Yearbook on Journal of the Japan Society of Nursing Research 2017

Awareness of Elderly Care Home Residents’ Families with regard to Expansion of
Nurses’ Medical Roles
Nobumasa Ogama

ABSTRACTThe study aims to identify the awareness of elderly care home residents’ families with regard to expansion ofnurses’ medical roles in the elderly care facilities, by carrying out questionnaire survey and semi-structured
interviews.
The results of questionnaire 305 family members responded identified their “awareness of medical practices conducted by nurses” and “correlation between awareness of medical practices conducted by nurses
and attributes of the care home residents and their families and medical care situations,” among others. In
addition, the semi-structured interviews with 5 family members revealed specific views of the families that
support the results of the questionnaire survey.

Key Words :nurse
practiceelderly care facility
familyhealth care policy

Introduction

be positively accepted by service users and on-site staff
members so that sustainable measures can be created withthe support of the citizens. One reason for this is the indicationthat “citizens themselves desperately want to participate in
the establishment of medical policy” (Honda, 2008, pp.362365; Kuriyama, 2010, pp.139-146). However, survey of theopinions and wishes of citizens regarding expansion of thediscretionary authority of nurses according to previous
studies is insufficient.
Hence, survey on recognition by home care patients whoenter elderly care facilities (hereinafter referred to as“residents”) is also considered needed. On the other hand,it can be assumed that in many cases, the residents may
have physical disabilities such as dementia, and whether
they can answer a survey with accurate understanding isquestionable. Consequently, persons related by blood ormarriage (hereinafter referred to as “family”) who bear
the role of legal representative from the judicial viewpoint,
and who can best estimate the intention of the resident, aretargeted in this study, and recognition of the expansion of
the discretionary authority of nurses in elderly care facilities
was clarified. This article discusses the results of this survey.
In addition, the author would like to consider how to utilize
high level practicing nurses, who have greater discretionary
capability than general nurses, in a comprehensive community
care system by carrying out an awareness survey on users of
medical services and their families, and the on-site nurses,
from viewpoint of citizen participation in the establishment ofpolicy. Contents included in this article are part of the survey
study carried out to obtain basic resources required for thisconsideration.

The government has considered the “integrated reform ofsocial security and tax,” and developed measures to further
strengthen social security, by stably securing revenue throughthe increase of consumption tax. Among these, one measureis the establishment of “comprehensive community care” as amechanism to receive timely medical care and nursing service,without being influenced by family structure and economic
conditions. In addition, the medical service provided as
one factor of this system must increase the security andsatisfaction of life of each citizen.
The Ministry of Health, Labour and Welfare (2012a)
pointed out that “reform of medical care and nursing service
itself is inevitable due to changes in the serious, miniaturizedversion of human society, such as the increase in the numberof senior citizens living alone and households with only
aged persons produced by trends in the nuclear family.”
Furthermore, the Ministry (2012b) also indicated the “needto organize the service provision system for end-of-life careand times of acute exacerbation, so that aged persons withhigher needs in medical and nursing care can be accepted into
facilities.” In other words, the needs of long-term care healthfacilities, especially elderly nursing homes, nursing and light
expenses, and charged senior homes (hereinafter referred toas elderly care facilities) are considered to significant increase
from now.
Moreover, consideration of the expansion of the discretionary
authority of nurses was carried out from the viewpoint ofpromoting team medical care, so that quality of life of various
home care patients can be further improved by care service,including the safe and prompt care by nurses who work closelywith the person receiving medical care. In June 2014, the“Medical and Nursing Comprehensive Ensuring Promotion
Law” was announced, and a new nurse training system tocarry out specific actions in the assistance of medical carebased on the manual, were established (Ministry of Health,Labour and Welfare, 2014).
From the viewpoint of the author, recognition of the
expansion of the discretionary authority of nurses should

I. Definition of Terms

1. “Medical practice”“Medical practice” refers to activities of the medical nature,such as examinations for clinical diagnosis, judgment tocarry out tests, and treatment (including the prescription of
medicines), which are considered to lack safety if carried out
by a general nurse.
2. “Expansion of the discretionary authority of nurses”
The authority to perform activities of the medical nature
as described above is granted to nurses.

Faculty of Nursing, SOKA University
Corresponding author. Tel.: +81 42 698 1941; Fax.: +81 42 698 1950.
E-mail address: noogama@soka.ac.jp

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This paper was published at “the Japan Society of Nursing Research” Vol.39 No.2 in 2016.

Yearbook on Journal of the Japan Society of Nursing Research 2017

II. Study Methods· In cases where receiving medical care by a physician ina facility is necessary but assumed as not possible, what
problems, anxieties and sacrifices are expected in the lifeof the residents· In cases where receiving medical care by a physicians
is desired or should be received, but assumed as notpossible, do they want the nurses to provide medicalcare (examination, judgment whether to implement an
examination, drug prescription, and medical treatment)?
· The reason why “medical care by nurses is acceptable,”and “medical care by nurses is better,” was given as a
response regarding medical care by nurses, and condition
to allow such medical care
· The reason why “medical care by physicians is definitely
better,” was given as a response for medical care bynurses· The reason why “either medical care is fine” was given asa response for medical care by nurses· In cases where medical acts are presumed to be carriedout by nurses, among the conditions of “specific direction
by a physician,” “comprehensive direction by a physician,”and “direction of a physician is not necessary”, which ismost demanded?

1. Study Design
After thoroughly understanding the general conditionof family awareness using a questionnaire, more specificopinions are surveyed by a semi-structured interview.

