

Evaluation/Practice(Current Actions)(Possible Actions)

StatusStatusStatusNecessary
Tools

OutdoorMovement

Supervision

Necessary
Tools

Ankle footPartialorthosis,

assistance orthosis,

T-caneAnkle footwalkingcane― 102 ―

Necessary
Tools

VerbalAnkle footguidanceorthosis,
T-cane6-1.Principles of evidence-based long-term care, and theimplementation of long-term care in support of self-sufficiency

6.ASSISTIVE SKILLS

Uncovering and Handling the Reasons Behind Daily Life Impairments
If users are unable to engage in their goal actions (movements) towards
self-sufficiency, it is necessary to uncover the reason they cannot engage in theseactions, and incorporate this into further discussion about their long-term caredirection.
Clarifying the Issue(What exactly can they do, and what can’t they do?)）Uncovering the Reason(s)(What are the multi-dimensional/scientific reasons they cannot engage in their goal action?)

Predicting the Future(How do we prevent possible issues in the future?)

Long-Term Care Direction(Why do they need long-term care? What kind of method(s) would be best?)

One day, a user that has been using a cane to walk suddenly stops walking on his
own. What kind of reason do you think could be behind such a daily life
impairment? Think from multi-dimensional perspectives about the possible reasonsand how you would handle them.
ReasonLong-Term Care Direction

①
②
③
④
⑤
⑥
⑦

― 103 ―

6.ASSISTIVE SKILLS

6-1.Principles of evidence-based long-term care, and theimplementation of long-term care in support of self-sufficiency

5. Principles of Long-Term Care Planning
Before delving into the specifics of creating a long-term care plan (individual
support plan), let’s first learn about the relationship between these care plans
and the long-term care process.
Long-term care plans are not created independent of other elements. Caremanagers create a care plan, which the long-term care worker puts into action
through the long-term care process, and the long-term care plan must be createdon the basis of clear evidence.
Relationship Between Care Plans and the Long-Term Care Process
Care Management Process

Long-Term Care Process

IntakeAssessment
Care Plan Creation

Long-term care staff members implement thecare plan through the long-term process.

Care Plan Implementation
Assessment
・Collecting data
・Understanding user needs andclarifying issues

Long-Term Care Plan Creation
・Setting an overall support direction
・Setting goals and a timeline
・Choosing support methods

MonitoringｃRe-assessment

End

Long-Term Care Plan Implementation
・Revise the care plan as necessary
according to changes in the user’s situation or
circumstance.

Evaluation of Long-Term Care Process(Re-assessment)― 104 ―

6.ASSISTIVE SKILLS

6-1.Principles of evidence-based long-term care, and theimplementation of long-term care in support of self-sufficiency

Care plans, created by care managers, are comprehensive support plans made to
fit the various needs of a user in their daily life, and which utilize a variety of social
resources. Based on these care plans, long-term care plans are support plans
wherein service providers approach the user’s daily life issues through theprofessional long-term care perspective, set goals, and establish action levels
towards these goals. As such, long-term care plans must be created on the basis ofcare plans.
Additionally, long-term care plans are just one step in the long-term care
process, and must be coordinated with what comes before and after it in order tomake sense in the grand scheme of a user’s care.
In order to create a long-term care plan that supports user self-sufficiency, it isnecessary to collect data appropriately at the assessment stage, the first step in thelong-term care process.

The necessary information is not limited to information about ADL and IADL. It is
important to gather information (both objective and subjective) from the following
channels as well, and gain an understanding of the issues of every user.
・Long-Term Care Requirement Grade・Life history (including occupation)
・Level of self-sufficiency in daily life for disabled elderly・Level of self-sufficiency in daily life for elderly with dementia
・Values, beliefs, religion
・Medical history
・Current diseases/illnesses
・Medications
・User’s wishes
・Family’s wishes
・Level of impairment (physical, intellectual, mental)
・Family structure
・ADL
・IADL
・Financial status
・Other special circumstance, etc.
* Information should be collected from the ICF perspective, as it allows you to gain
a comprehensive and holistic understanding of the user’s lifestyle.

― 105 ―

6.ASSISTIVE SKILLS

6-1.Principles of evidence-based long-term care, and theimplementation of long-term care in support of self-sufficiency

The Purpose of Creating a Long-Term Care Plan
For users, the plan is…

Who is the plan for?
What is going to accomplish?

With regards to multi-disciplinary cooperation, the plan is…

Implementing the plan will lead to…

As a result…

Realize an independent life for the user
(self-sufficiency support)― 106 ―

6.ASSISTIVE SKILLS

6-1.Principles of evidence-based long-term care, and theimplementation of long-term care in support of self-sufficiency

There is an infinite variety of user wishes and issues.
If the goal is just “be able to walk,” it may be difficult for them to remain
motivated in their daily lives, or feel like their lives are meaningful.
・I want to be able to walk again so I can sing again at a karaoke bar.
・I want to be able to walk again so I can watch a movie in a movie theater.
・I want to be able to walk again so I can visit Kyoto, where I have so many
memories.
・I want to be able to walk again so I can go see my brothers and sisters.

We as people have all kinds of these wishes and desires.
Each individual user has a different life history, and no matter how old they are orwhat kind of situation they are in, they have hopes and wishes that cannot be put
into words. Long-term care plans exist to support these users’ self-sufficiency so thatthey are able to fulfill these hopes and wishes.

What to Consider When Creating a Long-Term Care Plan
(1) The plan is realistic/possible

・Integration of user wishes and user abilities
・The care environment (number of staff members, time constraints, etc.)
・Financial resources, materials, tools, etc.

(2) The plan will give the user a sense of accomplishment

・A goal that is an accumulation of smaller goals
・Observable; set specific numbers, actions, etc. for evaluation purposes
・Make the user the subject, and express the goal in language like “I will ____,” “I cando _____.”(3) The plan will be something you will work on with the user towards
self-sufficiency(4) The plan maintains continuity from the assessment(5) Convey information in 5W1H fashion so it is understandable to all(6) The plan relates to the content of the care plan, and involves
multi-disciplinary cooperation(7) The plan can be backed up with evidence from the ICF perspective― 107 ―

6.ASSISTIVE SKILLS

6-1.Principles of evidence-based long-term care, and theimplementation of long-term care in support of self-sufficiency(Exercise)
Think of one specific user, and create a long-term care plan in support ofself-sufficiency.
User Name (Pseudonym)
Overall Support Direction

Long-Term Goals/Timeline

Short-Term Goals/Timeline

Support Methods
・Why
・What
・How
・When
・Where・Who

Other Things to Consider― 108 ―

6.ASSISTIVE SKILLS

6-1.Principles of evidence-based long-term care, and theimplementation of long-term care in support of self-sufficiency

Long-term care workplaces are obligated by law to create various records anddocuments, and it is true that you may have little time to devote to creating
long-term care plans. Make sure to remember on a daily basis, however, themeaning behind this process and what makes it so important, and take joy increating these long-term care plans.
Also remember that a user achieving his goal brings happiness not only to the user
him-/herself, but will help feel staff members feel motivated as well, as they arereminded as to the meaning in their work. And when educating long-term care staff
members, be sure to frame this not just as a step in the process, but as the very
meaningful task that it is.
Long-term care plans are created, with the cooperation with theusers themselves, so that the long-term care team can work towards
the same goals and maintain consistent care in order to solve user
issues and realize user wishes.

“Long-term care plans will change users’ lives.”― 109 ―

6. ASSISTIVE SKILLS

6-2.Basic knowledge on anatomical physiology, pathophysiology,
symptoms, illnesses, etc. necessary in long-term care

Learning Objectives and Target Achievements● Key Learning Points
Understand the principles on how to notice changes in symptoms
and illnesses.
● Target Achievements
Be able to educate others as to support methods for people with
illnesses and disabilities.

① Awareness of Illnesses/Symptoms, and Observation Principles
Main Points when Observing an Elderly Person’s Health Condition:
1) Do they have a fever?
2) Do they have energy?
3) Do they have an appetite?
4) Are they sleeping well?
5) Differences from their regular condition, etc.
Differences from their regular condition can be discerned through day-to-day
communication with the user as well as long-term care records. However, in order
for long-term care staff members to coordinate amongst each other, it is necessary
for them to know how exactly their condition differs from usual, and share thisinformation with the others.

