1 Introduction

1.1 Japan’s Super-Aging Society

Japan is one of several “super-aging societies” in the world today, with 24.1 % of the nation’s population over the age of 65. If the population continues at its current rate, the number of recipients of long-term care will likewise continue to increase (Fig. 1).

Fig. 1.
figure 1

Age-specific population of Japan

Full size image

As the wave of elderly continues to swell, current long-term care facilities are exhausted. The turnover rate for caregivers in these facilities is also quite high compared to other occupations, causing even dedicated staff to quit from overwork (Table 1).

Table 1. Comparison of the quitting a job rate
Full size table

1.2 Purpose of Research

The turnover rate for caregivers in these facilities is quite high compared to other occupations, causing even dedicated staff to quit from overwork. The option of training employees without a nursing background may be an integral part of the solution.

The least favorite part of nursing care among nursing-home workers is monitoring or keeping an eye on the senior residents. There is no manual on how to best monitor the elderly. There are no pointers that come with photos – as in transfer techniques – when it comes to taking care of the elderly. Because one does not have access to visual or audio demonstrations during classes on nursing care, students who specialize in nursing care have to learn on the job.

  • What is “Monitoring the Senior Residents”?

“Monitoring the senior residents” is one method to support the independence of senior residents in nursing homes. It is designed to protect the autonomy and independence of senior residents, and to prevent caregivers from limiting behaviors of elderly only based on caregivers’ discretions. However, should that caregivers determine the elderly to be at risk of injury or death, the caregivers must assist the elderly immediately. (1) In this research, we checked the manual of the nursing home subjected to this experiment. It covers how to greet the elderly, daily routine work such as “assistance moving from a wheel chair to a bed or chair”, “excretion assistance” and “dietary assistance”. It also covers how to use large washing machines, and emergency procedure in the event of “infectious diseases”, but it doesn’t include “monitoring the senior residents”. There is the close item titled “Communication”, but it refers only the basic knowledge about appropriate words and dialogues when speaking to elderly. (2) We wondered how nursing homes train new staff for “monitoring the senior residents” without any solid educational tools. In this study, we evaluate the difference in monitoring assistance skills between skilled and non-skilled caregivers.

2 Questionnaire Survey and Results

2.1 Survey Subjects

The subjects were 16 regularly employed caregivers working on the same floor in the nursing home where the experiment was conducted.

Table 2 shows how many years of experience the 16 subjects had as caregivers.

Table 2. The list of caregivers
Full size table

2.2 Questionnaire Survey

The purpose of this survey was to comprehend the caregivers’ senses when monitoring the senior residents. We conducted the survey on 16 caregivers: 10 unskilled workers with 1–3 years of experience, and 6 skilled workers with more than 4 years of experience. We clarified the survey results according to the length of working experience.

The Survey items are as shown below:

  • What do you think of your ability to “monitor the senior residents”?

    Very Poor, Poor, Okay, Good, Excellent

  • Are there any particular times during the day or days of the week when you find monitoring the senior residents to be most difficult? (Please write the exact day, time and reason)

2.3 Survey Results

Figure 2 shows the survey results of how the 10 unskilled workers with 1–3 years’ experience felt about monitoring the senior residents. Figure 3 shows the results of 6 skilled workers with over 4 years’ experience.

Fig. 2.
figure 2

The conscious of caregivers to monitoring senior residents (unskilled workers)

Full size image
Fig. 3.
figure 3

The conscious of caregivers to monitoring senior residents (skilled workers)

Full size image

Listed below are the reasons why the 10 unskilled workers with 1–3 years’ experience found it difficult to monitor the senior residents:

  • They have to engage in routine work while watching the senior residents.

  • They sometimes do not notice a change in the senior residents.

  • They need to concentrate on paying attention to the senior residents

  • It is very stressful when engaged in monitoring work by themselves.

  • They are rushed to handle many hyperactive seniors but enjoy communicating with the senior residents.

  • Hyperactive seniors cause a mental burden.

Listed below are the reasons why the 6 skilled workers with over 4 years’ experience found it difficult to monitor the senior residents.

  • Monitoring 30 to 40 senior residents places a mental burden on them.

  • They becomes sensitive to little sounds and voices.

  • They find it difficult to handle hyperactive senior residents

Figures 4 and 7 respectively show particular times of day when the 10 unskilled workers and 6 skilled workers found it difficult senior residents (Fig. 5).