2. Survey subjects and Data collection method
1) Questionnaire Survey
Screening of questionnaire monitors throughout Japan
held by a major survey company in Japan (INTAGE Inc.) is
carried out under the criteria of “having a relative by bloodor marriage in a long-term care health facility or senior home
(special elderly nursing home, nursing, light expense, or
charged). From this, 396 persons were randomly abstracted
from 9,035 monitors who satisfied the criteria, and were
given a questionnaire, which includes a description of the
purpose of the study, methods, and meanings.
2) Semi-structured interview
Through the questionnaire, families who could be interviewed
were requested. As a result, cooperation from 104 family
members could be obtained. Next, whether an actual meetingwith the interviewers at the survey site in Tokyo would bepossible or not was confirmed for 104 family members bytelephone, and written and verbal description of consent wasprovided to families who were considered to appropriate
for the purpose of this survey. Semi-structured interviews
were carried on 5 family members from whom consent was
obtained.
3) Survey Period· Questionnaire Survey December 2013
· Semi-structured interviews January -March 2014

4. Analysis method
1) Questionnaire Survey
For description and estimated statistics, IBM SPSS Statistics
Ver. 22 (including Exact test) software for statistical analysis
was used. In addition, in the implementation of estimatedstatistics, 9,035monitors of the survey company who satisfied
the criteria for the survey were presumed as the parent
group, and independent chi-square test or Fisher’s accuracy
probability test were carried out. Cramer’s coefficient wascalculated for correlation of variables showing family /residents attributes and medical care condition, and thevariables showing recognition of medical care performed bynurses. Probability significance was set at less than 5%.
2) Semi-structured interviews
Discussion regarding the expansion of discretionary authorityof the nurses was set as a verbatim report. Then, data
segmentation was performed by underlining part whichwere considered to be important for the purpose of this study.
Furthermore, concept names for lower abstraction levels
were added to appropriately express the segmented part byusing the expressions of the family as much as possible, while
showing awareness to avoid reading with the prejudice orpreconceived ideas of the researchers (encoding).
Next, division into concept groups with similar characteristics,
and labeling to reflect the characteristics (sub-categorized)
were carried out. Finally, for contents raised for the subcategories (categorizing), labels were added for highabstraction level by gathering similar semantic contents.
The author repeatedly carried out reviews, while receiving
supervision by a sociologist with extensive knowledge of
qualitative research on the validity of the analysis results.

3. Survey Contents
1) Questionnaire Survey· Family Attributes (gender, age, occupation, residence)· Resident Attributes (gender, age)· Frequency, place and main reason why the residents
receive an examination by a physicians· Does the resident receive 24 hour, 365 day response
medical care service from a physician?
· What problems will be caused if the users cannot receive
24 hour 365 day response medical care service from aphysician?
· Acceptance or rejection of nurses performing a
medical examination for diagnosis and conditions for
implementation· Depending on the condition of the residents, Acceptanceor rejection of the nurse determining whether an
examination should be carried out, and the conditions
for implementation· Acceptance or rejection of diagnosis by nurses todetermine if drug prescription is needed for treatment,
and the conditions for implementation
2) Semi-structured interviews
An interview for the following contents, including theconditions to use elderly care facilities and their impressionof the facilities, was carried out.
· Family Attributes (gender, age, relationship to theresident)· Resident Attributes (disease, level of nursing care, typeof facility experienced by the resident, total years as
resident)

5. Ethical consideration
This study was approved by a research ethics review by
the research institute to which the author belongs (Approval
No. 25012, Approval Date: October 3, 2013). The purposeof this study, freedom to participate or withdrawal, andconfidentiality of personal information were explained tothose targeted as subjects. Moreover, an agreement for survey
2This paper was published at “the Japan Society of Nursing Research” Vol.39 No.2 in 2016.

Yearbook on Journal of the Japan Society of Nursing Research 2017consignment was concluded with INTAGE Inc., and the survey
was carried out with the exclusive survey staff according thesurvey plan prepared by the author. Survey data was ownedby the author after a cosignment fee was completely paid.

“refused,” and the rates of each were clearly described.
More than 70% of the families showed recognition toaccept the medical practice performed nurses with conditions.
Moreover medical examinations for diagnosis by nurses, therate of requesting conditions was high, such as “experienceand acquired medical knowledge of the nurse,” and “receive
permission of a physician beforehand.” For drug prescriptions,among the rate of requesting conditions, “receive permissionof a physician beforehand” was the highest, followed by“experience and acquired medical knowledge of the nurse.”
In the recognition of “judgment whether to implement an
examination”, less than 80% of the families answered thatsuch could be accepted with conditions. The condition
supported with the highest rate was implementation “within
the range of the permission of a physician beforehand.” Also,
recognition that such is acceptable when “implementationof examination in case of emergency,” and “experience andacquired medical knowledge of the nurse” was observed.
The rate families accepted medical care with no conditions
was 24.6%, 11.8% for drug prescription, and 10.2% forexamination. On the contrary, the rate families answeredthat they wanted medical care by physicians was 3.6%, 17.0%
for drug prescription, and 9.8% for judgment whether toimplement an examination.
4) Relationship of recognition of medical practices performedby nurses, and attributes of the family and resident, andmedical care conditions
Following data shown in Table 2, correlation between
recognition of medical practices performed by nurses, andattributes of the family and residents, and medical careconditions, was summarized in a cross table, along with chisquare test or Fisher’s accuracy probability test in Table 3,
and then Cramer’s V measurement was added.
Considering these estimated values, significant difference
using the 5% standard was observed only in the correlation
between gender of the family member and implementationof examination by nurses (p = .015). For the strength of thisassociation, Cramer’s V was .166. Regarding variables showing
family attributes, frequency of medical care of the resident,with or without environment to receive 24 hour medical careby a physician, and recognition of medical care performedby the nurse, no conclusive correlation was observed in the
results.