― 110 ―

6. ASSISTIVE SKILLS

6-2.Basic knowledge on anatomical physiology, pathophysiology,
symptoms, illnesses, etc. necessary in long-term care

① Awareness of Illnesses/Symptoms, and Observation Principles<Case Study 1> Private Senior Home
Long-term care staff member Ms. A (1 year of experience) visits user Ms. B(history of heart failure) in her room. She usually finds her around this time readingin her chair, but today she finds her lying down in bed. When she looks closer, shefinds that she has sweat on her forehead and that there are signs of cyanosis on herarms and legs. When Ms. A asks Ms. B how she feels, she nods and says, “I’m okay.”
Ms. A goes immediately to the medical office and tells nurse Mr. C, “there’s
something wrong with Ms. B. Come immediately." Mr. C, however, is in the middle oftreating another user’s bedsores, and cannot go with her. He asks her for moredetails on Ms. B’s condition to see if there is anything that Ms. A can do, but Ms. A is
only able to tell him that Ms. B seemed “different from usual,” without any specifics.
After completing treatment of the bedsores, Mr. C hurries to Ms. B’s room, checks
her condition, folds up the bed, and uses the table and cushion to move her to asitting position.
Afterwards, nurse Mr. C comes up to you, an Advanced long-term care worker,
and tells you many times to educate the staff properly so they can provide adequate
reports.
How should you educate long-term care staff member Ms. A?
Using your knowledge on the symptoms of heart failure, consider which parts ofthe body needed observation, and the information that Ms. A should have given to
the nurse.

― 111 ―

6. ASSISTIVE SKILLS

6-2.Basic knowledge on anatomical physiology, pathophysiology,
symptoms, illnesses, etc. necessary in long-term care

② Reporting to and Cooperating with Other Disciplines<Case Study 2> Intensive Care Home for the Elderly
Mr. A (82 years old; orthostatic hypotension) has been walking on his own in his
daily life. On November 2, after dinner, his knees falter and give way suddenly when
he tries to stand up from his chair to return to his room, and he falls.
He is taken by ambulance to a partner hospital, where it is revealed he has
suffered a right femoral neck fracture, and must be hospitalized. A week later, he
undergoes surgery for an artificial femoral head.
PelvisFemoral Head

Femur
(Thigh Bone)His recovery after the surgery goes well, and he is able to leave the hospital on
December 5. He can walk on his own using a cane, but has been seen occasionallywalking without his cane.
What points do you, as an Advanced long-term care staff member, have to keep inmind in providing support for Mr. A? Also come up with ways to share information
with those of other disciplines (Ex: Using photographs or tablets, etc.).

― 112 ―

6. ASSISTIVE SKILLS

6-2.Basic knowledge on anatomical physiology, pathophysiology,
symptoms, illnesses, etc. necessary in long-term care

Surgery for Artificial Femoral Head Following Right Femoral Neck Fracture,
and Things to Be Aware of Post-Surgery
1) Preventing Dislocation
Have them avoid the following movements, as the treated joint may become
dislocated.
・Crossing their legs with the treated leg over the other.
・Using low chairs.
・Flexing the hip joints over a certain amount.
・Adducting the hip joints over a certain amount.
・Bending backwards using the hips.
2) Preventing Falls and Fractures
Watch to make sure they do not fall again.
・Make sure they use their cane properly. (Hold it with the hand on the
opposite side of the treated leg)・Maintain lower limb muscle strength through an appropriate level of
exercise.
3) Symptoms to Watch Out For
Contact medical staff immediately if you see the following symptoms.
・Reddening, inflammation, and/or swelling of the surgical scar.
・Breathing difficulties, chest pain.
4) Other・Reorganize their rooms to suit their new physical needs.
・Adjust the height of their beds.
・Reevaluate their bathing methods.

― 113 ―

6. ASSISTIVE SKILLS

6-2.Basic knowledge on anatomical physiology, pathophysiology,
symptoms, illnesses, etc. necessary in long-term care

<Case Study 2> Intensive-Care Home for the Elderly
Ms. B (81 years old) walks on her own in her daily life. She suffers from Type 2
diabetes, and a nurse gives her insulin shots three times a day before each meal. The
hospital has instructed her to eat healthier (limit calories), but because Ms. B also
suffers from Alzheimer’s Disease, she forgets that she received this instruction.
One day, during a family visit (once a week), long-term care staff member Mr. A
spots Ms. B’s husband giving her a bag of rice crackers (10 pieces; 600 calories intotal), her favorite food item. Mr. A, who is in charge of Ms. B, tells the husband to
avoid giving her food, but he doesn’t seem to take it very seriously, telling him, “it’sokay, because I’ve told her to eat only one per day.”
Mr. A has also noticed that Ms. B has begun eating other people’s leftover food.
Later, Mr. A comes up to you, an Advanced long-term care worker, to ask foradvice on how to handle this situation. Around the same time, a nurse also
approaches you and tells you to reevaluate the support methods for Ms. B, as her
HbA1C levels have gone over 8%.
Discuss what things you, as an Advanced long-term care worker, should be awareof when providing support for Ms. B. Also come up with ways to share the necessary

information with those of other disciplines.
* Take into account how Ms. B’s symptoms could worsen in the future if thissituation continues.

― 114 ―

6. ASSISTIVE SKILLS

6-2.Basic knowledge on anatomical physiology, pathophysiology,
symptoms, illnesses, etc. necessary in long-term care

<Case Study 3> Private Senior Home
Ms. C (91 years old) uses a wheelchair to move herself around in her daily life, due
to her lower back pain. Because she also suffers from chronic renal failure, sheundergoes artificial dialysis 3 times a week (Tue., Thurs., Sat.) at the hospital, and herwater intake (excluding meals) is limited to 600 ml per day.
During the day, she is often in the cafeteria and in other places where users
gather, engaged in conversation, as she says she feels depressed when cooped up in
her room. Though Ms. C understands the need to limit her water intake, she tends tocomplain when she sees other users drinking tea, saying, “I want to drink tea too,”and “I’m 91 years old, I don’t need to limit anything.”
What things should you, as an advanced long-term care worker, be aware of whenproviding support for Ms. C?
* Think not only of Ms. C’s renal failure, but the quality of her life as a whole.

<Case Study 4> Intensive-Care Home for the Elderly
Ms. D (75 years old) suffers from Parkinson’s Disease (Stage 4 on the Hoehn & Yahr
Scale) and requires support in all areas of her daily life. Ms. D herself would prefer
not to be a burden to anyone else, and has made it one of her goals to be able tochange clothes on her own.
What things should you, as an Advanced long-term care worker, be aware of whenproviding support for Ms. D in all aspects of her life, especially with regards to her
Parkinson’s Disease symptoms? Use care cards as reference in supporting herchanging clothes, and discuss with consideration for individual differences.

― 115 ―

6. ASSISTIVE SKILLS

6-3.Evidence-based assistive skills as related to ADL and IADL

Learning Objectives and Target Achievements● Be able to explain the basic principles of assistive skills.
● Be able to explain the evidence, or reasoning, behind why specificlong-term care methods were chosen.
● Be able to educate long-term care staff members as toevidence-based assistive skills.

In this training theme, we will discuss the basic principles of the assistive skills thatyou use in your daily work, and the reason why they must be used in certain ways.
Throughout this process, we will also ask you to imagine that you are in a position toeducate long-term care staff members in an actual workplace.
First, what is “body mechanics” as it relates to assistive skills in the long-term care
workplace? Describe what it is.

Body mechanics is…

― 116 ―

6. ASSISTIVE SKILLS

6-3.Evidence-based assistive skills as related to ADL and IADL

What are the 8 basic principles of body mechanics, and why are these principles
important? Give the evidence (effects) of each of these principles.
Basic Principles

Evidence (Effects)

1)
2)
3)
4)
5)
6)
7)
8)

Center ofGravity
Base ofSupport

StableUnstable― 117 ―

6. ASSISTIVE SKILLS

6-3.Evidence-based assistive skills as related to ADL and IADL

Next, think of specific users, and consider that you must provide them support
that involves ADL and IAD. Imagine that you are in a position to train other staff
members, and for each case think about (1) what kind of information would benecessary, (2) what kind of long-term care method you would use, and (3) why you
would use that long-term care method (evidence).
Change-of-Position and Sitting-Up Support<Case Study>
Ms. F (89 years old) requires long-term care because of weakness due
to old age. She has little strength in her lower limbs, and cannot draw
her knees up on her own. Because she lays in bed for long periods oftime, her position must be changed regularly. She also needs support tosit up in bed.
① Necessary Information② Long-Term Care Method(s)③ Evidence― 118 ―

6. ASSISTIVE SKILLS

6-3.Evidence-based assistive skills as related to ADL and IADL

Transfer Support<Case Study>
Mr. S (75 years old) is paralyzed on the left side of his body, and finds
it difficult to stand due to muscle weakness in his lower limbs. You must
transfer him from his position sitting at the edge of the bed to hiswheelchair, then take him to the cafeteria.
① Necessary Information② Long-Term Care Method(s)③ Evidence― 119 ―

6. ASSISTIVE SKILLS

6-3.Evidence-based assistive skills as related to ADL and IADL

Movement Support<Case Study>
Mr. K (80 years old) is paralyzed on the left side of his body due to a
cerebral infarction. He uses a T-cane to walk. Currently, his status isunstable and he requires support to walk. You must help him walk withhis cane to the front door of the facility, but he also needs support to go
down the stairs along the way.

