Long-Term Care for the Elderly in Japan

Transcription

1 CE Article Instructions to CE enrollees: The closed-book, multiple-choice examination that follows this article is designed to test your understanding of the educational objectives listed below. The answer form is on page 28. On completion of this article, the reader should be able to: 1. Discuss the historical and cultural factors associated with the long-term care needs of the elderly in Japan 2. Identify the social changes recognized in caregiving values in Japan 3. Describe the impact that the new insurance law will have on the long-term care of the elderly Long-Term Care for the Elderly in Japan Kiyomi Asahara, RN, PhD, Emiko Konishi, RN, PhD, Ayako Soyano, RN, BSN, and Anne J. Davis, RN, PhD Abstract: This article, using data from the first author s research, presents selected issues in long-term care (LTC) of the elderly in Japan. A brief discussion of historical and cultural factors frame the current realities of LTC. These realities include the vast numbers of elderly people in Japan, changing definitions of the relationship of the individual to the group, and enactment of the new Care Insurance Law for the Elderly to be implemented in the year Some of the work underway for this implementation is detailed. (Geriatr Nurs 1999;20:23-7) Geriatric Nursing Volume 20, Number 1 23

2 Japan has the second largest economy in the world after the United States and the distinction of having the longest life span for both women and men. Currently the elderly constitute 14% of the population, but by 2025, this figure will be 25%, and this trend is expected to continue for another century. 1 This demographic change has vast consequences for every social institution, including the family and the national health system. Historically, the Japanese elderly have been revered, but this attitude is changing. Contemporary society highly values personal productivity and looks to the future as much as to the past. In earlier times, new ideas had to be proved compatible with tradition to be acceptable. In more recent periods, however, tradition has had to seem compatible with new, independently persuasive ideas to be retained. In some ways, the traditional and the modern are not easily united in Japan; they may exist side by side but do not stand in harmonious combination. One aspect of society perceived by the West to be strongly Japanese has been the relationship between the individual and society. The deeply rooted norms of obligation to the group with little emphasis on the individual and individual rights are being questioned and, in some quarters, even modified to fit modern life. Against this backdrop of traditional and modern Japanese values, this article provides some insights into the developments and problems of long-term care (LTC) for the elderly in Japan. This focus on selected social and nursing issues in LTC for the elderly demonstrates that, in Japan, the success of extending life has come at a price social, psychologic, economic, and personal. SELECTED BACKGROUND INFORMATION The hospital has been the major care center for the elderly in Japan. Ministry of Health and Welfare statistics from 1993 show the total population of people older than 65 to be 16.9 million. Of this number, 93.8% live at home and 6.2% are living in institutions, including hospitals. The proportion of institutionalized elderly to total elderly population increased from 1.6% in 1960 to 6.2% in Health services for the elderly have shifted since the 1960s from an emphasis on acute care to LTC. In the 1960s, the government subsidy of welfare services was established to include special nursing homes for the elderly with home living problems and community-based services, including day care, respite care, home help aides, and domiciliary care support centers. Two care systems were established in the late 1980s and early 1990s: intermediate facilities for discharged hospital elderly patients and a home-visit nursing care system for the elderly. Japan has three reimbursement systems: The National Health Care Plan for the Aged, which covers medical services for people 70 and older A plan for those younger than 70, which is compulsory and includes employment- or regionbased health insurance. Citizens pay 20% to 30% of the total incurred cost of medical care. Welfare services supported by the general tax fund, which pays for nursing homes and community-based services The diversity of these systems is one of the factors for new initiatives to deal with the elderly population. These initiatives include: The year strategy (the Golden Plan) to promote health care and welfare services for the elderly aimed at more efficient use of medical and custodial care resources The 1994 revised Golden Plan The Care Insurance Law for the Elderly, to be implemented in 2000 Several forces drove these changes. The average health care cost for elders skyrocketed: the average percapita health care cost rose to five times that for nonelderly citizens. 1 The national health care system was at risk because of the amount of money going into the plan for the elderly. In 1993, because alternatives to hospitals were not available, the average length of hospital stay was 41.9 days, more than four times the U.S. average. This figure and similar statistics compelled the government to act. 2 FAMILY CAREGIVING: GENERAL COMMENTS For many years, Japanese society has maintained a cultural value and traditional form of caregiving in which the family cares for its older members. Essentially, older family members have lived with an adult child, usually the oldest son, whose wife is the main caregiver. During the 19th century, the government instituted a rigid family system in which individuals were registered in an official family registry and were required by law to conform to the multigenerational household with the oldest man as the head of the household. 3 Preference favored oldest son inheritance and patriarchal arrangements; daughters and younger sons were expected to leave the family home. The purpose of this legal system was to maintain the continuity of families. This arrangement also was used during the second world war in the 1940s to strengthen the solidarity of the Japanese people. 4 After the war, a new family system was established. However, values from the earlier system remain strong for many Japanese people. Currently more Japanese elderly live with their adult children than is the case in the United States. The social fabric of Japanese life remains strongly centered on the family, and the Japanese people continue to be concerned about their families Geriatric Nursing Volume 20, Number 1