Fig. 4.
figure 4

Most difficult time to monitor senior residents (unskilled caregivers)

Full size image
Fig. 5.
figure 5

Most difficult time to monitor senior residents (skilled caregivers)

Full size image

The reasons put forward by the unskilled workers are listed below:

  • All caregivers are busy during bathing time.

  • With taking senior residents to tables and preparing their meals after bathing time, they do not have time to do other tasks.

  • When cleaning up tables after meals and administering medicine dosages, the senior residents tend to be hyperactive.

The reasons put forward by the skilled workers are listed below:

  • Most caregivers come down to the first floor during bathing time and cannot take immediately assist hyperactive residents or residents requesting toilets.

  • The caregivers have to be alert when administering medication doses and cleaning up tables.

  • The caregivers need to pay attentions to many things, such as taking seniors to the toilet or bed.

As shown in Fig. 2, only two new staff selected “very poor” in response to the first question. Half of the new staff and skilled workers answered “okay”. This is an unexpected result, because the author expected that most caregivers would answer “poor”.

Considering these results, monitoring does not include physical contact with senior residents. This means that there is less risk of care-induced mistakes. We presumed that most caregivers feel that they must be careful only if the senior residents tend to be active. As shown in Fig. 4, some new staff answered that they have no particular time of day when they feel challenged monitoring the senior residents. Comparing the results in Figs. 6 and  7, more new staff answered that they do not have any particular day or time that they feel challenged monitoring the senior residents. This means that the new staff cannot predict the risks caused by neglecting “monitoring the senior residents”. 44 % of staff answered that they feel challenged monitoring the senior on days when they bathe them.

Fig. 6.
figure 6

Most difficult day of a week to monitor senior residents (unskilled caregivers)

Full size image
Fig. 7.
figure 7

Most difficult day of a week to monitor senior residents (skilled caregivers)

Full size image

3 Verifying the Monitoring Skills of New Caregivers

3.1 Subjects

The subjects were four new caregivers working on the same floor in the nursing home.

The average age was 22.3 years old. 3 were male and 1 was female.

3.2 Survey Method

The survey was conducted in a hall on a floor in the nursing home from 3:30 – 4:30 pm on a bathing day. We observed the new caregivers monitoring the senior residents by themselves. We recorded the entire series of experiments on a video camera. We repeated the same procedure for each of the four subjects. After recording, we conducted individual interviews with each of the subjects.

Figure 8 shows the allocation in a hall where a new caregiver is engaged in monitoring the senior residents by him/herself.

Fig. 8.
figure 8

The allocation in a hall in the nursing home (★ New staff ● Senior residents in wheel chairs spending time near tables)

Full size image

Although there were differences in the numbers of senior residents during the four survey times, an average number of 26 senior residents in wheel chairs spent time around the tables. The new staff member was engaged in monitoring the senior residents by him/herself.

All events which happened when the staff member was monitoring were clarified using an “event flow chart” based on the RCA (Root Cause Analysis). We also evaluated their “monitoring skills” based on their interviews. The author experienced both the old and the new admission systems; in the old system, administrative institutions allocated the elderly to nursing homes, and in the new system, the admission contract can be made directly between the elderly and the nursing home. The author observed the survey from the viewpoint of an administrator; thus, the evaluation results had the potential to bias.

In order to evaluate objectively, we asked two care managers with more than 5 years working experiences, who are now engaged in different tasks in care service, to observe and evaluate the survey.

Care Manage 1: Male, 29 years old. After 6 years of work experience, he obtained a care manager license and now has two years’ experience working as a care manager.

Care Manager 2: Female, 49 years old, has nursing license. After 5 years of work experience, she obtained a care manager license and now has more than 10 years’ experience working as a care manager.

*Care Manager 2 has experienced both the old and the new admission systems, just like the author.

3.3 Survey Results

Case 1: Male Caregiver with Two Years’ Experience

(Case 1 (Evaluation of Monitoring Skills assessed by Interviewing the Subject))

  • The subject can react based on the rules specified in the manuals. His intellectual level is high.

  • The subject does not think about “Why senior residents take these actions”, or “Why they say such things.”

He is not accustomed to think from the viewpoint of the senior residents.

  • The subject is less skilled and less experienced at predicting the occurrence of risks.

CM1

  • Without thinking about the reason, the subject said “Please stay here” in a nonchalant attitude.

  • The subject just followed the method of the skilled caregivers, but he is not accustomed to thinking why the senior residents wanted to move.