① Necessary Information② Long-Term Care Method(s)③ Evidence― 120 ―

6. ASSISTIVE SKILLS

6-3.Evidence-based assistive skills as related to ADL and IADL

Meal Support<Case Study>
Ms. D (93 years old) suffers from Alzheimer’s Disease, spends hermornings with her head down on the table, and does not usually wakeup for meals when workers call out to her or shake her lightly by theshoulder. For this reason, it has become common for her to missbreakfast and/or lunch. What kind of support is necessary in order tohave such a user eat their meals?
① Necessary Information② Long-Term Care Method(s)③ Evidence― 121 ―

6. ASSISTIVE SKILLS

6-3.Evidence-based assistive skills as related to ADL and IADL

Bathroom Support<Case Study>
Mr. P (82 years old) finds it difficult to sit up, suffers from some urinary
incontinence, does not communicate his urge to go to the bathroom,
and wears a diaper. He is about to eat dinner, so you must go to his roomand change his diaper on the bed.
① Necessary Information② Long-Term Care Method(s)③ Evidence― 122 ―

6. ASSISTIVE SKILLS

6-3.Evidence-based assistive skills as related to ADL and IADL

Bathing and Hygiene Maintenance Support<Case Study>
Mr. O (72 years old) is paralyzed on the right side of his body. He is also
obese and suffers from diabetes and high blood pressure. He can standup and walk using hand railings. He loves to take baths and looks
forward to bathing in his house more than anything else. You must help
him take his bath.
① Necessary Information② Long-Term Care Method(s)③ Evidence― 123 ―

6. ASSISTIVE SKILLS

6-3.Evidence-based assistive skills as related to ADL and IADL

Organization of Living Environment
What kind of perspectives must you consider when you organize
users’ living environments to honor their lifestyle and values and allow
them to live safely and true to themselves? Think about the following
points.
① What kind of “actions” do users engage in in their “life locations” (facility orhome)?

② What are some concrete examples of organizing a living environment?

③ Why is organizing their living environments necessary?

― 124 ―

6. ASSISTIVE SKILLS

6-3.Evidence-based assistive skills as related to ADL and IADL

What kind of answers did you come up with for each category?
When using assistive skills, it is necessary first to collect the necessary
information. Having the necessary information clarifies the issues that users face intheir daily lives, and allow you to choose appropriate long-term care methods. It isalso necessary to be able to explain why you choose the methods with evidence.
When educating long-term care staff members, for instance, it would be
beneficial for you to explain the evidence behind the following elements oflong-term care.
Change-of-Position and Sitting-Up Support
・Why we have to provide explanations before engaging in any kind of support,
and why we need users’ approval.
・Why we have to draw up the users’ knees when we change their position on thebed.
・Why we cannot turn users on their side (so their side is perpendicular to thebed) when changing their position on the bed to prevent bedsores.
・If the user suffers from hemiplegia, why we cannot have the paralyzed side of auser’s body supporting their body on the bed.
・When guiding them into sitting on the edge of the bed, why it is necessary tobring their feet down towards the edge of the bed while helping them lift their
torso.
Transfer and Movement Support
・Why we ask users to sit close to the edge of the bed when we transfer them.
・What angle the wheelchair must be positioned relative to the bed whentransferring a user.
・The appropriate length of canes that are used to assist users in their walking.
・If the user suffers from hemiplegia, why we provide them support from behind
their paralyzed side.
・If the user suffers from hemiplegia, why we tell them to go up the stairs with
their mobile side first, and down the stairs with their paralyzed side first.
Meal Support
・Describe the basic posture for meals.
・Why the elderly in particular need to drink lots of water.
・Why we recommend users start with soups at the beginning of their meal.
・Why we wait to confirm that they have swallowed their previous bite, before
helping them with the next.
・Why users should not lie down immediately after a meal.

― 125 ―

6. ASSISTIVE SKILLS

6-3.Evidence-based assistive skills as related to ADL and IADL

Bathroom Support
・Why it is necessary to be able to recognize signs that a user wants tourinate/defecate.
・Why leaning forward makes it easier to defecate when using Western-style
toilets.
・When using a portable toilet on the bed for bathroom support, why we must lift
up the user’s torso and make sure it is touching their kneecaps.
・Why we massage users’ stomachs in clockwise circles.
・Why it is important to observe the characteristics of users’ urine/feces.
Bathing and Hygiene Maintenance Support
・Why we wipe users’ bodies from the extremities towards the center of theirbodies.
・Why it is necessary to make sure the changing room and bathtub room are warm
before helping a user bathe.
・Why we engage in bathroom support for users before helping them bathe.
・Why we avoid bathing users before and after meals.
・Why elderly users should not be in the bathtub for long periods of time.
Organization of Living Environment
・Why it is necessary to adjust light and sound elements in an elderly user’s living
environment.
・The appropriate temperature and humidity of elderly users’ rooms.
・Why we make sure there is room for users around their feet, related to theblankets and futons on the bed, etc.
Other Emergency Measures
・Why it is necessary sit a user upright if they are suffering breathing difficulties.
・Why it is necessary to turn a user on their side on the bed if they are vomiting.
・Why we must make sure the user’s airways are clear if they are unconscious.
It is important in your daily work to wonder to yourself, “why this? why that?”
and work towards seeing situations from the ICF perspective in order to be able tochoose the right evidence-based long-term care methods.

― 126 ―

6. ASSISTIVE SKILLS

6-4.Skills related to consultative assistance

Learning Objectives and Target Achievements<Learning Objectives>
In this subject, you will gain an understanding of the necessity of consultative
assistance in the long-term care workplace, and learn the basic perspectives
necessary to provide this assistance to users and their families as an Advanced
long-term care worker.
<Target Achievements>(1) Gain an understanding of the background behind the consultative assistanceskills necessary in long-term care workers.
(2) Gain an understanding of the perspectives necessary to be able to provide
consultative assistance as a long-term care worker.

(1) Caregivers and Consultative AssistanceFirst let’s take a look at the definition of a caregiver.
The term “certified care worker” as used in this Act means a person with expert skills
and knowledge who has received the registration provided in paragraph (1), Article
42, and uses the appellation “certified care worker” to engage in the business ofproviding care for a person with physical disabilities or mental disorder andintellectual disabilities that make it difficult to lead a normal life (including mucus
aspiration, and other conduct that is necessary for the everyday life of the person,
exercised under the direction of a medical doctor (limited to the services provided
for in Ordinance of the Ministry of Health, Labour and Welfare; hereafter referred toas “mucus aspiration, etc.”), and providing instructions on caregiving (hereafterreferred to as “caregiving, etc.”) to the person and the person’s caregiver.
(Article 2 Paragraph 2, Certified Social Worker and Certified Care Worker Act)― 127 ―

6. ASSISTIVE SKILLS

6-4.Skills related to consultative assistance(2) The Background Behind the Necessity of Consultative Assistance Skills inLong-Term Care Workers
In order to discuss why consultative assistance skills are necessary in long-termcare workers, let’s first take a look at the “2017 Annual Report on the Aging Society”(Cabinet Office, Government of Japan).
1) At-Home Long-Term Care
40% of men and 30% of women wish to live at home, in the environment they
are used to, even when receiving long-term care.
2) Elderly Caring for the Elderly
There is an increasing amount of people who wish to live at home, in theenvironment they are used to, even when they are required to receive long-termcare.
In over 60% of the cases of at-home long-term care, the main provider oflong-term care is an individual who lives in the same house. Looking even further
into the details, you will notice that 26.2% of these people are spouses, and that69% of these men and 68.5% of these women are over 60 years old, which would
make many of these households cases of elderly caring for the elderly.
3) Dementia Long-Term Care
The statistics for those who require long-term care, etc. show that the top reason
for needing long-term care is “cerebrovascular disease (stroke)” at 17.2%, followedby “dementia” at 16.4%.
4) Terminal Care
When asked where they would like to spend the final moments of their life ifthey became ill with no significant hope for recovery, 54.6% of people said “home,”
followed by “a hospital or some other medical facility” at 27.7%.
(“2017 Annual Report on the Aging Society,” Cabinet Office, Government of Japan)― 128 ―

6. ASSISTIVE SKILLS

6-4.Skills related to consultative assistance

People who come to require long-term care enter an elderly long-term carefacility and receive long-term care. The way of thinking, however, has begun tochange, from long-term care workers simply providing care to these people tohelping them maintain their lifestyles at home, even when the user does requirelong-term care.
As in the annual report above, the social factors that surround people who
require long-term care is diverse and complex. Their interplay gives rise to avariety of issues, which can be complicated as well.
Long-term care workers must be able to provide consultative assistance to theusers and their families, and provide advice and guidance that suits theirconsultative needs. This is the role that is coming to be required of long-term care
workers as they support user lifestyles.

(3) Perspectives Necessary to Engage in Consultative Assistance as a Long-TermCare Worker
1) Mutual Interaction Between Individual and Environment
There is an interplay between individual and environment that is based on
their mutual interactions with each other. Various factors influence each other tocreate issues.
It is easier to understand this as it applies to long-term care if you think about
it from the perspective of the International Classification of Functioning, Disabilityand Health (ICF), which is the basis for the implementation of long-term care
processes.
2) Perspective on “Strength”
The assumption is that people have the strength to be able to solve their own
issues. The idea is that people who currently have issues and need support are insituations where they cannot properly utilize their problem-solving abilities. It is
important not to view these people as “weak” people in need of saving.