3 CULTURAL VALUES AND FAMILY CAREGIVING IN JAPAN Confucian values imported from China have greatly influenced Japanese culture, and this effect is reflected in the norms of obligation to the elderly. Furthermore, the Japanese social world is divided into the outside and inside (soto and uchi) with family members as insiders and all others as outsiders. 6 This distinction between what is culturally defined as socially inside and outside influences concepts of family privacy. At times, family members resist when outsiders overstep these social definitions and act as if they are insiders. 3,5 The one Japanese cultural characteristic best known throughout the world is that of group-centered orientation. This trait values the group above the individual and people are expected to follow the norms of the group. The group s needs have a higher priority than the individual s. People are concerned over whether their behavior corresponds to their group s norms and expectations. Individuals are very attentive to what others think of them, their behavior, and the extent to which they are considered good group members. 7,8 These cultural values combine to make family obligations to the elderly a potent factor in the daily lives of Japanese families. Although this social norm has many positive aspects, some problems also exist. 3,5,9 For example, typically daughters-in-law (34%), spouses (27.0%), and daughters/sons (20.2%) take care of their impaired older parents. Sometimes they undertake this work with neither any formal social and nursing services nor informal support from neighbors and friends. Families avoid placing their elderly relatives in nursing homes because a stigma is attached to this act, and they do not use social services, such as respite care, because they do not want outsiders to enter the family s private world. Caregivers do not openly express their needs or the burdens they experience in this role, and this lack of openness and acceptance of help can lead to elder abuse on occasion. These cultural values and norms have been a major factor in the continuation of family caregiving to older parents in Japan. Caregivers continue to provide care by substituting the positive evaluations from others for their own personal satisfaction and needs and value their caregiving as evidence of their own abilities. They are socially rewarded by fulfilling this role and being a good family and community member. 5 Few alternatives have been available to these family caregivers. The Japanese government, using deeply embedded social values, essentially and tacitly has imposed this caregiving role on family members without establishing a culturally appropriate home care system that could benefit families. RECENT CHANGES IN CAREGIVING VALUES After World War II, Japan s younger generation, influenced by individualistic values from the West, began placing greater value on personal productivity. 6 With changes in the symbolic meaning of the caregiving role, younger family members tended to voice their own needs with regard to caregiving burdens and their need to use social services. Families began placing their elder members in nursing homes or, A major factor in some cases, neglected influencing the to provide care for their elderly family member living alone. This picture of caregiving in changing caregiving values and roles is more Japan is the complex than presented decline in family in these comments. Regional differences with regard to caregiving are members evident when comparing available to rural areas with urban areas. As might be expected, rural families tend to hold fast to the traditional values and the caregiving role that socially defines them as good within that community. The two most complex situations are the caregiver who holds both traditional and individual values that create psychologic conflicts and the conflict between the elderly person s traditional values and the caregiver s individualistic values. The extent of these conflicts will be determined by the caregiver s perception of the balance between traditional and new values. This balance in turn is greatly affected by other factors, including the caregiver s age, living arrangements, regional differences in social norms, etc. All these variables taken together can be used to predict the use or disregard of social services and caregivers burdens. 5,9,10 A major factor influencing the recent changes in caregiving in Japan is the decline in family members available to assume this role. Japan s birthrate has declined dramatically while the elderly population has increased. Because many people are well over 75, their caregiving requirements are more serious and demanding on the caregivers, who themselves are aging. This scenario means the caregiving burden becomes greater. Another factor in caregiver availability is the trend toward nuclear families. 1 In 1994, the percentage of household elders living with their children was 55.3%. 11 This recent changes in assume this role. Geriatric Nursing Volume 20, Number 1 25