III. Results

1. Results of the Questionnaire Survey
The number of valid respondents was 305 persons, with avalid response rate of 77.0%.
1) Attributes of family and residents
Gender of family members was almost equal, at 152 men(49.8%), and 153 women (50.2%). The age range was 19–76
years, mean age was 52.65 years. Gender of the residents wasmore female than male at 206 women (67.5%) and 99 men(32.5%). Mean age was 78.13 years (Table 1).
Table 1. Attributes of the family and residents (questionnaire)
Men
Gender (%)
Women

n=305
152(49.8)
153(50.2)

Mean age ±SD(range)52.65±11.35(19～76)

Mean age ±SD78.13±16.59

Civil servant / company workers 191(62.6)
Full-time home makers
75(24.6)
Occupation Unemployed / retired
31(10.2)(%)
Students
4( 1.3)
Others4( 1.3)
FamilyHokkaido / Tohoku region11( 3.6)
Kanto region
216(70.8)
Koshinetsu / Hokuriku region
7( 2.3)
Chubu / Tokai region16( 5.2)
Address (%)
Kansai region32(10.5)
Chugoku region5( 1.6)
Shikoku region3( 1.0)Kyushu / Okinawa region15( 4.9)
Men99(32.5)
Gender (%)
Women
206(67.5)
Residents

2) With or without an environment to receive medical careby a physician when needed
The number of families who responded that they were in
an environment where medical care by a physician could
be received as needed, 24 hours, 365 days was 151 persons(49.5%), and the number of families who responded that they
were not, was 154 persons (50.5%), almost same number.
Of the 154 persons who responded that they were not in anenvironment to receive medical care by a physician whenneeded, 75 persons (48.7%) who were asked whether they
“have trouble with not being able to receive medical careby a physician when they wanted” and responded “yes.”
As for one reason for trouble, more than 80% of the family
answered “response to the sudden appearance of symptomsof the users.”
3) Recognition of the medical practices performed by nurses
Table 2 shows recognition of medical practice performedby nurses by families of a resident living in an elderly carefacility. Furthermore, subjects were divided into those who“unconditionally accepted,” “accepted with conditions,” and2. Results of the semi-structured interview survey1) Attributes of the family and resident
Of the 5 family members who received an interview survey,
two were women, three were men, and range of age was withthe late 40s to the late 60s. Degree of nursing care need of
the residents was 3 and higher, and experienced multiple
facilities. Moreover, average years of residency in thesefacilities were approx. 6 years (Table 4). Average time forthe interview was 48 minutes.
2) Recognition of the expansion of discretionary authority ofnurses by families of residents in elder facilities
According to discussion on the expansion of the discretionary
authority of nurses with the family, three categories and 13
sub-categories could be abstracted (Table 5). Hereinafter the
categories are shown by 【 】 , and sub-categories are shownby [ ].
【Hope that expansion of discretionary authority of nurses
connects to expansion of the medical service provisionsystem】 could be abstracted from 6 sub-categories. Some
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This paper was published at “the Japan Society of Nursing Research” Vol.39 No.2 in 2016.

Yearbook on Journal of the Japan Society of Nursing Research 2017

Table 2. Recognition of medical action performed by nurses (questionnaire)
n=305
Determining
Rate ofRate ofRate of
Medical carenprescription bynto performn
Acceptance / Drug
Acceptance / whether
Acceptance /performed by nurses (%)
nurses(%)
an
examination
by(%)
Rejection
Rejection
Rejection
the nurse
Unconditionally75
Unconditionally Unconditionally36
Unconditionally Unconditionally31
Unconditionallyaccepted(24.6) accepted 24.6% accepted(11.8) accepted 11.8% accepted(10.2) accepted 10.2%
PrescriptioncanAccepted if theCan be allowed if
13
be accepted if the
13
12nurse has many
the nurse has many (3.9)
(4.3)
nurse
has
many
(4.3)
years of experience
yearsofexperienceyears of experience
Prescription canbe accepted if the
Accepted if the
Accepted if thenurse has many
nurse has many
nurse has many
79
years
of
experience,52
54
years of experience, (25.9)
years of experience, (17.7)
andacquired(17.0)
and acquiredandacquired
medical knowledge,
medical knowledge
medical knowledge
such as medicine
and pharmacy
Prescription by
Accepted only
Accepted if thenurses can be
37
15
when needed as55
medical care is 24
acceptediftheAccepted
Accepted(12.1)(4.9)
emergency(18.0)
hours response
medical care is 24
with
with
examination
hours response
conditions
conditions
Accepted
71.1%
79.9%
Prescription by
withAccepted if lessnursescanbeAccepted
if
less
6
7
1
conditions
expensive than by a (2.0)
accepted if lessexpensive than by a (0.3)
71.8%
physicianexpensive than by a (2.3)
physicianphysicianAccepted if the
Prescription if the
Accepted if the
21
14
20
nurse is frequently
nurse is frequently
nurse is frequently
(6.9)
(4.6)
(6.6)
involved
involved
involved
Prescription by
nurses can be
Examination can
Accepted if
accepted in thebe permitted in theapproved by a
48
116
102
range ofrange of specified
physician(15.7)(38.0)(33.4)
permitted
byabyaphysicianbeforehand
physicianbeforehand
beforehand
Strongly desire
Accepted if
Strong desire drug
judgment of
15
52
30
symptoms areprescription by a
Reject 17.0% implementation
Reject 9.8%
(4.9)
(17.0)(9.8)
stablephysicianperformed by aphysicianWish to havemedical care
11
Reject 3.6%
performed by(3.6)
physicianand muscle power due to hospitalized treatment, andfeelings that expansion of medical services are needed,
and fear that [Quality of life in the facility will be reducedby hospitalization], leads to the approval of medical care
implemented by nurses. In addition, for the residents, since
the elderly care facility is where they live, they would liketo receive medical services at the facility where they areaccustomed. Hence residents, indicate approval of expansionof the discretionary authority of nurses in response to[Medical services needed where residents live].
All five family members spoke about their plans for endof-life of the residents in the facility. If expansion of thediscretionary authority of nurses is carried out with the
purpose of supplementing [Expansion and enhancementof end of life medical service in elderly care facilities], thismeasure is considered to match trends of the generation.
In addition to realizing the above described requests
through the expansion of the discretionary authority ofnurses, families showed five 【conditions to bear medical
practices】. One condition is [clarification of the medical range
carried out by nurses]. Determining to what degree medical
practices the nurses are permitted to carry out is considered
important, and the need to divide medical practices by thefamilies, while seeking rapid response by the facility in casesof poor resident condition and painful symptoms, showed
the possibility that nurses could contribute to this matter.
From these codes, [Expectation to contribute to the easingof pain of the resident] could be configured. Furthermore,in cases where the resident requires a medical examination
at the hospital, there is concern that much time would beneeded to receive such medical care and lead to physicalburden and worsened symptoms of the resident. To address
such cases, medical practices by nurses is expected to expand
and enhance medical services of the facility. Hence, the subcategory [Expectation leading to the reduction of burdenof the residents] could be abstracted. Some families felt
burdened by the situation where facility will call each time theresident of the elderly care facility needs to visit the hospital,
and must go to the hospital with the resident. Even in cases
where the facility staff goes to the hospital, the families are
faced with the financial burden of being separately billed for
medical fees which are not included. As a result of expansionof medical services in the facility by medical practice of thenurses, the families have the [Expectation of reduced burden
on the resident].
Moreover, worries regarding further loss of cognition
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This paper was published at “the Japan Society of Nursing Research” Vol.39 No.2 in 2016.