― 129 ―

6. ASSISTIVE SKILLS

6-4.Skills related to consultative assistance3) Perspective of Partnership
It is important to maintain the perspective that the long-term care worker andthe user are partners, working together. From this perspective, you are notproviding them a service (hierarchical relationship), but working together as
equals to solve issues.
4) Perspective of Listening
Listening is very important when providing consultative assistance. To “listen”
is different from simply hearing what they say.
To “listen” means to try to understand the heart of what the user and theirfamilies are trying to convey, whether they are discussing their thoughts or anissue they may be having.

(4) Assessment Perspective
When users and their families come to you for consultation, it is because they arehaving trouble with something. There is a wide variety of topics you can be
consulted on, but this does not mean that everyone will be able to convey precisely
what their trouble is, and what the root issue may be.
For this reason, long-term care workers must have the skill to figure out “their
trouble,” and “the issue.”This requires assessment skills.
The following are the criteria for assessment.

― 130 ―

6. ASSISTIVE SKILLS

6-4.Skills related to consultative assistance

Assessment Criteria① What are the client’s issues?
② Detailed explanation of the issues (when did it start? how often? etc.)③ What does the client think of these issues? What emotions do he/she feel andhow are he/she behaving?
④ At what stage in the client’s development or lifecycle are these issues croppingup?
⑤ To what extent are these issues impairing the client’s ability to live his/her
daily life?
⑥ What are the human and/or material resources that can be used to solve theclient’s issues?
⑦ What problem-solving methods and/or plan has been thought of to solve theclient’s issues?
⑧ Why did the client decide to ask for help? Was it the client who decided to ask
for help?
⑨ Are the people and situations related to the issues making the issues better orworse?
⑩ What kind of unmet needs and desires does the client have that may becausing these issues?
⑪ Who and what systems are related to these issues?
⑫ What are the client’s skills, abilities, and strengths?
⑬ What kind of external resources does the client need?
⑭ Medical, health, and mental health information related to the client’s issues⑮ Client’s life history⑯ Client’s values, life goals, and thought processes(Watanabe, Ritsuko. Koreisha Enjo ni Okeru Sodan Mensetsu no Riron to Jissai[‘Theories and Practicalities of Consultations in Support of the Elderly’] [2007].)
You are not required to go through all of these assessment criteria every time you
receive a consultation. Adjust the points to focus on depending on the content of
the consultation.

― 131 ―

6. ASSISTIVE SKILLS

6-4.Skills related to consultative assistance(5) The Realities of Consultative Assistance Provided by Long-Term Care Workers
Let’s go through some case studies of consultative assistance provided bylong-term care workers engaged in at-home long-term care.
Case Study 1
Mr. A (70 years old) lives with his son and his wife (43 years old; 42 years old) andhis grandson (10 years old) at home. Mr. A has been classified Long-Term Care
Requirement Grade 2, and is paralyzed on his left side due to cerebral infarction. He
uses an in-home long-term care service 3 times a week, but during the day his son’s
wife takes on most of the long-term care duties. His son’s wife has troubletransferring him from his bed to his wheelchair, and has recently come to thein-home long-term care worker and told her that she has pain in her hips due to thistask.
What kind of advice/guidance would you give her?

Case Study 2
Ms. B (69 years old) lives with her husband (73 years old) at home. Her husband
has been diagnosed with dementia, and is classified Long-Term Care Requirement
Grade 2.
He is self-sufficient for most of his daily life, but recently, Ms. B has come up to thein-home long-term care worker and said that her husband does not know where thebathroom is, and will sometimes urinate in places that are not the bathroom, and it
is tedious for her to clean.
What kind of advice/guidance would you give her?

― 132 ―

6. ASSISTIVE SKILLS

6-4.Skills related to consultative assistanceCase Study 3
Ms. C (50 years old) lives with her parents (both 81 years old) at home. Her father
has been classified Long-Term Care Requirement Grade 1, and has some slightdementia. He occasionally uses a short-stay long-term care service, while also
receiving at-home long-term care.
While her father is using the short-stay long-term care service, Ms. C comes tovisit, wanting to see how he is doing. During this visit, Ms. C comes up to a short-staylong-term care worker and asks for advice—her father has started not being able todo things he used to be able to do, and she feels frustrated and angry every time thishappens. How is she supposed to control her feelings?
What kind of advice/guidance would you give her?

The consultation in Case Study 1 was about long-term care skills, Case Study 2
about care related to dementia, and Case Study 3 about the psychological effects oflong-term care.
Other than these, there are also people who will consult you on what institutions
they should discuss their issues with, or what kind of social resources are available
for them to use.
Depending on the content of their consultation, you must be able to report the
information to other disciplines as well, and not simply end the consultation.
Advanced long-term care staff members must also be able to supervise the advice
and guidance that long-term care staff members provide to users and their families
through consultative assistance.

― 133 ―

7. LONG-TERM CARE PROCESS

7-1.Guidance of staff in matters related to the long-termcare process

Learning Objectives and Target Achievements

1. Be aware of staff members' abilities in relation to the long-term care process,and give the proper educational guidance, at the right moments, to eachindividual staff member depending on where in the process their users are
and the staff's performance
2. Explain to new staff members and mid-career recruits the logical thoughtprocess behind the long-term care process, and train them through every step
until they can actually practice long-term care through the steps of thisthought process
3. Evaluate the results of staff members' assistance based on the long-term care
process with the staff members themselves, and educate them further byreviewing both their abilities and the long-term care process
4. Look for social resources both inside and outside of the facility that can help
staff members come up with creative ways to handle user needs, inaccordance with the user needs evidenced in assessment results, and maintaina workplace environment that encourages staff members to speak up withcreative ideas【学習のねらいと到達目標】

0. Why Is a Long-Term Care Plan Based on the Long-Term Care Process Necessary?

5. 
職員それぞれの介護過程をたどる実力を把握し、”Isn’t it enough to be able to practice assistive skills as各職員が担当する利用者
a care worker?”
However, “there isn’t a need to provide
full support to every single user.”の介護過程の経過と成果物に対し、職員の個にあわせた教育的な指導を効 Where does the difference between the users in ①-⑤ come from? How would
果的なタイミングと方法で行うことができる
we provide consistent care?
6. 新人職員や中途採用の職員などに対して、介護過程という論理的な思考過① Ms. A can use the bathroom by herself, without
any particular help from thestaff
程で介護が展開されていることを伝え、思考過程をたどり介護が実践きる② Mr. B can use the bathroom by himself as long as a staff member helps him
レベルまで目標を段階的に設定しながら育てることができる
walk to the bathroom
7. 職員が実践した介護過程に基づく支援結果に対し、職員と共に評価を行③ Ms. C can use the bathroom by herself as long as a staff member helps her
walk to the toilet
い、職員の能力と介護過程の両面に対し、振り返りを通した指導が実施で④ Mr. D can use the bathroom by himself as long as a staff member helps him
きる
walk into the bathroom and pull down his pants
8. 利用者のニーズに対し、
アセスメント結果に沿いつつ、自由な発想でニー⑤ Ms. E needs the support
of a staff member to walk into thebathroom, pull
down her pants, and sit on the toilet; after using
the bathroom, she needs
ズを達成する方法を職員が考え出せるよう、
施設内外の活用できる社会資
support to wipe and pull up her pants

源を発掘しつつ、自由なアイディアを発言することが推奨される職場環境
 Doing everything for the user, using the same methods to support every user, andを整える
being taught by someone else how to support each user=> Care workers who provide care in these ways are not care workers“Long-term care plans” establish a method of care that that is common to theteam, and are tailored to each user’s situation to best support theirself-sufficiency, helping them solve their issues and realize the lifestyle they wishfor

― 134 ―

7. LONG-TERM CARE PROCESS

1.

7-1.Guidance of staff in matters related to the long-termcare process

The Similarities Between the Long-Term Care Process Thought Process and the Staff
Training (Education) Thought Process
There are similarities between assessing each user and providing support for theirindividual needs, and training staff members (students) in ways that consider their levelof study and tailored to their individual growth
1) See users/students in objective ways (perspective), collect facts about them, andorganize these facts in order to provide care/education (observation)2) Use your understanding of users’/students’ abilities and knowledge and deepen
your reserve of information on them (assessment/understanding where a student
is in their training)3) Based on 1) and 2), think about what kinds of things the user wishes to do in their
daily life, or what kind of person the student wishes to be and wishes to be able todo, and decide how best to care for/educate them4) Propose a plan to best care for/educate them (long-term care plan/education plan)
5) Provide actual care/education, and record progress and results (implementation)6) Constantly think about how users could get closer to the things they wish to do,and students closer to the person they wish to be, and what is the better care.
Point out the reasoning behind certain types of care, and improve upon them(evaluation and revision)
The only thing that makes “logical support/education” possible is the systematicand logical “thinking” of care workers/educators.

