Nursing for the older people
in Japan
3. Japanese Nursing Association in Action

Japanese Nursing Association

1. The Aging of the Japanese Population
2. Nursing for the Older People: Current
Situation and Challenges
3. The Japanese Nursing Association in
ActionJapanese Nursing Association2

Initiatives of Japanese Nursing Association in
the Aging Japanese Society

As the aging of society proceeds, JNA is seeking tostrengthen the functions of nursing in home-visit
nursing and at long-term care facilities.
 The number of older people who require highintensity caring and/or with dementia are
expected to increase in line with the rapid
aging of society. This calls for enhanced rolesof nursing at home and in long-term care.
 It is urgently required to establish a system tosustain long-term and continuous home-basedcare, even with high intensity caring or withlow capability of the family caregivers.

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Strengthening Nursing
Functions at Facilities

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Efforts to Address the Issues• Strengthening management skills of nurses
who work at long-term care facilities• Securing nurses who work at long-term carefacilities• The opportunities to obtainspecialized
knowledge and skills for nurses working at
long-term care facilities• Bolsteringcollaboration
with
other
professions inside and outside the facility, andlocal networks
Nursing at long-term care facilities is facing the issues such as a limited allocation ofnurses, unclear scope of work, few training opportunities for acquiring specialized
knowledge and skills, and weak collaboration with other professions inside andoutside the facility or local networks.
JNA promotes services to pursue the following four goals, in order to provide safe
and secure care in collaboration with other professions, by strengthening nursing
functions and managing a few number of nurses, who support the life of older
people with high needs for health care:1) Strengthening management skills of nurses who work at long-term care facilities;2) Securing nurses who work at long-term care facilities; 3) The opportunities toobtain specialized knowledge and skills for nurses working at long-term carefacilities; and 4) Bolstering collaboration with other professions inside and outside
the facility, and local networks.
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Key Projects of JNA• Developing and disseminating the “Systematictraining program for nurses at long-term carefacilities”• Collecting inputs concerning end-of-life care at
long-term care facilities, and identifying theissues• Developing the “Guideline for nursing practiceat long-term care facilities”• Conducting an actual status survey on nursing
at facilities for care of the elderly• Education and training

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Proposing a Systematic Training
Program for Long-Term Care Facilities
Purpose:To establish a system for nurses at long-term carefacilities with few training opportunities to takesystematic seminars on nursing to support the life ofolder people;
To encourage local networking through the planning andmanagement of seminars

Each nurse who works at long-term care facilities is required to have specialized
knowledge and skills, as well as management and other skills to see to the entire
facility. However, there are few training opportunities targeted at theenhancement of nursing expertise, nor are available systematic programs for that
purpose. This makes it difficult for nurses to acquire, in steps, required knowledge
and skills across the broad fields. JNA's committee has systematized essentialtraining items for nurses, so that they could take seminars locally and promotelocal networking. These items have been summarized as the Systematic Training
Program for Nurses at Long-Term Care Facilities.

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Features of the Systematic Training
Program for Long-Term Care Facilities
1. Viewpoint of management skills that every
nurse should have
2. Nursing knowledge and skills required atlong-term care facilities are summarized inthree categories.
3. A tool for seminar planning and management
in collaboration with more than one facilities
and organizations
1.

2.

3.

Because a few number of nurses provide care in collaboration with otherprofessions at long-term care facilities, every nurse is also required to play
management roles for the entire facility. This is why the viewpoint fordeveloping management skill is incorporated into individual training items.
Because long-term care facilities are places where older people lead their daily
lives, nurses need to re-acquire specialized nursing knowledge and skills fromthe viewpoint for supporting the daily lives of residents. The knowledge andskills incorporated into this program are grouped into three categories: 1)
Characteristics of long-term care facilities and roles of nursing, 2) Knowledge
and skills for nursing practice, and 3) Knowledge and skills to leverage theeffects of practice.
It is difficult for a single facility or incorporated organization to plan andmanage systematic training that meets the needs of nurses with different
professional careers and academic backgrounds. It is possible that local
facilities and related organizations collaborate and provide systematized
programs, based on this program. Such collaboration may also encourage theestablishment of local networks.
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Three Categories and 24 Training Items
1. Characteristics of longterm care facilities androles of nursing

Basic viewpoints for nursing care required at long-term care facilities
Assessment to support daily lives
Physical assessment
Care for the people with dementia
Assistance for maintaining living functions
Basic care to support the daily
lives of residents

Rehabilitation for maintaining physicalfunctions
Care for eating and swallowing
Care for excretion

2. Knowledge and skills
for nursing practiceCare for bedsores
Response to acute deterioration

Response to acute deterioration

End-of-life care

Care in the end-of-life period
Prevention of and response to accidents

Safety management

Infection control
Establishing safety management systems at
the facility
Effective interpersonal skills at long-term carefacilities

Collaboration and coordination(team building)

Basic knowledge for local collaboration

Support to decision making by residents andtheir families
3. Knowledge and skills
to leverage the effects ofpractice

Knowledge on institutions

Institutional knowledge to respect the dignityof residents
Laws and regulations concerning long-termcare and nursing
On-site teaching methods for nursing students