Carried out
as needed

Approx.
once / 2-3
months1 time ormore /
month

65 years orolder

50-64 years

Less than 50
years

Women

Men

This paper was published at “the Japan Society of Nursing Research” Vol.39 No.2 in 2016.

583 persons(81.4%)

28 persons(70.0%)

52 persons(72.2%)

17 persons(81.0%)

37 persons 112 persons(24.0%)(72.7%)

38 persons 107 persons(25.2%)(70.9%)

18 persons(25.0%)

4 persons(19.0%)

39 persons 116 persons(23.9%)(71.2%)

11 persons(27.5%)

47 persons 108 persons(28.8%)(66.3%)

17 persons(16.7%)

31 persons 118 persons(20.3%)(77.1%)

44 persons 101 persons(28.9%)(66.4%)

5 persons( 3.2%)

6 persons( 4.0%)

2 persons( 2.8%)

0 persons( 0.0%)

8 persons( 4.9%)

1 persons( 2.5%)

8 persons( 4.9%)

2 persons( 2.0%)

4 persons( 2.6%)

7 persons( 4.6%)

.024

.061

.112

.119

.910

.899

.099

.111
73 persons 16 persons(71.6%)(15.7%)

27 persons(67.5%)

9 persons(22.5%)

58 persons(80.6%)

15 persons(71.4%)

8 persons(11.1%)

3 persons(14.3%)

18 persons 108 persons 28 persons(11.7%)(70.1%)(18.2%)

18 persons 109 persons 24 persons(11.9%)(72.2%)(15.9%)

6 persons( 8.3%)

3 persons(14.3%)

18 persons 112 persons 33 persons(11.0%)(68.7%)(20.2%)

4 persons(10.0%)

19 persons 117 persons 27 persons(11.7%)(71.8%)(16.6%)

13 persons(12.7%)

13 persons 112 persons 28 persons( 8.5%)(73.2%)(18.3%)

23 persons 105 persons 24 persons(15.1%)(69.1%)(15.8%)

Note 1) a= chi-square test or Fisher’s accuracy probability test
Note 2) * : p <0.05
Note 3) “Frequency‌of regular medical care by physician for the residents”: Due to residents who did not receive medical care by physician in past six month(for the residents)
With or withoutYes
an environment toreceive medicalcare by a physician
in a timely way, 24 None
hours (n=305)

Frequency ofregular medicalcare by physician
for the residents(n=256)Age of thefamily member(n=305)

Gender of thefamily member(n=305)

Drug prescription by nurses

Determining whether nurses should perform examinations

.030

.090

.043

.104

.868

.368

.893

.191

82 persons 10 persons(80.4%)( 9.8%)

32 persons(80.0%)

4 persons(10.0%)

57 persons(79.2%)

19 persons(90.5%)

6 persons( 8.3%)

1 persons( 4.8%)

15 persons 121 persons 18 persons( 9.7%)(78.6%)(11.7%)

16 persons 123 persons 12 persons(10.6%)(81.5%)( 7.9%)

9 persons(12.5%)

1 persons( 4.8%)

12 persons 133 persons 18 persons( 7.4%)(81.6%)(11.0%)

4 persons(10.0%)

17 persons 130 persons 16 persons(10.4%)(79.8%)( 9.8%)

10 persons( 9.8%)

8 persons 128 persons 17 persons( 5.2%)(83.7%)(11.1%)

23 persons 116 persons 13 persons(15.1%)(76.3%)( 8.6%)