2.

Understanding That Long-Term Care is Conducted Through a Logical Thought Process
Known as the Long-Term Care Process
1) “Perspective” that care workers should maintain
The (dictionary) definition of perspective:① Where the eye is looking… Where?
② The state of one’s ideas … How?
2) Understanding that the way you see the world around you (the way you
understand impairments) greatly affects your “perspective,” “care,” and“education” with regards to understanding users and staff members
Ex) A student falls into a ditch on the side of the roada. Is it the student’s fault (individual) for not noticing the ditch?
b. Is it society/the environment’s fault for having an uncovered ditch?
→ Be aware that there are many different ways to see the same situation
a: Medical Model:
Considers diseases and impairment to be an issue with the individual,
who must receive treatment, rehabilitation, etc. from professionals; theuser must exert their own willpower to overcome impairment
b: Social Model:
Considers problematic situations to be an issue with the environment,
and aims to overcome impairment by improving the environment andpreventing society as a whole from experiencing the same issues― 135 ―

7. LONG-TERM CARE PROCESS

2.

7-1.Guidance of staff in matters related to the long-termcare process

Understanding That Long-Term Care is Conducted Through a Logical Thought Process
Known as the Long-Term Care Process3) Neither the Medical Model or the Social Model is superior to the other—what is
important is how they are applied① Problem-Oriented Assessment/Care Plan (Medical Model)
Perspective that considers impairment to be cause of declines incommunication skills and range of action, and seeks to treat the cause (curethe actual affected area, impairment, etc.) (Passive: the individual mustchange)② Goal-Oriented Assessment/Care Plan (Social Model)
Perspective that considers everything except the individual to be environment(including care workers), seeks to change this environment to make it easierfor individuals to perform to the best of their ability, and supports them to live
independently even with their impairments (continues to exist/gets worse)(Active: society must change)*One is not superior to the other—we must make effective utilization of both=> Use the ICF and life function way of thinking, which combines the two=> The necessity of communicating these two models to both users andstaff members to shape their way of thinking

2. Understanding That Long-Term Care is Conducted Through a Logical Thought
Process Known as the Long-Term Care Process4）How Changes in the Conceptualization of Impairment Change theConceptualizations of Care and Care Workers
Focus on Medical Model
Impairment

An abnormality

Abilities(Conceptualization)

Abilities that have declined
due to old age and disease

Support(Way of Thinking)User Identity
Staff Member Identity
Care Worker Identity(You)

Make up for declines in ability
and prepare for upcoming
risks (problem-oriented)
Impairment has meant morethings that are risky or thatcannot be done
Someone who makes up for
declines in ability andprevents risks― 136 ―ICF = Medical + Social
Part of an individual’s unique
identity
Current abilities that havegone through changes due toimpairments, etc.
Improving abilities +environment, developing
further ability (goal-oriented)
Use an accumulation of
support to develop abilities
and accomplish goals
Someone who analyzes user
ability and who provides anaccumulation of support

7. LONG-TERM CARE PROCESS

7-1.Guidance of staff in matters related to the long-termcare process

2. Understanding That Long-Term Care is Conducted Through a Logical Thought
Process Known as the Long-Term Care Process5) Implementation of Long-Term Care Processes Based on the ICF Way ofThinking
Roomis on the right
廊下の右端にend部屋があるof the hall

例）廊下の右端にお部屋のある認知症のEx) For Mr. B, who has dementia, to get to his room,
Bさんが、自分の部屋にたどりつくまで
whichis on the right end of the hall

現実環境における
Situationin the Current
Environment
実際状況

3.

Improvement of

環境改善

Environment

Individual
個々人にDevelopment
対するof能力開発Abilities

Everytime Mr. B is standing in the
Bさんが「どちらにいけばよhallway wondering which way he is
いか知りたい」と思っている
supposed to go, a care worker goes
時、支援者がそっと近づき、
gentlyup to him and points to his
room,
and says, “it’s the third door
その都度指を指して「三つ目down.”のドアですよ」と伝える

Care
workers repeat “it’s the third door” to
支援者がBさんに自室の場所を憶えて
teach
Mr. B, and try to have him remember
もらおうと思い、「３つ目ですよ」と繰り
where his room is. At some point, Mr. B may
返し、教える。Bさんが「帰りたい」とthink,“I want to go back to my room,” thenrememberfor himself that his room is the third
思った時に、いつか「３つ目のドアだっ
door
down.
た!!」と自分で思いおこし、たどり着く(Goal-Oriented)（目標志向型）(Problem-Oriented)（問題志向型）

Evaluate the results of staff members' assistance based on the long-term care process
and educate them by reviewing both their abilities and the long-term care process
1) What is “critical thinking” and “review”?
 If the result was undesirable, it is not enough to think, “I’ll learn from this,”“I’ll be more careful”
 In critical thinking, it is important to ask yourself why something happened
the way it did, and think of methods to improve both your skills as a worker
and the methods you use for your care (self-education)
 Critical Thinking Processa. What were the facts in this care/education situation?
b. Why did these facts come about, and what reasons and possibilities are
inherent in them?
Why did these reasons and possibilities occur?
(Encourage self-reflection in care workers and students)c. Propose a possible practical solution for the causes and possibilities
brought up in (b).
(Practical = Set a timeframe and use methods and content that can beevaluated)
2) The result of support given is evaluated on the basis of whether the user’s goal has
been achieved through the long-term care process, and the goals and methods ofthe care are evaluated whether it is in line with the facility’s philosophies.

― 137 ―

7. LONG-TERM CARE PROCESS

7-1.Guidance of staff in matters related to the long-termcare process

4. Look for social resources both inside and outside of the facility that can help staff
members come up with creative ways to handle user needs, and maintain aworkplace environment that encourages staff members to speak up with creative
ideas
1) Does the user’s life as a whole have the same elements that my life does? Each
person is an independent individual (with their own diversity and complexity).
We are also, however, social beings who live independently in society whileworking with and depending on others.
Are you seeing the entirety of a user’s life? (Image)The triangle in the front: How you see them (how muchof the user’s life you can see, etc.)
The arrow represents your perspective(like peering at the user through a hole)
The colored box in the back is who the user actually is You only see what you want to see through a frame of your own design, so you
can barely see who the person actually is2) The Assistive Skills to Support the Entirety of a User’s Lifestyle
Providing basic support (meal, bathroom support)
Building relationships, cultural/social activities (discovery and use ofresources inside and outside the facility)
In order to create an environment where staff members can come up withcreative ways to support users and put it into practice, it is necessary to maintain afoundation and model (manager) in the workplace that encourages this to happen― 138 ―

8. DEMENTIA CARE

8-1.Guidance of staff in matters related to dementia

Learning Objectives and Target Achievements“Key Learning Points”: Goals and Summary◇1. Understand a summary of the policies.
◇2. Understand the underlying diseases of dementia, diagnostic criteria, themain symptoms, and BPSD.
◇3. Be able to use non-drug therapies and activities.
◇4. Be able to use concepts like “validation” and “humanitude” and activities
like the “himotoki sheet”◇5. Be able to use the “himotoki sheet” to solve ethical issues“Target Achievements”* Be able to practice dementia care as a professional and educate staff members
as to its practice.

* Fill in the blanks with the correct terms as you move through thissection.

1. Summary of Policies
1) Let’s discuss the 7 pillars of the “New Orange Plan (Comprehensive Strategy
to Accelerate Dementia Measures)① Advance the implementation and development of measures designed todeepen understanding of dementia② Provide the appropriate medical care, long-term care, etc. at the appropriate
times, depending on the level of dementia③ Strengthen policies for early-onset dementia④ Provide support for workers that care for people with dementia⑤ Advance measures to create ①____________ that are considerate of theelderly, including those with dementia⑥ Research and develop prevention methods, diagnostic methods, treatment
methods, rehabilitation methods, and long-term care models for dementia,
and advance the use and implementation of research results⑦ Focus on the perspective of people with dementia and their families☝₁

Fill in “①_____________” with the correct term.
1― 139 ―

8. DEMENTIA CARE

8-1.Guidance of staff in matters related to dementia

2) Discuss “focus on the perspective of people with dementia and theirfamilies,” one of the 7 pillars of the “New Orange Plan”, and think about whatkind of measures would be necessary to make this a reality.

