COVER STORY • Exploring for the Best Models of an Aging Society – Lessons from Japanese Experience • 9Interview with Yukari Amano, Senior Associate Professor, University of Shizuoka, Junior College
Department of Social WelfareReality of Caregiving in Japan– a Japanese Expert’s Story

By Japan SPOTLIGHT
With its rapidly aging society, Japan needs to prolong the lifespan and good health of older people asmuch as possible. Nonetheless, it will eventually see an increasing number of elderly people either
hospitalized or needing caregiving. With the development of institutional arrangements to prepare forthese needs, including long-term care insurance, what will be the reality of caregiving for elderly people inJapan?
Japan SPOTLIGHT interviewed Yukari Amano, a nurse and expert on caregiving in Japan, and seniorassociate professor at the University of Shizuoka, Junior College Department of Social Welfare.
(Interviewed on May 13, 2019)

Introduction
JS: Could you please introduce

yourself? How did you startworking in caregiving?

role. So I started to work as a volunteer for a
facility caring for orphans affected by HIV run
by a Japanese. No remedy for HIV had been
discovered then and I was obliged to see
those infants’ lives passing away under myeyes. It was truly horrendous. But I noticed
the different care methods there and ways ofengaging with patients, and I started to feellike coming back to a caregiving position andworking again. A year later I came back toJapan and started working as a lecturer for acourse for home helpers at a nursing school.
I found there a difference between caregiving
and nursing. Caregiving has different
priorities from nursing, which is aimed at
supporting cures for a disease or preventionof a disease and recovery of health. It wasnecessary for me to learn about caregiving

Amano: I was originally a hospital nurse.
After graduating from a nursing school, I
worked for a facility for handicapped children
in my hometown and then moved to auniversity hospital in Yokohama. I was there
working as a nurse for rehabilitation andworking also on a job closer to caregiving forpatients suffering from cerebral infarction or
intractable diseases. Though I found joy inseeing those patients cured and leaving
hospital, it was a truly laborious andYukari Amano
exhausting job. I thought I would not be able
to keep working there until retirement. I was under so much stressfrom the beginning.
that I felt I was hearing calls for a nurse even while I was asleep inI got a qualification as a care worker and care manager through a
my bed at home, and occasionally I became worried that I may havecorrespondence course and I got a job as a part-time instructor atmade some mistakes during my work.
the University of Shizuoka’s Junior College, where I am working now
Meanwhile, ever since taking a trip to Thailand following a friend’s
as a permanent professor. I then specialized in clinical humansuggestion, I have been in love with the country. After several visits,science at graduate school. I think all of my experiences so far,I became eager to live there some day and thought about quitting myincluding my life in Thailand and language study there as well as myjob in order to do so. Thus before I was in my 30s, I quit being alearning about the differences between medical remedies andnurse and went to live in Thailand for one year. In Thailand, I studied
caregiving, are linked to my research today. In particular, mythe language for three months at a school in Chiang Mai in theexperience in Thailand is a basis for my teaching and research, evennorthern part of the country. I forgot about being a nurse andthough it was only one year’s experience and 20 years have passed
enjoyed my life, learning about yoga and Thai massages as well as
already since then.
traveling.
But then I started feeling ill at ease about having no job or social
https://www.jef.or.jp/journal/

Japan SPOTLIGHT • July / August 201939

COVER STORY 9

Details of Experience in Thailand
JS: What exactly did you do as a volunteer at the Thaiorphanage?

Amano: Though I had a qualification as a nurse in Japan, I could notwork as a nurse in Thailand. I was helping professional medical staff
there as a volunteer worker as much as I could, such as sitting withthe kids in medical consultations, taking their temperatures forrecords, playing with them, and so on. In addition, I was able to takeadvantage of my experience as a nurse in health checks for thechildren and keeping their skin clean to prevent infections.
JS: You mentioned that there were no remedies for

HIV at that time. What were you thinking whileworking as a volunteer there?

Amano: Certainly, having seen so many kids dying as a result of HIV,I thought it was a vital question how to protect their lives and raise
their immunity to prevent the virus from spreading. In spite of all the
medical efforts, it was inevitable that there were some lives we could
not save. This is what happens all the time in our work. So I also
thought it was vital to think about how these kids could have a happylife under such severe circumstances. It was important to think about
how they could live just like other people do, such as going toschool, shopping or working after becoming an adult. It was
important for the whole community to share their knowledge toenable the children to have a life just like other kids. My working
experience in that orphanage was only several weeks, but I find thata few of them, low-grade elementary school students then, areworking now in society. Seeing this, I believe that it is important tothink about total care and support for patients in terms of a wide
range of aspects, such as quality of life, social life, education and soforth, as well as medical remedies.
JS: The number of Philippine caregivers is increasingin Japan. What do you think about caregiving in aforeign country in the light of your own experience inThailand?