.063

.078

.007

.166

.544

.647

.999

.015*

Strong wish
Strong desire
Strong desire
Uncondition- Accepted
to have
Uncondition- Acceptedfor drug
Uncondition- Accepted
Probability
Probability
Probability
to have
with
ally
with
medical care Cramer’s V
Cramer’s V
ally
with
prescription Cramer’s V
allyaasignificancesignificancesignificancea
judgment by
accepted
conditions
accepted
conditions performed
accepted
conditions
bya physician
by physician
a physician

Medical care performed by nurses

Table 3. Relationship of recognition of medical care performed by nurses, and attributes of the family and residents, and medical care conditions

Yearbook on Journal of the Japan Society of Nursing Research 2017

Yearbook on Journal of the Japan Society of Nursing Research 2017

Table 4. Attributes of the family and resident (Semi-structured interview)

No.
1
2
3

Gender of
the family
memberAge ofRelationshipthe family
to thememberresident

Disease of the resident

Woman

Late 40s

Respiratory disease /dementia

Woman

Late 40s

Daughter-in- Mental disorder / dementia
law
DaughterMan

Early 50s

Son

4

Man

Late 50s

Son-in-law

5Man

Early 60s

Son

Cerebrovascular diseases/
dementia
Bone / muscle diseases /dementia

Cerebrovascular diseases/
left side paralyzed

Degree ofnursing careneeded by
the resident

Type of facility experienced by
the resident

Total years as
resident

5

Nursing Elderly Health Facilities
Special elderly nursing homes

Approx. 3 years

5

Nursing Elderly Health Facilities
Special elderly nursing homes

Approx. 5 years

43
5

Nursing Elderly Health Facilities
Special elderly nursing homes
Nursing Elderly Health Facilities
Special elderly nursing homes
Charged senior homes

Approx. 5 years

Approx. 7 years

Nursing Elderly Health Facilities Approx. 10 years
Special elderly nursing homes

treatment at a hospital, and those with care needs during
end of life in the facility have increased. However, it is also
indicated that maintenance of the environment to provide
services which comprehensively understand the healthcondition of the residents is insufficient, while focusing on the
support of the life of the residents (Hirose, 2012, pp.314-316).
When describing this condition, about half of the families
answered that the resident is not in an environment where
they can receive medical care by physician when needed, as
shown in the results of the questionnaire survey of this study.
Request for further improvement in qualitative service at thefacility could also be heard in the interview survey results.
The family may predict that if the medical practice of thenurses leads to expansion of medical services at the facility,
this would lead a reduction in the burden of the family.
Recognition to approve expansion of the discretionary
authority of nurses was shown in the desire 【Hope theexpansion of discretionary authority of nurses leads toexpansion of the system to provide medical services】, because
sufficient satisfaction of current services at the elderly carefacility has not been achieved.
Hence, maintaining an environment in order to enhanceand expand medical service at the facility is required toensure the life of residents in the place where they have lived
for a long time. The expansion of discretionary authority ofnurses is a part of such maintenance. If medical practice basedon the accurate symptom management leads to improvement
in symptoms and relief of pain of the residents, at least has
the possibility of avoiding a burdensome visit to the hospital.

physician and those permitted to be performed by nurses
must be pointed out. Next, the condition that [Education andtraining which corresponds to bearing medical practices isrequired] has been indicated for nurses to bear new medical
practices, even in coordination with a physician, while
recognizing that [Coordination with the physician is essential]
by some kind of direction by the physicians. As the fourth
point, some families consider [Placing responsibility only on
the nurses is not realistic]. The reasons for this are; since ahigh emotional burden is placed on nurses, an increase in thenumber of nurses able to bear high level medical practices
cannot be expected, and in addition to dividing responsibilities
will be advantage of the nurses, there was recognition that
there is a sense ease if responsibility is placed both on thenurses and the physician. The last condition is the opinionof [hope that the nurses maintain the attitude to fulfill the
responsibilities associated with implementation of medical
practice]. If nurses with new authority are created, it is hopedthat they are prepared to bear the responsibilities. In addition,
the families said that they think that persons who bear the
medical practice should be evaluated by the responsibilities
they bear, rather than as physicians and nurses.
Some families feel there is a need to implement 【measures
to address the lack of manpower in elderly care facilities】.
Including concern as to whether sufficient nursing care of
the residents is provided, the families have [dissatisfactionin the quality of care itself due to the lack of manpower] sincefacility staff changes so often. Furthermore, concern that
nurses with extensive knowledge and high skills will soonleave, could be seen since [low facility retention rate of nurses
and the nursing staff] was significant. Nurses who bear highlevel medical practices may not stay at the elderly care facility,
as long as no fundamental measures are taken for the nurses
and care workers to stay at the facilities.