Group Work

3) Your Role as Long-Term Care Staff Members
You will need to advance the implementation and development of measuresdesigned to deepen understanding of dementia.
One way to do this is to host a “Dementia Supporter Training Course.”
Goal:

Gain the correct knowledge and understanding of dementia, train “dementia
supporters” throughout Japan that can help people with dementia as muchas possible, as well as their families, in the community, and help build
communities that are considerate to the elderly people with dementia, etc.
Target Audience: Community residents, staff members at financial institutions andsupermarkets, students at elementary/middle/high schools, etc.
● What is Expected of a Dementia Supporter① Have an appropriate understanding of dementia untainted by prejudice.
② Watch over people with dementia and their families with consideration and empathy.
③ Help out in any way that you can, no matter how simple, in the lives of neighbors withdementia and their families.
④ Look for ways to help in the community and a create a network, supporting each other,cooperating, and coordinating.
⑤ Lead community efforts to improve and develop the community.
2― 140 ―

8. DEMENTIA CARE

8-1.Guidance of staff in matters related to dementia

4) Explaining Dementia in an Easy-to-Understand Way
Material from the “Dementia Supporter Training Course”
1. Understand dementia

7. What to remember when communicating with people with dementia
The idea that people with dementia are completely unaware of theircondition is a myth. They are the first to notice their own symptoms.
Factors: They forget things, or their ability to do household chores/work declines,

and they begin to notice that something is wrong.
As they experience again and again the forgetfulness specific to dementia, whereinsufferers cannot remember what they forget even when they have been reminded ofit, they begin to feel anxious that something is wrong.

People with dementia are not ignorant of their condition. In fact, it is the sufferer themselvesthat are the most worried, the most upset, and who suffer the most.
9/14: I keep messing up and causing my sister trouble. I start not knowing what I’m doing, andthere is just so much shame, so much frustration. Every day starts off like this.
Handkerchief, some tissue paper, my wallet, 1512 yen, always with me.
I’ll be going to Aozora. Aozara for rehabilitation.
Recently I don’t know what I’m doing.
From the journal of a woman with dementia. * “Sister” refers to her daughter.
Her entry journal reveals her frustration and anxiety towards not knowing what is happening, what will happen, in
her own head.

The Sadness Hidden Behind “I’m Not Forgetful!”
There are often instances where people with dementia will insist “I’m not forgetful!” or refuse to go to the doctor, causing trouble to theirfamily.

Reason: “I couldn’t possibly have dementia!” This sentiment can be a defense mechanism to protect themselves
against the unexplainable anger, sadness and anxiety they feel about their own condition.
It is not an easy task for those around the “person who suffers from dementia (the disease)” to understand how they truly feel. But it isimportant that these moments of lashing out are often expressive of sufferers’ hidden sadnesses.

* Communicate, Connect, Expand● Make creative efforts to help people understand the suffering and sadness ofpeople with dementia. For instance, using the journals/notes of people withdementia and their families.
● Make sure to understand that you are in a position to communicate to others“what is expected of a dementia supporter”
Ministry of Health, Labour and Welfare
http://www.mhlw.go.jp/stf/seisakunitsuite/bunya/0000064084.html
http://www.mhlw.go.jp/stf/seisakunitsuite/bunya/0000089508.html― 141 ―

8. DEMENTIA CARE

8-1.Guidance of staff in matters related to dementia

2. The Underlying Diseases, Diagnostic Criteria, Main Symptoms, and
BPSD
1) Difference Between “Dementia” and “Forgetfulness” (due to aging)

Dementia

Forgetfulness Due to Aging

I am not ①____________ that I
forget anything
I even forget ②____________ that
I’ve had
I can’t remember even with hints

I am ①____________ that I forgetsome things
I forget some of the ②___________
that I’ve had
I can remember if given hints

It impairs my ability to live my dailylife
My ③___________ abilities havedecreased

It does not impair my ability to live mydaily life
My ③____________ abilities have notdecreased☝2

Fill in ①～③ with the correct terms.

● Make sure long-term care staff members can explain the differences.
2) Dementia Caused by Lifestyle Habits
There are certain lifestyle-related diseases caused by habits like overeating,alcohol, lack of exercise, smoking, etc.
These include diabetes, lipid abnormalities, high blood pressure, stroke,obesity, etc.
Lifestyle-related diseases in the elderly are related to the onset of dementia.

● These diseases make it easier for people to develop vasculardementia.
3) The Effects of Lifestyle-Related Diseases on the Brain● Diabetes:
Decreases insulin secretion and causes insulin resistance, whichmakes it difficult to eliminate glucose effectively from thebloodstream and increases insulin resistance, causing chronicallyhigh blood sugar and increasing the risk for cerebrovascular andcranial nerve impairments● Lipid Abnormalities: Increases the amount of triglycerides and cholesterol in the
bloodstream and causes arteriosclerosis, which narrows the bloodvessels, causes poor circulation, and weakens the blood vessels,
thus increasing the risk for heart disease, cerebral infarction, andcerebral hemorrhage― 142 ―

8. DEMENTIA CARE

8-1.Guidance of staff in matters related to dementia

4) Underlying Diseases
Neurodegenerative Alzheimer’s disease, Lewy body dementia, frontotemporal
Diseasesdementia, Parkinson’s disease, Huntington’s disease, etc.
Cerebrovascular
Vascular dementia, etc. as a result of cerebrovascular
Diseasesdiseases like cerebral infarction and cerebral hemorrhage
Traumatic Disease Brain contusion, chronic subdural hematoma, etc.
Brain Tumor
Brain tumor (primary, metastatic), Ollivier’s disease, etc.
Infectious Disease Meningitis, encephalitis, Creutzfeldt-Jakob disease, etc.
Metabolism andAlcoholism, thiamin deficiency, liver failure, etc.
Nutrition Disorders
Endocrine Diseases Hypothyroidism, hyperparathyroidism, reactive
hypoglycemia, etc.
Toxicity Disorders
Drug addiction, carbon monoxide poisoning, metal
poisoning, etc.
Collagen Disease
Behcet’s disease, Sjogren's syndrome
Other
Idiopathic normal pressure hydrocephalus, chronic
pulmonary insufficiency, etc.

● What are the three main types of dementia, and which of them canbe prevented/treated through prevention/treatment of these
diseases??
(1) Three Main Types of
Dementia(2) Dementia That Can Be
Prevented and/or Treated― 143 ―

8. DEMENTIA CARE

8-1.Guidance of staff in matters related to dementia

5) Diagnostic Criteria/Diagnosis and Evaluation(1) Diagnostic Criteria
Main Criteria: (1) Diagnostic Criteria for Dementia (Ministry of Health andWelfare Research Team, 1989)(2) DSM-IV-TR (American Psychiatric Association)(3) ICD-10 (WHO)(2) Diagnosis and Examinations① General physical examination
What is important is distinguishing whether or not they have a treatable typeof dementia. Physical evaluations are necessary to check for the existence ofphysical diseases that may be the cause of the dementia.
☝ Let users and their families know that knowledge of this information isnecessary, especially if they feel unsure or worried about the examinations.
② General brain examination③ Brain imaging examination④ Psychological examination to measure intellectual ability⑤ Other: Gene testing, pathological examination

6) Understanding the Main Symptoms and BPSD
The “main symptoms” refers to symptoms that ⑥____________ who suffersfrom dementia will experience in general.
BPSD occur when the main symptoms affect the person to behave or feel incertain ways. They emerge based on the person’s personality,⑦_____________, and psychological stages, and there are⑧_______________. Some of these can be improved with the appropriate careand rehabilitation.

☝3 Fill in ⑥～⑧ with the correct terms.

― 144 ―

8. DEMENTIA CARE

8-1.Guidance of staff in matters related to dementia

Anxiety
Depression

Peripheral
Symptoms(BPSD)

Incontinence
Coprophilia
Denial of
Care

Main Symptoms

Wandering◆ Memory impairment◆ Disorientation◆ Impaired understanding anddecision-making ability◆ Executive function impairment◆ Aphasia, agnosia, apraxia

Hallucinations
Illusions

Demandingto Go Home

Violence
Verbal Abuse
Eating Disorders
Eating Non-Edible
ThingsDelusion
Sleep
DisordersDeliriumhttps://info.ninchisho.net/symptom/s10☝The severity of BPSD is said to be particularly affected by how the person istreated by those caring for them.
Family is the most common example. However…

Dementia can sometimes get worse as a result of the long-term care
workplace…
Ex)
①
②
③
④
⑤
⑥

Not allowing them to go outside because you are afraid they will cause trouble
Criticizing them for any trouble they cause
Denying their feelings and wishes
Ignoring them
Correcting their mistakes
Ordering them to do things☝Discuss these kinds of situations and how to handle them with long-term carestaff members, and come up with possible solutions.

― 145 ―

8. DEMENTIA CARE

8-1.Guidance of staff in matters related to dementia

4．Non-Drug Therapies and Activities* Long-term care staff members must be able to support people with dementia inorder to lessen their symptoms, and create an environment that is comfortable
for them to live in.
Fill in the blanks with details and practice those you can actually do.
Type
Details① Reminiscence Therapy② Reality Orientation③ Music Therapy④ Exercise and Physical

Therapy⑤ Occupational Therapy

Muscle strengthening, balance training, range of
motion exercises (for the joints)
Household chores/household roles, handicrafts⑥

Recreation Therapy⑦

Horticultural Therapy⑧

Calisthenics

Radio calisthenics, rhythm calisthenics, folk
calisthenics, stretches⑨

Environment

Advice/guidance for long-term care workers,
etc.

Maintenance

What did you think about the practice?