Amano: I was in general only in a supporting role as a volunteer inThailand, as my limited language capacity would not allow me towork as a professional staff at a medical institution. But when I had
occasion to talk with medical doctors in my work, I felt under strongpressure to follow their instructions, as there were some words
which I did not know. You would have to be ready for such pressure
in working as a specialist in a facility in a foreign country. I thought
at that time that I would not be able to work as a specialist and earn
40 Japan SPOTLIGHT • July / August 2019a salary in a foreign country. I felt that giving voice to my ideas inpoor language would make me look like a child, even if I could makemyself understood. Foreign nurses or caregivers working in Japan
will have the same challenge more or less – bridging this gap
between their thoughts and their use of language. In our daily life, we
may not find this to be such a big challenge, but when we are
involved in difficulties at work, we find it hard to communicate
exactly how or what we feel. The wrong choice of words could makeus misunderstood and could harm our relations with our boss orcolleagues. What would have been understood or taken for granted
in our own country may be misinterpreted in another country’s
culture. So there will be a need for psychological support from thecommunity for foreign caregiving workers to allay these difficulties,
as one’s own individual efforts will not be enough.

Caregiving for the Elderly
JS: You are now specializing in caregiving for theelderly. What are the key elements of this?

Amano: I would say the key is to recognize in advance these elderly
people’s preferences in the final stage of their life since the need for
caregiving emerged and share them with their families and closefriends. Many elderly people in Japan will not say any word about
how they would want to spend their remaining days. There must be
many who would like to die at home, but they usually would notinsist on anything. In general, they would tend to follow whatever
their family would say, being afraid of causing trouble to the family
or friends or being considered to have dementia and lost the capacity
for making judgements or decisions. In many cases, their realdesires would not be listened to. This issue could be a
psychologically heavy burden for the family as well, so I think it is
crucial to let the elderly talk freely with their family or close friends
as well as the medical or caregiving experts about how they would
like to die, or by whom or how they would prefer to be taken care of.
JS: In Japan, we are entering what we call a centennial

aging society, in which caregiving experts for theelderly will play an increasingly key role. Do you think
there are sufficient numbers of such experts inJapan?

Amano: The statistics show there is a shortage of experts. According
to an estimate by the Japanese Ministry of Health, Labour andWelfare, there will be a shortage of around 130,000 caregivers inJapan in 2020 and 340,000 in 2025. The statistics may not give areal sense of crisis, but there is no nursing home in the country thatwould not complain about a shortage of caregiving staff. More thanCOVER STORY 9

10 years ago, when we asked nursing homes to accept an internshipfor our students, they occasionally rejected us, as they were so busy
that they could not take care of the students. Now they would eagerly
ask such students to come to their facilities, even offering to pay
their transportation expenses, as it is crucial for nursing homes torecruit students educated as caregiving experts.
So nursing homes now greatly respect the need to raise andrecruit experts for the future of their profession and listen to thoseyoung people’s views on caregiving. When we organized a seminarfor caregivers, we had many replies from them that they would not
be able to participate due to their busy work schedule because of theshortage of caregiving staff even though they would have liked toparticipate in networking with their fellow caregivers from various
other places. They are so busy doing their jobs that they would not
be able to meet the need to raise the quality of their work.
JS: Thanks to long-term care insurance in Japan, I

believe that a nursing home’s services are now welldeveloped. Of course, the quality of services will
depend on the people working there as caregivers.
For example, “positioning” to support postureenabling a patient to feel most comfortable bymaking use of a cushion or other tools seems to be ahighly elaborated technique. There are some who aregood at this and some who are not. What do you
think is necessary to get this skill?

Amano: “Positioning” is one of the basic skills necessary for staff
working on caregiving and assisting rehabilitation, but due to thelack of sufficient learning opportunities at those schools for
caregiving, some are good but some are not. No matter how niceand sincere a caregiver may be, due to a lack of skill he or she might
handle an elderly person too roughly. Whenever that elderly person
sees this caregiver, the memory of pain will return. This is naturaland not an exaggeration. Elderly people have fragile bones and lessmuscles and fat. With the decline of their physical capacity, they
could suffer from articular contracture, and then they would feelstrong pain if they are touched carelessly. Therefore, paying attention
correctly to their pains and worries, judging from their physicaltension or expressions, speaking with them based on precise
observations and thinking about the right method of caregiving will
be very important. Unless caregivers do so, they would not be able
to make those elderly feel secure, even though they can place acushion or a pillow to maintain their posture. Caregivers would needto judge the physical and psychological condition of the elderly
person in question. Without this ability, they could not carry out
appropriate positioning. With positive outcomes such as the
improvement of the elderly’s posture and their sleeping thanks to it,

and the appreciation of the elderly and their families, caregivers will
become more confident in their job. Such experience based on
repeated trial and error would lead to the acquisition of high skills.

Raising Caregivers
JS: You are teaching students to be caregivers at

nursing homes. What do you find most challenging inyour work?

Amano: At a caregiving facility, there are a wide range of people
working such as non-professionals, care managers, nurses,
nutritionists, rehabilitation experts, and so on. It is extremely difficult
to define which level of the work should be a minimum requirement
for those people. To be more specific, how much can they share abasic knowledge of anatomy and physiology, as well as diseases,
and thus provide care work based on common knowledge?
On the question of “positioning”, without some knowledge of bone
structure and muscle movement, you cannot do it effectively.
Meanwhile, with little expertise but an agreeable personality, some
could communicate well with the patient’s families. Thus a variety ofstaff could contribute well to total caregiving work. But for a care
worker, it will be a minimum requirement to speak out their own
opinions in talking with medical and welfare experts. They will needto raise the quality of their work on the whole by collaboration.
JS: What is tube feeding? To whom would this beapplied?