2. Reasons for the family to value the nurses
Some families perceive nurses as a close presence. Furthermore,
it is clear that the potential needs of the implementation of
medical practices of nurses can be extracted.
Why does the family perceive nurses as a close presence?
One reason can be said to be the strong “closeness” between
the family and the nurses.
Reasons for the goodwill and attractiveness in this humanrelationship are accessibility, physical attraction, similarities,
complementarity, reciprocation of goodwill, etc. By simple
repetition, familiarity with one another increases, and as aresult, develops into goodwill.
Moreover, Wakimoto and Fujiwara indicated the phenomenon

IV. Discussion

1. Expectation of improvement in the quality of life of theresident and family
Disease composition of the residents in elderly carefacilities has diversified, and residents with chronic disease
have significantly increased. Regarding recent trends, cases ofresidents entering a facility right after completing acute phase
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Yearbook on Journal of the Japan Society of Nursing Research 2017

Table 5. Recognition of the expansion of discretionary authority of nurses by families and residents in elderly care facilities(Semi-structured interview)
Category

Hope that
expansion of
discretionary
authorityof nurses
connects to
expansion of
the medical
serviceprovision
systemSub-category

Expectation tocontribute to theeasing pain of theresident

Expectation
leading to the
reduction of
burden of theresident
Expectation
leading to the
reduction of
burden of thefamilyQuality of lifeat the facility
will decrease byhospitalization
Medical service
needed for the
residents to live

Code

Because I want something to be done as soon as possible in cases of painful symptoms such as “the injury hurts,” “can’t eat
because I don’t feel good,” if the nurse on hand can provide medical care, it will be helpful.
When I visit, I frequently observe bad condition (of the resident) and inform the facility staff, but they only respond as “I tell(the physician) on the next visit,” but it doesn’t appear any kind of treatment was provided. So I want the nurses or someone
to provide some kind of treatment.
Because (the resident) himself/herself and family want to relieve pain which hinders the life that suits the resident, so won’t
they understand if something happens as a result of medical practices by the nurse?

Especially when in a bad condition and the resident requires a medical examination at the hospital, there is concern that muchtime would be needed to receive such medical care and lead to physical burden and worsened symptoms of the resident. To
address such cases, medical practices by nurses are expected to expand and enhance medical services of the facility.
The resident is not in the condition to receive medical care although he or she wants to, taking the person to the hospital for
medical care “because here is not a hospital” is incorrect.
Although being in a facility with a view of emergency response, it seems that a quick response for the symptoms is notprovided, so I want medical care by nurses to lead to solution of the present situation.
As long as there are aged people with disease, I think facilities which provide medical care will be needed more than ever. I
would accept the expansion of discretionary authority of nurses to do so.
The facility calls each time the resident needs to visit hospital, and requests for the family accompany the resident to thehospital. It is a large burden. If nurses can provide medical care at the facility as much as possible, the family would also
appreciate it.
Sometimes the family asks the facility to judge whether the resident should go to the hospital or not. If high level nurses areneeded for this judgment, it should be established.
The facility additionally bills us for medical expenses every time the resident needs to go to the hospital. I want medical care
response to be expanded within the facility, so if the nurses can play an active roles in this, I want such nurses to be trained.
If the resident is admitted to the hospital, the problem may get better, but dementia and muscle power will decrease, andquality of life of the person will be reduced after returning to the facility, so an environment in the facility which can respondshould be organized as much as possible.
When (the resident) is admitted to the hospital for treatment of disease, response clearly worsens, maybe due to the change
in the environment.
Symptoms such as fever, etc. occurred regularly, so the facility where the resident lives should respond to a certain degree.
The facility considers the life and comfort of the resident, so I want the facility to provide medical care if possible. I can agree
to the expansion of discretionary authority of nurses for this reason.
The resident essentially hates hospitals, and wishes the facility where the resident lives for a long time can treat diseases andsymptoms to some degree. If expansion of the discretionary authority of nurses is needed, it should be carried out as soon as
possible.
Medical care to minimize pain during end-of-life is needed. I think expansion of authority for not only physicians, but also
participation in medical care by nurses who are close to the resident, is the natural progression in this generation.

Expansion andenhancement of
end-of-life medical
service in elderly End-of-life care at elderly facilities is considered to increase from now, so I think it is important for facilities to have system toprovide a certain degree of medical care, not only hospital.
facilities
Determining to what degree nurses are permitted to carry out medical practice is considered important, and dividing medical
practices which can be performed only by the physician and those which can be performed by nurses should clearly identified.
Clarification
When the condition of the (resident) does not change, and changes in medication are not needed, I think the nurses can alsoof the range ofhandle this.
medical practices
The mechanism that physicians perform things that only a physician can do, and nurses bear things which nurses can also do,
performed byis considered needed. If these roles can be clearly differentiated, I don’t think this would be a problem.
nursesI think there is big gap between medical practices for internal organ diseases, and minor symptoms occurring in daily life. For
drug prescription and treatment of minor symptoms, I think nurses can also handle it.
For medical practices performed by nurses, I want such medical care to be performed under the direction of a physician.
judgment regarding medical care should be carried out by a physician. Instead of the idea of medical practices being
Coordination with Finalcarried out as determined by the nurse only, it would be better to consider how to focus on smooth coordination with thephysician is anphysician.
essential condition
The range of medical practices for nurses to perform can be expanded, but I want a mechanism where the physician can makethe final judgment on the validity of the medical practices.
Require education A method that grants certification to participate in clinical training which is carried out for physicians, also to nurses who
Conditions
and training which have certain clinical experience should be considered.
for nurses to corresponds to
New authority can be granted to the nurses who have a solid education and training, not nurses as they are now.
bear medical bearing medical
Nurses have not been educated to make diagnoses and to prescribe medicine, so education in order to bear new medical
practices
practices
practices is needed and should be firmly provided.
Allowing nurses to bear the responsibility on their own is practically impossible. Even if it does occur, I don’t think many
Placing
people will want to be a nurse who must bear such high level medical practices.
responsibility
I wish that both physicians and nurses have positions of responsibility. For nurses, it is better to perform medical practices
only on theunder some kind of direction of the physician.
nurses is not
When thinking about the mental burden on nurses, performing medical practices where the responsibility is placed only of
realistic
them seems impossible. As a family member, I feel it would be better if the physician bore responsibility.
Hope that thenurses maintain
Instead of thinking only within the range of the physicians and nurses, persons who bear the medical practices should be
an attitudeevaluated.
to fulfill the
responsibilities
associatedwith theIf the nurses are given new authority, I want them to be prepared to firmly carry the responsibilities.
implementation of
medical practices
Dissatisfaction in If the facility staff changes often, I worry if resident received sufficient nursing care, so ensuring enough staff members should
the quality of care also be considered.
Measuresdue to the lack of (The resident) is always in bed. This may be due to few staff members, so I worry if dementia and loss of muscle power willto address
manpower
worsen.
the lack of
manpower in Low facility
I think the caregiving staff and nurses are not treated well, and the staff changes so often. I worry if good nurses can beelderly care retention rate ofretained in such workplace.
facilities
the nurses and the
At workplaces with a low retention rate, I think kind nurses with extensive knowledge and skill will quickly leave.
nursing staff