CM2

  • The subject was less considerate to the behavior or comments of the senior residents. He just reacted in an impromptu manners, so he could not predict accidents.

Case 2: Female Caregiver with Two Years’ Experience

(Case 2 (Evaluation of Monitoring Skills assessed by Interviewing the Subject))

  • The subject could not think from the viewpoint of the senior residents.

  • The subject can react based on the rules specified in the manuals, but she was less conscious of predicting risks.

CM1

  • Lifting a head of sleeping person without speaking to them is prohibited. I feel that it is necessary to teach this subject “common sense actions”.

  • The reasons that this subject failed to speak to the elderly residents is because she does not know the importance of these rules and words.

CM2

  • Of course, anybody would be surprised or upset if someone touched their face while they were sleeping. She is less considerate of other’s feeling. This makes me very uneasy because this action is not appropriate for a caregiver.

  • The subject lacks the skills to predict risks. She also lacks the ability to think from another person’s perspective.

Case 3: Male Caregiver with One Year of Experience

No event happened when this subject was monitoring the senior residents. We picked up this event when the female caregiver with two years’ working experience went through the hall.

(Case 3 (Evaluation of Monitoring Skills Assessed by Interviewing the Subject))

  • It is good that this female caregiver enjoys conversations with senior residents.

  • However, she does not know that touching an older person’s head is rude, even if it is expressing her affection.

  • She didn’t realize that this action is a problem because the senior resident did not display any signs of feeling uncomfortable.

CM1

  • I understand that she likes residents, but she should refrain from acting like this in front of others.

CM2

  • She was not offensive, but she does not know the rules for how to appropriately communicate with the residents.

  • She was inconsiderate of the respect and dignity the residents deserved. These kinds of staff exist in every elderly care facility, not just this nursing home.

Case 4: Male Caregiver with One Year of Experience

(Case 4 (Evaluation of Monitoring Skills Assessed by Interviewing the Subject))

  • The subject has a high awareness for pursuing the assignments according to the manual, but he has less applied skill.

  • The subject did not think from the perspective of “If I were him/her”.

  • The subject knows the philosophy to prioritize senior residents always, but he was overwhelmed by hesitance to ask for the support of senior caregivers.

CM1

  • It is understandable that the subject would rather cause trouble for the residents than bother his senior caregivers. But considering the feeling of the residents, there were other solutions. For example, if the senior caregivers told the new staff “Please call us anytime when you need help”, the new caregiver should feel it easy to monitor by himself.

CM2

  • Caregivers feel stress when using the word “Please wait for a while”. Having firm emotional strength to handle any irregular situations is necessary.

4 Discussion and Results

In modern nursing homes, people in more severe states are given priority when admitted to facilities. Thus, the contents of care services becomes more complex and multiplied, and “end of life” care service is also required of the facilities. In such situations, caregivers engage in daily work with a lot of pressure. Every caregiver bears the risk of a fall occurring when they are on monitoring duty by him/herself. While caregivers say “We are anxious about preventing accidents from happening”, we did not feel any sense of crisis from all the new staff who engaged in monitoring in this research. In fact, one resident had a fall occur during the research.

We observed skilled caregivers engaged in monitoring in the same hall on different days, and we realized that the obvious differences between skilled and unskilled caregivers are the ability to “predict risks” and “think from the residents’ perspective”. Caregivers with a high observation skill and risk prediction allocated senior residents to tables according to their conditions. They always kept their eyes on the residents while cleaning up the tables after meals. Even when they cleaned up the leftovers, they always kept their eyes on the residents while devising ways so the residents could not see. On the other hand, the new caregivers just focused on pursuing the routine work within the hours, cleaned up the tables without making any clatter, and did not pay attention to the residents.

5 Conclusion

In the Social Worker and Care Worker Law, Article 2, Clause 2, the national qualification for care workers is defined as; “Under the name of care worker, care worker means a person with special knowledge and techniques who provides care services for bathing, excretion and diet to persons who are unable to engage in daily life due to physical or mental disabilities, or who engages in the instruction of care services to caregivers”. The legal definition of nursing care is sufficient with this definition. However, the author feels the importance to take more time to teach new caregivers about the comprehensive knowledge concerning diseases and dementia when hiring. We proposed to give the opportunity to new caregivers to learn “Why this care service is necessary”, and “How to devise a care method according to the symptoms of diseases”. In order to improve their skills in monitoring senior residents, it is necessary to provide more educational opportunities in considering the feelings of senior residents from their perspective.