― 146 ―

8. DEMENTIA CARE

8-1.Guidance of staff in matters related to dementia

4．The Use of “Validation,” “Humanitude,” and the “Himotoki Sheet”
1) Summary of “Validation”“Validation” is a technique for communicating with people with dementia, proposed
in 1963 by Naomi Feil in the U.S. It is used particularly for those with Alzheimer’s
Disease. “Validation” sees the behavior of people with dementia as all having some
sort of meaning, and attempts to discern the reason behind their behavior. It alsoseeks to communicate with these people without lies and without
obfuscation.
2) 14 Basic Techniques① Centering

Long-term care workers must center their thinking
and repress their frustration② Open-Ended
Questions

Ask open questions that can be answered freely③ Rephrasing

Repeat the same words back to the person; rephrase
what they said to give them a sense of security④ Exaggerated
Exaggerate situations in order to make it easier for◇5.
「ひもときシート」を用いた倫理的葛藤の解決
Expressions
them to express their feelings⑤ Asks Them
Opposite Question

Think of something you want to help them
remember and ask them questions to help them getthere⑥ Reminiscing

Talk about nostalgic memories; use past experiences⑦ Use Ambiguous
Expressions

Communicate using ambiguous expressions⑧ Use Senses They
Like

Find a sense that they like (sight, smell, touch), andspeak in words that relate to this sense⑨ Friendly EyeContact

People with dementia often have a narrowed field ofvision; meet eyes with them to give them a sense of
security* Technique shared with “humanitude.”― 147 ―

◇5. 「ひもときシート」を用いた倫理的葛藤の解決

8. DEMENTIA CARE

8-1.Guidance of staff in matters related to dementia⑩ Speak in a Low,
Clear, Gentle Tone

Elderly people have trouble hearing higher-pitchedsounds; a low, gentle tone makes you easier tohear and gives them a sense of security⑪ Touching

Touch them on the hands and shoulders, where
they feel comfortable being touched* Stop if they seem uncomfortable with being
touched

⑫ Use Music

Communicate by listening to or singing songs theyused to like together⑬ Mirroring

Mirror (imitate) the person’s movements and facial
expressions⑭ Connect
Unfulfilled Human
Desires to Their
Behavior

If they are restless, think about which of the threemain human desires may be unfulfilled—the desire
to be loved, the desire to help others, and thedesire to process their emotions

Provide advice/guidance to long-term care staff members that are confused orlack the confidence to be able to communicate with people with dementia, andhelp them maintain their motivation towards long-term care.

● Let’s think about this through case studies.
A person with dementia…

・Is restless and looking for something
・Packs their bags, says they are going home, and tries to leave
The long-term care staff member responds:“This is your home.”“The front door is broken so you can’t leave.”“There aren’t any more buses and trains, so let’s drink some tea and wait.”
This kind of care is known as “passing care,” or care where you “let things go.”This passing care is said to cause in people with dementia the feeling thatsomething is wrong, that they are being lied to.

☝ As an Advanced long-term care staff member― 148 ―

8. DEMENTIA CARE

8-1.Guidance of staff in matters related to dementia

Try out basic validation techniques.
The long-term care staff member asks:“Where is your home?”“Who lives in your home?”“How many children do you have?”“Are you worried about your home? Do you want to go check up on it?”In this way, you can try to figure out the reasoning that led to them wanting to “gohome.”● Techniques
・Ask questions that are easy to answer
・Maintain a consistent conversation for a certain period of time
● Effects
・The person realizes the value in where they are trying to return to
・ They feel secure because the long-term care worker is trying to understand their
feelings
・There is an opportunity for them to understand the position they are in3) “Humanitude”“Humanitude” as a concept was developed through the joint research of Yves Ginest
and Rosett Marescotti in France.

* Skills required to be with people who have dementia and who are
difficult to communicate with
The quality that makes people feel like you are communicating with them in a kind
way, and feel that they are recognized, and that you are on their side—acompanion. This allows them to recognize their own humanity, gradually open
up their heart to those around them, and maybe even start thinking “I want to beof help to other people,” or “I want to continue to live a meaningful life.”
https://www.minnanokaigo.com/guide/dementia/humanitude /― 149 ―

8. DEMENTIA CARE

8-1.Guidance of staff in matters related to dementia

The Basic Concept of “Humanitude”
See

Talk

Touch

Stand

Humanitude is made up of approximately 150 skills, centered around the fourconcepts of “see,” “talk,” “touch,” and “stand.”✔ The practice of “see, talk, touch, and stand” can sometimes surprise people.
It is important to think kindly of the person, and implement these skills in a waythat is suited to their reaction.
● See
Bring yourself to their height, and look into their eyes at a short distance for along period of time. By bringing yourself to their height, you are eliminating any
intimidation or pressure, and allowing them to feel that you are working together
as equals. People with dementia often have narrowed fields of vision, but thismethod allows you to communicate with them without causing surprise.
● TalkTalk to them gently, repeatedly using positive words. When touching them toprovide long-term care, make sure not to touch them suddenly, but to tell themfirst in words what areas of the body you will touch.
● TouchTouch their body. Do not grab them from above. Instead, rub their back, put yourhand gently on their back as they walk, etc. to give them a sense of security.
● Stand
It is important that people be able to stand on their own so they do not become
bedridden. Try to have them stand as much as possible when brushing theirteeth, cleaning up their appearance, or bathing. Standing as much as possible
prevents decline of muscle power, gives a wider perspective, and also increases
the amount of information they process.

☝ Guidance to long-term care staff members:

Learning all 150 of these skills can be quite a burden. However, have themunderstand that caring for those with dementia requires this kind of high-levelprofessionalism.

― 150 ―

8. DEMENTIA CARE

8-1.Guidance of staff in matters related to dementia

4) The Ethics of the “Himotoki Sheet”● The Goal of the “Himotoki Sheet”
Instead of focusing on treating the symptoms of dementia, the goal of the“himotoki sheet” is to help people with dementia maintain their dignity, theirrelationships with their families and the community, and live a way of life that istrue to themselves and their past lives.
Supporters must learn the ability to not get caught up in the words and behaviorsof people with dementia, read the messages and signals hidden behind them, andanalyze their life history and life situation in order to figure out what the issues arefor the person themselves.
http://www.dcnet.gr.jp/retrieve/info/fig02.html

From “Mr. A with Dementia” to “Mr. A”
The “himotoki sheet” allows long-term care workers to recognize that theirevaluation and understanding of the user is based on their own opinions anddecision-making, and figure out whether they have any biases or subjective
impressions that may be coloring these evaluations. It also evaluates whether you
as a long-term care worker are hurting the dignity of the users.
Analytical analysis gives you an understanding of the necessity of informationcollection and having adequate assessment abilities.
You will learn that the moral interpretations of long-term care workers are based
upon this analysis.
Empathic understanding allows you to think of people not as “Mr. A with dementia”
but as “Mr. A,” and understand what kind of thought processes this individual has.

You will learn that the way to provide care to people with dementia is to be awarethat:“Every person is different. There are many answers, but no rightanswers.”― 151 ―

8. DEMENTIA CARESTEP 1: Evaluative
Understanding

Discern and evaluate theissues first from yourperspective as a supporter.
A) Organizing Issues I
The issues that you (as asupporter) see
B) Organizing Issues II
The measures that you (as asupporter) have thought of

8-1.Guidance of staff in matters related to dementia

STEP 2: Analytical
Understanding

Verify the facts from multiple
dimensions and organize
information towards solving
the root issues.
C) Write down any of theperson’s words andbehaviors that may berelated to their issues
D) Organize the backgroundand factors behind the issues― 152 ―STEP 3: Empathic
Understanding

The supporter develops theirown thought process fromthe perspective of theperson themselves to solve
their issues.
E) Think of the issues you
wrote down in (1) Organizing
Issues I from the perspectiveof the person themself
F) Write down as manythings as possible that you
think you could do to help
the person solve their issues

9. PALLIATIVE CARE/TERMINAL
CARE

9-1.Guidance of staff in matters related to palliative care/terminal care

Learning Objectives and Target Achievements

1. Starting from when the user is admitted into the facility, make sure to educate
long-term care staff members to be able to provide the user and his/her familywith information and consultations (based on care worker ethics and careprinciples) so they have the resources to make decisions for end-of-life
2. Educate staff members as to the process of death, nurture their outlooks onlife and death, and train them on basic behaviors at the deathbed andterminal care methods
3. Be aware of how to make decisions on in-house medical practice depending on
the steps of terminal care, and to cooperate with other disciplines and takein-house leadership
4. Following terminal care, look back on the care that was given with relatives
and staff members, and discern information that can be utilized for grief careor for the next instance of terminal care