7
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Yearbook on Journal of the Japan Society of Nursing Research 2017

where “Within the reasons as to why the other person has
the same attitude, confirmation of validity of one’s own
attitude can be raised, and this comfortable emotional
reaction connects to gaining familiarity” (1997, pp. 85-96).
Consideration of self, rather than consideration of others, isa strong motivation in self-approval. High communication
skills are needed to acquire and maintain such self-approval(Okegawa, 2011, pp.23-34). Furthermore, to manage andmaintain a close relationship, communication which reflectsconsiderations such as seeking self-disclosure, expressing
acceptance and respect of the other person, and expressing
one’s feelings to develop a mutual relationship, are required(Daibou, 2004, pp.1-10).
Truly, communication skills based on the above described
points exist in the life assistance by nurses. For example,
showing a sympathetic attitude as an attitude of understandingof the pain of the residents, and intentionally praising
the resident by finding his or her good points, in order toraise improve one’s ability such as empowerment and selfmanagement. One aspect of sharing problems and sufferingwith the residents and family is a basic attitude of nursing care.
Hence, nursing is a medical expert job with high familiarity,
and requires relative medical practices and life assistance, thefamily is considered to find presence value in those who could
bear medical practice.

medical practice for operations performed by nurses. They
are considered to judge “conventional knowledge and skill
held by the nurses cannot ensure safe medical practice.”
Furthermore, there is a tendency not to completely reject
the fact that some nurses can bear medical practice. It may
be that the families can sense the possibility that such a nurse
training education system will connect to safe and effective
medical service.
Regarding another condition, some families showedrecognition that [Placing responsibility only on the nurses
is not realistic].
Clarification of responsibilities assigned to medical practiceof the nurses is an important issue of this political measure.
In addition, the families themselves do not wish to make snap
decisions and leave this point unclear.
In case an unexpected event occurs to a resident due to the
medical practice of a nurse, provisions such as “professional
negligence resulting in bodily injury” and “professional
negligence and involuntary manslaughter” of Penal Code,and “illegal acts” and “non-fulfillment of obligation” in Civil
Code can be applied.
Recently, the number of medical lawsuit cases havedrastically increased, and the number of cases under disputein local court is approximately 3,000 cases (Koizumi, 2009,
pp.113-119). One reason for this increase is that, although
wonderful achievements have been made in modern
medicine in many ways, and invasive examinations andtreatment methods have decreased due to progress in medical
techniques, there is also growing public awareness thatreceiving medical services does not guarantee a good result(Koizumi, 2009, pp.113-119).
The author is concerned that under the current conditions,accelerating the medical practice of nurses may increase thenumber of medical lawsuits. Families who may wish to sue
nurses who cannot be said to have a high social status, who
fail to fulfill the obligations of the medical contract existing
between the service provider and receiver, are predicted
to increase, in addition to feeling that medical practice byunderdeveloped knowledge and skill has a high possibilityof leading to failure. Some families are thought to show
recognition that [Placing responsibility only on the nurses
is not realistic], since they cannot remove all doubt that if
nurses in charge of providing safe medical practice will not
be held responsibility for “illegal acts” and “non-fulfillment of
obligation,” can they be accountable for implementation, andbe liable in cases of lost lawsuits?
Some families want [nurses who maintain the attitude tofulfill the responsibilities associated with implementationof medical practice]. If the discretionary authority of nurses
is expanded, the range of responsibility to be carried out
will also be expanded. Nurses who accept this medical
practice and are prepared to accept this responsibility areapproved. Moreover, because safety is highly valued, nurses
who have confidence and have prepared all the processes of
implementation, are supported.
Hence, as a condition of expansion of the discretionary
authority of nurses, this authority should be given to nurses
who have a conviction called “a sense of mission,” shouldn’t it?
Moreover, to bear medical practice, having this qualification
or not should be evaluated by the educational agency, etc.
Furthermore, consideration of an educational program todevelop this quality also corresponds to an important pointof focus.

3. Conditions for nurses to bear medical practice
Results of questionnaire survey showed a tendency of
non-approval for discretionary authority without conditions,even though there is leeway in the acceptance of medical
practices by nurses. Furthermore, the interview survey could
clarify some reasons why such discretionary authority withconditions is preferred. The main reason is concern for safety
in medical practices performed by nurses.
Families consider safety to the maximum limit, and demanda clear distinction in medical practices which should be
performed by a physician and those which can be handled
by nurses as well. Furthermore, the need to coordinate
with physician is also pointed out. Accordingly, the author
considers that current recognition of the family is that they
do not want to medical practices to be decided and practiced
only by the judgment of the nurse. Don’t they want a systemthat can ensure a safe and secure life at the facility morethan ever, by determining team medical care establishedon multi-occupational cooperation, and selecting nurses ascandidates of human resource? Hence, regarding medical
practice performed by nurses, the need for coordination withthe physician is high.
Kitahama (2011, pp.292-294) and Takahashi (2011, pp.354357) indicated that there is a difference in the level ofknowledge and skill in medical care when comparing nurses
in Japan and Nurse Practitioners and Physician Assistantsin the U.S. Nurses in Japan have not received fundamental
education regarding medical care operations such as diagnosis
and treatment. From the legal viewpoint as well, these cannot
be carried out as part of daily operations. In other words,
there is no contradiction by the existence of both evaluations
for nurses in Japan. This means that because nurses do nothave sufficient knowledge and skill to bear medical practice,
the appropriate education and training will be needed if new
discretionary authority is given to nurses.
Perhaps because families are aware of this point, they
request education and training which is appropriate to bear
8