Education and training

Establishing systems for on-site teaching tonursing students
Establishing education and training systems toenhance competences of nurses

For each of the 24 items listed above, JNA also proposes 1) purposes, 2) attainment
goals, 3) training forms and details, 4) evaluation methods, and 5) required time.
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Developing the Guideline for Nursing
Practice at Long-Term Care Facilities
Purpose:Leading innovations in nursing at long-term carefacilities, as a written guide for nurses who workat long-term care facilities

JNA's special committee developed the draft Guideline for Nursing Practice atLong-term Care Facilities in 2011, for the purpose of clarifying the roles of nursing
at such facilities and enabling nurses to acquire required nursing knowledge andskills. Practical effects of this guideline were verified at six facilities in 2012. This
verification included evaluation according to indicators, interviews with nurses, andfocused interviews with nursing managers and other individuals. Based on the
results of this verification, the guideline was published as a book in June 2013, witha strengthened viewpoint of everyday life, enhanced emphasis on management
functions, clarified requirement for collaboration with other professions, andadditional items for family support.

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Guideline for Nursing Practiceat Long-Term Care Facilities
1. Characteristics of older people
2. Roles of nursing and nursing practice
3. Establishing a system for nursing practice atlong-term care facilities
4. Establishing a system for acquiring andenhancing specialized knowledge and skills

The Guideline for Nursing Practice at Long-Term Care Facilities presents specificand feasible ways for nursing practice, so that front line nurses can provide
effective care in collaboration with other professions. The Guideline also aims
at encouraging nurses to think and act by themselves with relation to care forresidents, team management, etc.
The structure of the Guideline enables users to check and identify care items
that they have achieved and those that have yet to achieve, based on
explanation describing specific knowledge and rationale.

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Seminar for Developing Nursing Leadersat Welfare Facility for the Elderly
Requiring Long-term Care
Purpose: To obtain knowledge and skills
required for the following goals:• Supervise the care to support the user's life
with dignity• Participate the planning of seminars for nurses
held on a prefectural basis, and develop
seminar programs and instructional skills toserve as an instructor• Establish and promote networks to share
information and collaboration on protectionof rights in local communities
The seminar for developing nursing leaders at welfare facility for the elderly
requiring long-term care is provided by JNA, as a service entrusted by the Ministryof Health, Labour and Welfare. The seminar was started in 2005, targeted at nurses
who serve as leaders at welfare facility for the elderly requiring long-term care, andare recommend by their prefectural governments. The three-day seminarcomprises lectures and exercises on management, leadership, enhancement ofcare quality, ethical care, risk management, collaboration and other knowledge andskills required for fulfilling nursing roles at facilities for the elderly.
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Strengthening the Functionsof Home-Visit Nursing

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Efforts to Address the Issues• Strengthening management basis for homevisit nursing• Extending functions and scales of home-visit
nursing• Support to securing human resources forhome-visit nursing

In order to enable long period of home-based care, home-visit nursing is critical.
Nevertheless, visiting nursing stations are faced with difficulties such as thediversifying and complicated user needs, inefficient work due to the small scalesof stations, increased burden on staff, inferior management conditions at smallscale stations compared to larger stations and incapability of providing services
around the clock. In order to tackle these difficulties, JNA has taken efforts tostrengthen management basis for home-visit nursing, to extend functions andscales, and to support securing human resources for home-visit nursing.

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JNA's Key Projects Aimed at Strengthening
the Functions of Home-Visit Nursing• Promoting combined services• Seminars to develop managers of visiting
nursing stations• Policy proposals and requests

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Background of Establishment of the
Combined Services
Requirements for continuing home-based care
• Support for family caregivers• Timely intervention by healthcare professionals• Short-term stay and other stay services for older people
with high needs for health care
• Availability of the consultation with nearby professions
on the long-term caresource: based on interviews by the Japanese Nursing Association

In order to continue secured life at home, stable and seamless service provision isessential. However, it is difficult to continue home-based care with home-visit
nursing only, because the average time per visit is only about 60 minutes under thecurrent system. At the same time, it is also unfeasible that small-scale visiting
nursing stations as we see should provide 24/7 support service.
JNA held interviews on cases where requests of older people who wanted to stayhome through to the end of their life could not be fulfilled, for the purpose ofidentifying causes and issues in those cases. The results showed that therequirements for continuing home based care included support the capacity ofcaring by family caregivers, timely intervention by healthcare professionals, shortstay and other stay services for older people with high needs for health care, andavailability of the consultation with nearby professions on the long-term care.
JNA proposed to the government that a new service was required, which permit to
combine the home-visit nursing and long-term care, daycare, stays and consultationby professions as necessary, in accordance with physical conditions of the users andother factors. Based on JNA's proposal and other inputs, the government
introduced new combined services in April 2012, where home-visit nursing andmultifunctional long-term care in a small group home setting (commuting/daycare,stays and home-visit nursing) were provided in a comprehensive manner.
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Before Combined Services Were
Introduced
Service Provider A