4 statistic indicates that nearly half of elders are living alone or with an elderly spouse or are institutionalized. Another change that has affected family caregiving is the increase in women working outside the home. With better education and different life plans, women are not as readily available to assume the family caregiving role as in the past. THE CARE INSURANCE LAW FOR THE ELDERLY (CILE) In addition to these social factor changes, medical expenses for the elderly have increased to the point that the government recently enacted the Care Insurance for the Elderly Now the tasks Law, 1 a socially important law that will be implemented in the year before Japan Although many complex details are being systems to worked out, CILE s two major characteristics are: Care for impaired elders will be provided of care needed, based on family application to municipal governments. A system of plan and evaluate services will be created by organizing medical, social, and health departments. This care will be networks for financed by taxation of all adults older than 40, including the elderly professionals and themselves. The elderly and their organizations so family caregivers can make a care plan and that this law can choose service providers by themselves. be implemented The process to identify the extent of care needs next year. begins when the family submits an application to the municipal government, which then sends a staff member to identify the degree of care needed by the applicant. Based on the results of this investigation and comments from the physician in charge, a special committee authorizes the extent of care needed by the applicant. The committee s judgment of health care needs then is funded within established cost limits that determine the number and kind of services received. The CILE covers two types of services: home care and institutional care. The care recipient and family can choose to develop a care plan themselves or ask professionals to do it. include developing determine the level care, and establish health and welfare The most central person in this service is the care manager. Nurses, among other health professionals such as home health workers and social workers, will serve in this role, depending on the needs of the patient. Now the tasks before Japan include developing systems to determine the level of care needed, plan and evaluate care, and establish networks for health and welfare professionals and organizations so that this law can be implemented next year. NURSING AND THE CILE Dramatic changes in Japan s health care system are underway. Because most Japanese people tend to accept government direction, the new law and specific elements of its care system are expected to promote change from traditional to new norms, such as practices for using social services. Family members will not have to carry the heavy burden of caregiving alone. In addition, the strict social definition of the good family member so closely tied to assuming this caregiving role may ease, which may be better for both the caregiver and the elderly family member in the long run. Both now and after the implementation of CILE, nurses are assuming a vital role in such activities as community health education. Nurses are identifying their own roles in home care and providing quality care to the elderly and their families. Nursing in Japan has a long history of working closely with people and helping them in times of sickness and health. In the 21st century, nursing roles will be extended and developed in new ways. Japanese nurses are preparing to meet the new challenges presented by CILE enactment. REFERENCES 1. Ministry of Health and Welfare. Annual report on health and welfare Kosaka M. Developing a health service system for the elderly in Japan. J Care Management 1996;5: Harris PB, Long SO. Daughter-in-law s burden: an exploratory study of caregiving in Japan. J Cross-Cultural Gerontol 1993;8: Kano M. The ideology of family system in prewar times. Tokyo: Sobundsha; p Asahara K. Ethnographic study on the continuing caregiving and farming for family caregivers of the impaired elderly in a depopulated rural village [dissertation]. Tokyo: University of Tokyo; Sakuta K. Sociology of value. Tokyo: Iwanamishoten; Tadashi I. The structure of sekentei. Tokyo: NHK Books; Asahara K, Momose Y. Study on the consciousness structure of sekentei and the changing factors in elderly. Jpn J Nurs Res 1995;28: Momose Y, Asahara K. Relationship of sekentei to utilization of health, social, and nursing services by the elderly. Jpn J Public Health 1996;43: Asahara K, Momose Y. Study on the relationships of sekentei to utilization of health, social, and nursing services and care burden for family caregivers of the impaired elderly. J Japan Acad Gerontologic Nurs 1997;1(2): Ministry of Health and Welfare. Annual report on health and welfare All authors are employed at the Nagano College of Nursing in Komagane City, Nagano, Japan. KIYOMI ASAHARA, RN, PhD, is an associate professor. EMIKO KONISHI, RN, PhD, is a professor. AYAKO SOYANO, RN, BSN, is a clinical instructor. ANNE J. DAVIS, RN, PhD, is a professor. Copyright 1999 by Mosby, Inc /99/$ /1/ Geriatric Nursing Volume 20, Number 1

5 CE Test I.D. No.: G96068 Contact hours: 1.0 Processing fee: $9 Passing score: 9 correct answers (75%) 1. A cultural characteristic known as group-centered orientation is best described as: A. The group places the needs of the individual first. B. The group s needs have a higher priority than the individual s. C. Individual needs are followed by the group. D. Individuals are encouraged by the group to achieve their goals first. 2. A major factor in the recent changes in caregiving in Japan is attributed to: A. A decline in available family members to assume role B. A decline in the number of aging individuals C. An increase in Japan s birthrate D. Adequate available health care options for the elderly 3. Financing the Care Insurance Law for the Elderly will be accomplished by: A. Taxation of all working adults B. Taxation of adults with elderly parents C. Taxation of all adults older than 40 D. Shifting funds from acute care settings 4. What site traditionally had been the major care center for the elderly in Japan? A. Hospitals B. Long-term care facilities C. domiciliary care support centers D. Day care 5. An example of changing attitudes in Japan that affects caregiving is: A. A strong focus to retain tradition B. An insistence for new ideas to be compatible with the old C. Great emphasis on obligation to the group D. An increased value on personal productivity 6. The process used to identify the extent of care needs begins: A. When an elderly person is hospitalized B. When the family submits an application to the government C. Automatically when an individual reaches a certain age D. When the physician orders it 7. The group that typically cares for the impaired older parent is: A. Daughters-in-law B. Spouses C. Sons D. Daughters 8. One factor associated with the caregiving role and women that has changed is: A. The trend away from nuclear families B. An increase in the birthrate C. An increase in women working outside the home D. A decline in women s health status 9. The most central person in the services provided by the Care Insurance Law for the Elderly is the: A. Social worker B. Physician C Nurse D. Care manager 10. What percentage of Japan s population is estimated to be elderly by the year 2025? A. 14% B. 25% C. 41% D. 34% 11. The balance between traditional and new values is affected by all the following EXCEPT: A. Age of the elderly person B. Caregiver s age C. Regional differences in social norms D. Living arrangements 12. One role that nurses can expect to be a part of involves all the following EXCEPT: A. Community health education B. Establishing networks for health professionals C. Sole decision-making regarding care needs D. Care manager duties Geriatric Nursing Volume 20, Number 1 27

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