Amano: Tube feeding is the medical activity of feeding those who areunable to get any nutrition through their mouth by a tube into thenose or stomach by gastronomy. This was previously allowed to bepracticed only by nurses and medical doctors. But at this moment, acare worker trained for this under certain conditions is allowed topractice it. It was originally approved for patients with amyotrophic
lateral sclerosis (ALS). Even if you suffered from ALS when you werestill young, with respiratory organs assured to function by opening
the trachea, you could survive a long time. In this case, it would benecessary to practice tube feeding three times a day while absorbing
phlegm under 24-hour surveillance. Care provided only by the family
would be limited and it would be impossible to ask a nurse to cometo do so at home on every necessary occasion. Without care
workers’ doing this job, we could not protect a patient’s life. So it is
now exceptionally approved for certain care workers professionallytrained to practice this medical care. This is also applied to the casesof patients at home suffering from other serious diseases or theelderly at nursing homes where nurses are not staying every night,
on condition that the patient is in a stable condition or collaboration
Japan SPOTLIGHT • July / August 201941

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between a care worker and medical doctors or nurses is possible.
This is how tube feeding is now put into the curriculum for educationof a care worker.

Foreign Human Resources for Caregiving
in Japan
JS: For caregiving, can we take advantage of foreign

human resources in Japan? With language barriersand culture gaps, how do you think we can use
foreign care workers?

Amano: I have been researching about education for foreign humanresources for care work since 2008, and my thesis for my Master’s
degree was on this issue as well. Having studied it for 10 years, I
find the language barrier will not necessarily be a serious obstacle
preventing foreign care workers from doing their job in Japan.
Rather, I find some foreign care workers get a higher reputation thanan average Japanese one does.
In other places like Germany, Australia and Taiwan, many foreign
care workers provide high quality care. In Asian countries, forexample, they still have a custom of caring for family members andthus some Asian care workers in Japan take care of the elderly as if
they were their family members, which is different from the case ofJapanese care workers who consider their service just as a part ofthe long-term care insurance system. So for the elderly in Japan, thiswould be greatly appreciated. It is also true that most of the foreign
care workers coming to Japan are firmly determined to continue todo their job in Japan and quite a few would like to take advantage of
their working experience in Japan after they return to their own
countries.
In this light, I believe it will be necessary for Japan to respond totheir resolution. Meanwhile, I pretty much understand that Japanesecare workers or leaders in caregiving feel it is difficult to train foreign
care workers who lack sufficient experience under the current
situation. I think it will also be necessary for Japanese care workers
or leaders themselves to have learning opportunities in providing
these foreign workers, whose cultural as well as educational
backgrounds are various, with professional skills while offering them
support in their daily lives in Japan. At the moment, this is left toindividual efforts. This is one of the challenges for public policy.
JS: Will it be necessary for Japanese to recognize theimportant role of foreign care workers in Japanese
caregiving?

Amano: Yes. We will need to learn from each other, otherwise things
will not go well. I believe that we Japanese could learn about key
42 Japan SPOTLIGHT • July / August 2019

customs in caregiving from other Asian care workers, such as how
to treat senior people or offer mutual support among family
members and local communities which the Japanese havethoroughly forgotten today.
JS: Do you think that the know-how accumulated so

far in Japanese caregiving could be a model for the
rest of the world?

Amano: There are various views on caregiving depending upon anation’s culture or institutions. It will be difficult to find a model thatcan be applied to different nations, though Japan looks like a pioneerin caregiving as it is more exposed to rapidly progressing aging than
the rest of the world and provides substantive public services forsocial welfare. But the Japanese experience may not necessarily be agood reference for the rest of the world. However, I think our care forpatients suffering from dementia has reached a certain level withaccumulated know-how. I have heard that in certain Asian nations
they use a tranquilizer for patients suffering from dementia to calm
them down when they lose their presence of mind and become
violent. In Japan, it is now well perceived that appropriate
engagement with those patients can change their attitude. This isshared by many citizens and they know now that care work will playa key role in the remedy for dementia rather than medical treatment.

Future Plans
JS: Could you let us know what you are planning to doin your work in the future?

Amano: What I would like to do is create an Asian-wide project for
raising care workers in Asia. The shortage of care workers is acommon big challenge for all Asian nations and they are now allengaged in building education programs for care workers. For
example, China has its own qualification system for care workers andthe Chinese are very interested in introducing a Japanese curriculum
or text book for care workers into China. Vietnam and Indonesia arealso keen on this. I am very interested in the background of care
workers in each nation, how they could work in Japanese caregiving
facilities and what career steps they could follow after returning totheir mother country. In studying these issues, I want to think about
how each Asian nation could improve its care work through Asianwide collaboration among the caregiving entities.

Written with the cooperation of Naoko Sakai who is a freelance writer.