Service Provider B

Multifunctional longterm care in a small
group home

Home-visit nursing

Home-visit long-term care +daycare + stays

Users

Multifunctional long-term care in small group home is a service where the three
types of care (home-visit long-term care, daycare and stays) are combined inaccordance with conditions of the user. This service is difficult to be used bypersons in relatively severe conditions with higher needs for health care,because medical procedure by nurses are prohibited on a service provider's site.
At the same time, a user of multifunctional long-term care in a small groupshould receive home-visit nursing from another service provider.
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Comprehensive and Flexible Combined
Services Also Respond to Emergency
Situations
DaycareHome-visit
nursing

Stays

Home-visit
long-termcareHome-visit
nursing

Combined service provider
Home-visit
Daycare + Stays + long-term +careHome-visit
nursingHome-visit nursing
providerThe combined services system integrates multifunctional long-term care in a small
group home with home-visit nursing, enabling a single service provider to provide thefour types of care (home-visit nursing, home-visit long-term care, daycare and stays)
through 24/7 management. Because the provider of combined services manages all
the services on a centralized manner, it can provide a flexible combination of services
immediately responding to situations of the user and his/her family.
The maximum capacity of combined services is 25 registered users. If the business isalso designated as a home-visit nursing provider, then the provider may deliver
extensive home-visit nursing to local residents. This helps the service provider tostrengthen its business management basis through diversification.

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Standards for Staffing at a Provider of
Combined Services
Day

Daycare: ≥ 1 staff member FTE (of which ≥ 1 nurse) to 3 users
Home-visit: ≥ 2 staff members FTE (of which ≥ 1 nurse)

NightNight shift: ≥ 1 staff member
Night duty: ≥ 1 staff member throughout the time zone
* Not required on days without a single staying users* No standards for the allocation of nurses (arrangement as
necessary)

Nursing staff≥ 2.5 staff members FTE (of which ≥ 1 full-time nurse or publichealth nurse)* The nursing staff may also work for the visiting nursing stationin the case of integrated management.

Long-termcare support
specialists

Must be allocated (may also work for the another post; may bepart-time)

Manager

A dedicated full-time manager must be allocated, satisfying
either 1) or 2) below:
1) Individual who has at least three years of long-term careexperience with users who have dementia, and has completed
the specified training; or2) Public health nurse or nurse

The nursing staff of a provider of combined services may also work for the homevisit nursing provider in the case of integrated management. As long as the staffing
standards for a home-visit nursing service provider are satisfied, the same can besaid for the provider of combined services.

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Features of Combined Services• Fixed monthly package fees based on long-term carelevels• Users with high needs for health care services can be
accepted.
• Efficient and effective care

Japanese Nursing Association has undertaken pilot projects toward theintroduction of combined services, and verified the specific achievements. The
results showed that the combined services were capable of flexible andimmediate combination of services in accordance with conditions of the user,
thereby enabling services for users immediately after leave from a hospital orusers in unstable conditions. It was also identified that other benefits of thissystem included the provision of effective and efficient care based on the sharingof user information and care policy among nurses and long-term care staff.

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Benefits of Combined Services
Users• Reassurance based on comprehensive services including home-visit,
stays and daycare, delivered by familiar staff in a nearby facility.
• Because flexible services are available in accordance with the user's
conditions, frequent revision of care plans is not required.
• Because contract should be executed with a single service provider
only, the frequency of correspondence is minimized.
• Because the fee should be paid on a fixed monthly basis, long-termcare expenses do not increase excessively.
Service provider• Flexible staffing in accordance with the user's conditions• Efficient sharing of information and policy among staff members• Efficient care provision becomes possible.
• Stable revenue is gained, because the fee per user is paid on a fixedmonthly basis, regardless of frequency of use.
In order to continue home-based care, a wide variety of services are required.
Under the long-term care insurance system, care plans are prepared combining
necessary services, in accordance with required long-term care and support level. A
user executes contract with a long-term care service provider based on care plans,
and receive necessary services. A ceiling is set for service use, in accordance withthe user's necessity for long-term care.
It has been a challenge where a user receives services from more than one service
providers, it takes time sharing relevant information, revising care plans in responseto changes in conditions, and arranging for necessary services. Under the combined
services system, this challenge is resolved because a single service provider may
deliver combined services, thereby benefiting both the users and the service
provider.
JNA provides visiting nursing stations across Japan with information, support andknow-how for introducing and managing combined services in a proactive manner.
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Seminars to Develop Managers ofVisiting Nursing Stations
Purpose:To develop managers capable of adequately
managing and operating home-visit nursing
business in a changing and expanding environment
Targets:
Managers of visiting nursing stations who consider
expanding their business

It is critical to strengthen management skills in order to expand the scales of visiting
nursing stations.
JNA holds seminars for developing managers capable ofadequately managing and operating home-visit nursing business in a changing andexpanding environment.
These seminars are aimed at acquiring abilities to satisfy the needs of society
through stable provision of safe and high-quality services, through diverse seminar
items including compliance, training opportunities for staff, labor management, andinformation management.

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Policy Proposals and Requests• Requests concerning securing staff• Requests concerning assessment andcalculation of medical fees and long-termcare fees

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