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Yearbook on Journal of the Japan Society of Nursing Research 2017

4. Concerns regarding lack of manpower at elderly carefacilities.
Some families feel the need to take 【measures to address
the lack of manpower in elderly care facilities】 in order toretain nurses who bear a large part of medical practice inelderly care facilities.
Shimazaki (2013, pp.333-340) predicted the “when estimating
the percentages of the labor population in 2025, the nursing
staff will be 3.1%, caregivers 3.9%, and overall staff in the
medical and nursing field will be 10.2%.” Furthermore, forthe labor population who can bear medical and nursing caremust remain at approx. 10% of the total population, measures
to ensure human resources with a realistic viewpoint and toincrease these numbers are needed. Also the point that good
human resources will not be attracted if the appeal for nursing
and care giving jobs is relatively low in the labor market and it
is difficult to prevent leaving a job and reappointment to a job.
In other words, improvement and standardization of
educational standards of nursing and caregiving jobs areneeded, and setting a payment suitable for the labor is alsoneeded. How the national budget can be distributed to thesefields is thought to influence improvement in elderly carefacility functions demanded by society.

was five persons. In consideration of these points, whenfamilies with residents in elderly care facilities throughout
Japan are presumed to be the survey target group, selection
bias towards recognition of the expansion of discretionary
authority of nurses cannot be denied. Consideration of asurvey method which minimizes bias of the respondents isneeded in the future.
Conclusion

Regarding the expansion of discretionary authority ofnurses, clarifying recognition by families with residents
in elder facilities is set as the goal of this study, and aquestionnaire survey and semi-structured interview survey
were carried out. As a result, the following conclusion was
obtained.
As a result of the questionnaire survey, the rate of families
who show intention to approve expansion of medical
practice performed by nurses with conditions was morethan 70%. Furthermore, as a result of consideration of theinterview survey results, three points were shown as theoutcome expected by the families, namely 1) connection withincrease in peace of mind and convenience for the resident
and family, 2) connection to the service that values the lifeof the residents, and 3) connection to the expansion andenhancement of terminal phase medical care.
Regarding conditions indicated by the families, five
points were raised, as 1) thorough education and training
which corresponds to bearing medical practice, 2) practicebased on coordination with the physician, 3) delegation of
responsibility of medical practice, 4) nurses who have attitude
to complete the responsibilities associated to implementationof medical practice, and 5) clarification of the range of
medical practice performed by nurses. The reason why these
conditions appeared is that families do not want for nurses todecide the details of the medical practice and perform it only
by judgment by the nurses from the viewpoint of safety, andthey wanted to establish a system which could ensure a safe
and secure life at the facility more than ever, by establishingteam medical care based on multi-occupational cooperation.
Due to the above reasons which can be said to be theviewpoint of how medical service was valued, these arethought to connect to the rejection in the correlation between
recognition of the medical practices performed by nurses,
attributes of the families and the residents, and medical careconditions.

5. Relationship of recognition of medical care performed bynurses, caregiving conditions, etc.
Regarding the correlation between recognition of medicalcare performed by nurses, attributes of the family andresident, and medical care conditions, only the gender ofthe family member and recognition of judgment to carry out
examinations was significant according to a 5% standard.
Moreover, Cramer’s V was .166, so this correlation is considered
to be negative. Also, between other variables, estimatedvalues cannot be said to necessarily be related, are shown.
The following points regarding the results are pointed out
by the author.
One value of medical service held by most families is therecognition that no other job can practice medical care better
than that of the physician. However, families also predict that,with the expansion and enhancement of medical service asa result of increase in the discretionary authority of nurses,
there is a possibility of connecting to better service withhigher convenience for the residents in elderly care facilities
and their family. Hence they support [clarification of the
medical range carried out by nurses] and [Education andtraining which corresponds to bearing medical practices isrequired], in addition to coordination with physicians anddiffusion of medical practice responsibilities as conditions
for nurses to bear medical practice, and think that, if these
conditions can be met, they will lead to stable services andnot cause safety issues. In other words, it was presumed that
because families value medical service which is not affectedby conditions of medical care of the residents and attributes,
etc. of the residents and family, so the correlation between
their recognition for the medical care performed by nurses,
and caregiving conditions, etc. is connected to rejection.

Acknowledgments

We would like to express our appreciation for the cooperation
shown by the families of the residents in elder facilities.

The survey in this study was carried out with the “2015
Next Generation Joint Research Project Subsidy, Soka
University” This article is part of the doctoral thesis of theauthor presented in September 2015 (graduate thesis, Hosei
University) with partial addition and correction.

6. Limits and Issues of the results of the survey results
Regarding respondents of this survey, there is bias in theoccupation and address of the family cooperating in thequestionnaire survey, in addition to a major survey company
carrying out monitoring. Furthermore, the number of family
members targeted in the semi-structured interview survey

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