1. The Process from Admission to Terminal Care
1) Admission: Consult the user as to their stance on terminal medical care anddecisions for end-of-life in general(In some cases, the family may have to make the decisions)2) Enter the “terminal” stage of care on the basis of doctors’ and nurses’
evaluations and opinions
3) Explain the process to the family, gain their approval, and move into
implementing terminal care
① Collecting information during the terminal care stage② Creating a care plan for a period of preparation that predicts a
timeframe for end-of-life③ Creating a care plan for when a user begins to show signs of being
critically ill
 Requires conferences with family, care managers, consultative
assistants, nurses, long-term care workers, registered dieticians,
adult guardians, etc. to explain the care and gain their approval Verify coordination with the doctor in charge
 Verify the organizational structure in the facility capable of handlingterminal care
(24-hour communication system, the creating of a guideline formonitoring/support when the nurse is not present, the maintenanceof the environment necessary for terminal care)
4) Provide counsel and support for the rituals at time of user's death (washingand dressing rituals, deathbed rituals)5) Support family members and other staff members after the user’s death(grief care, conferences)
6) Complete the care process for the user and complete all administrative
procedures― 153 ―

9. PALLIATIVE CARE/TERMINAL
CARE

9-1.Guidance of staff in matters related to palliative care/terminal care

2. Basic Behaviors at the Deathbed and Terminal Care Methods
1) Conceptualization of Life and Death “Terminal” means… borderline, boundary, final
 “Terminal care” is care meant to maintain a life as close as possible tothe individual’s wishes, up until the point of death, which exists on thesame continuous plane as the rest of their life
 It is necessary for each staff member to ask themselves, “what isdeath?” To think about death is to also think about “living,” “life,” and“dignity.”2) How do you want to live until the very moment of your death? Therein lies
the goal of terminal care.
Even in situations where recovery cannot be expected, individuals should be
able to live full lives, with their dignity respected Psychological: “I want to live in a way that is true to myself;” struggles
with fear of death Physical: Wishes for terminal medical care, including life-sustaining
treatments; management of pain and suffering
 Social: Where they wish to live (without feeling like a burden on others) Mental: Creating an environment where users are free to practicewhatever religion or belief they holdNo matter what kinds of decisions users and their families make, our jobs
are to help relieve fear and suffering and create a peaceful environment, byunderstanding user wishes, strengthening coordination with medical
institutions, sharing information amongst multiple disciplines, and making
sure the process goes smoothly.
3) Basic Behaviors at the Deathbed(1) Death exists on the same plane as our daily lives.
What is important is maintaining the user’s will to live, and helping
them to live the way life they have always lived. It is not a period of“waiting” before death(2) Look at the entirety of the user’s life, and maintain a way of life thatremains true to who they are.
Try not to focus too much on health, instead making careful, creative
efforts to make up for declines in psychological, physical, and social
ability as well, so they are able to maintain their way of life(3) Meet the needs of users and their families through coordination
between medicine and welfare.
As users get closer to end-of-life, there will be certain changes to vital
signs, etc.
Understand that intimate coordination between healthcare and welfare
is the basis for our being able to provide for user needs, in order toeliminate physical and psychological suffering as much as possible andease the tension in your mind as well(4) Ensure lack of regrets not only for the user but for the family as well
Support the user as a team, along with the family, so that not only theuser but also the family, whose lives must go on even after the user’s
passing, can be free of regrets(5) Not to let the facility’s/staff’s lack of knowledge and/or skills cause an
earlier passing
Educate and prepare staff members so as not to let their lack ofknowledge and/or skills cause an earlier passing― 154 ―

9. PALLIATIVE CARE/TERMINAL
CARE

3.

9-1.Guidance of staff in matters related to palliative care/terminal care

The Steps of Terminal Care
1) Preparation Period Before Predicted End-of-Life Timeframe
Medical and welfare professionals clarify and divide each of their roles/functions in
the process
Make sure team care proceeds smoothly, according to the facility’s care“philosophy”
 Doctors/nurses: Meet with family to explain and discuss the situation
 Facility, partner hospitals, and commissioned doctor: Share information aboutchanges to the user’s condition
 Social worker: Explain the direction of the facility’s terminal care, establish
consent forms
 Nurses: Help eliminate suffering, palliative care
 Care managers and long-term care workers: Create care plan, implement careplans, and report to others
 Nutritionists and chefs: Provide meals in accordance with user health andtastes, even if just one bite Environment maintenance: Preparing places for family to stay (upon request)
Emotional Preparation for Those Giving Terminal Care
 Understand the user’s situation
 Infer/read the emotions of users and their families, even if they do not
outwardly express them Commit to providing the care that must be provided, and try as much as
possible to give additional care as well
 Make sure all staff members are considerate to the feelings of the users, andmake sure they do not feel isolated

3.

The Steps of Terminal Care
2) Period After User Begins to Show Critical Signs
 Understand the natural process of death in human beings, and explain this tothe family.
The process begins with circulatory impairments in the extremities, decreases
in vital signs like blood pressure, changes in breathing (Cheyne-Stokes
breathing, mouth breathing, etc.) (let them know that users feel little paineven if they are suffering from breathing difficulties, due to reduced
functioning of their brains, and that this is a natural process), and that there isa high chance their hearing ability is intact until the very end
 Engage in palliative care to relieve suffering from symptoms during criticalconditions according to the doctor's direction.
IV fluid replacement, oxygen therapy for breathing difficulties, sputum
suction, etc.
 Moving the user into an individual room for deathbed based simply on thewishes of the user or their family
Changing the environment without consideration may actually cause
psychological damage
 In the future, discussions will become necessary as to when artificial feeding(gastrostomy, etc.) and dialysis should be terminated (currently in Japan, it isdifficult to apply the guidelines for the removal of ventilators and othertechnologies, but focus will most likely be on precedents, etc. as well)

Maintain the usual care for all users residing in the facility― 155 ―

9. PALLIATIVE CARE/TERMINAL
CARE

4.

Looking Back on Terminal Care with Family and Staff Members, and Discerning
Information That Can Be Utilized for Grief Care or the Next Instance of Terminal Care
1) Support the family members, whose lives must go on even after the user has
passed Immediately after the user’s passing, give the family time to say goodbye
 The process after the user’s passing can be conducted in part with the family,
if they wish to participate






4.

9-1.Guidance of staff in matters related to palliative care/terminal care“Commemoration” Care: Grief Care Period of crisis between loss and recovery
 People need time to thoroughly experience, express, and understandtheir sadness
 Shock (longing, emptiness) → Loss (alienation)→ Shutdown (depression)→ Healing/Recovery (efforts to adapt and handle sadness)
People oscillate between these states many times throughout themonths, weeks, and days, and even over the course of just one day It is important for the family members themselves to be aware of thisprocess as well (that this is a normal reaction)
Predict the user’s passing, and explain in advance the various procedures(social workers, administrative workers, etc.).
Various procedures involving temples/churches, funerals, bank accounts, andadministrative procedures for insurance, and social security, etc.
Withdrawal procedure, calculating any fees/returns, verifying and returning
personal belongings, end-of-life/end-of-care records

Looking Back on the Care with Relatives and Staff Members, and Discerning
Information That Can Be Utilized for Grief Care or the Next Instance of Terminal Care
2）Staff members require care both as “people” and as “professionals”（1）As People- The lack of experience with human death before working in the long-term carefield
- The shock and sadness of losing someone that they have cared for for a long time
- If not properly dealt with, these can serve as causes for staff members towithdraw and eventually resign from their jobs
- They need opportunities to grieve, talk about their sadness, and receive
follow-up care（2）Looking back as a Professional, and Connecting the Experience to Future Care
“Were we able to alleviate his/her suffering?”“Was the family confident in our terminal care?”“Was the family ready for the day of the user’s passing?”“Were the user and the family able to communicate with each other?”“Were the family and staff members able to communicate with each other?”“Was there sufficient coordination between healthcare/long-term care staff
members?”“Did we have a sufficient understanding of the user’s and his/her family’s
end-of-life wishes?”“Were we able to provide them with sufficient nutrition, water and alleviate
his/her suffering?” etc.

― 156 ―

2017
“Project to Train Core Personnel for Regional Industry in Vocational Schools,” Commissioned Projectby the Ministry of Education, Culture, Sports, Science and Technology
Module‐type development project for a program to train long‐term care personnel, withconsideration for community relations and international standards
Japan Welfare Education College, Keishin‐Gakuen Educational Group (Chief Director: Mitsutoshi
Kobayashi)
Date of Publication

February 23, 2018

Publisher

Mitsutoshi Kobayashi

EditorKatsuhiko Kikuchi

6F Udagawa Building, 2‐16‐6 Takadanobaba, Shinjuku‐ku, Tokyo JAPAN, 169‐0075
Keishin‐Gakuen Educational GroupTEL
Author03‐3200‐9071

FAX

03‐3200‐9088

Motoyuki Kawatei, Masaki Nagashima, Yuki Watanabe, Aiko Tomono,
Akinori Kiyosaki, Sachie Hatsugai, Tomoyuki Sawa, Miyuki Saito,
Shigeru Matsunaga

Printed/Bound

Kijima Printing, Inc.
2‐9‐6 Shirogane, Chuo‐ku, Fukuoka‐shi, 810‐0012
TEL

092‐531‐7102

FAX

092‐524‐4411