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1 Introduction

The lives of care receivers at the “Yuzu-no-sato [1]” severe dementia day care facility are mentally and physically balanced. It is rare for care receivers to refuse to come to this facility, and we think that “The approach of Yuzu-no-sato occupational therapy program (Yuzu-OTP)” helps them to feel calm, relaxed, and willing to stay [2]. Yuzu-OTP is carried out for one hour every day. Some care receivers paint a color to the sketch, another care receiver winds wool into a core of wrap film, the other winds small stockings piece around a hanger (making a hanger mop). Moreover, the staff at Yuzu-no-sato personalize each program in response to a care receiver’s pleasure by selecting a suitable work for the care receiver to do and/or making arrangements for him or her to engage in suitable tasks [3]. Balance between skills and challenge occurs the flow experience which is the crucial component of enjoyment [4]. Thus, the care receiver can develop a feeling of accomplishment, and it has been established that such a feeling can be effective in alleviating the behavioral symptoms of dementia [5].

A staff meeting for reflection is an important step in providing suitable work for each care receiver, because the suitable work is found from how the care receiver did the work. However, another day care facility that tried to conduct a Yuzu-OTP could not hold the meeting and arrange the work for each care receiver, as only one staff member prepared materials and provided work for the care receivers, and no reflection on the program was carried out [6]. This is a common phenomenon: Although clinical nurses routinely attend reflection meetings, we have learned that at least in Japan, care staff at day care facilities for elderly people with dementia rarely have such meetings. Multiple factors may prevent staff from having daily meetings. For instance, because the day cares suffer from chronic labor shortages, staff cannot take time away from providing care to gather for a meeting. Moreover, since most staff members work part time, they cannot afford to extend their work time to attend meetings. However, the leader of Yuzu-no-sato told us that such meetings are important to provide good care when we interviewed her. These meetings do not necessarily need to include all staff members or be scheduled at a structured time. It is permissible for only a few staff members to gather and spend a few minutes reflecting on how each care receiver performed.

The most important issue is that the staff at many day care facilities do not know how to conduct these meetings. In particular, when we interviewed to the director of another day care facility, we have learned that although staff members can report on care receivers’ physical rehabilitation, bathing care, meal assistance, and toileting assistance, they are unaccustomed to reflecting on the occupational therapy program. These staff members do not know what they should observe and consider in the program, and therefore they have problems reflecting on it.

In collaboration with the leader of Yuzu-no-sato, we explained how Yuzu-OTP should be carried out to the director at day care facility X, which is seeking to provide an occupational therapy program to care receiver with dementia. Moreover, we observed the occupational therapy program at facility X [6]. At the same time, we externalized what the staff at Yuzu-no-sato consider in the occupational therapy program on a piece of paper and prepared a sheet on which staff at facility X could write down their observations. These materials were then provided to the facility X. As a result of the trial, it was difficult for staff at facility X to write down their observations on the sheet. Thus, they could never hold a meeting. We thought that staff at facility X did not have the willingness to hold the meeting, because they could not externalize their awareness.

We aim to actualize Yuzu-OTP at other day care facilities, including facility X, and to make Yuzu-OTP an integral part of good care for people with dementia. Therefore, we seek to construct a system that allows staff to conduct meetings to reflect on care receivers’ performance in the occupational therapy program. In this paper, we describe the features of Yuzu-OTP and analyze the meetings that take place at Yuzu-no-sato.

2 Related Works

In past research, an application was developed for staff to enter their observations and photos on a tablet terminal and share this information with other staff members [7]. However, many staff at day care facilities were unfamiliar with a kind of tablet terminal, and would be difficult for them to take it out of their pocket during care. Thus, they would feel uncomfortable using the tablet terminal and writing down their observations on the screen. While there is also a smart voice messaging system available for staff to record their observations [8], which circumvents the need to write, this would also be uncomfortable for staff, as they would feel self-conscious in recording their notes in front of care receivers and their families.

3 Features of the Approach of Yuzu-no-sato Occupational Therapy Program

In this section, we introduce some of the features of Yuzu-OTP based on a previous work [3]. In the workroom at Yuzu-no-sato, there are tables set up throughout like islands, allowing several people to sit together. The staff members allocate where each care receiver will sit each day based on the care receiver’s ability and compatibility with others.

As shown in Fig. 1, one of the features of Yuzu-OTP is that staff members talk to each care receiver and perform some works together during the program. In general, for occupational therapy programs at other facilities, the staff member initially explains how the work will affect the care receiver’s physical function. Since the general program aims for the care receiver push through the work, the staff encourages him or her to persist. However, in some cases, no staff member talks to the care receiver during the program. In contrast, at Yuzu-no-sato, there is at least one staff member at each table. The staff asks the care receiver to carry out the work politely, for example, “Could you help me?” or “You are a very good worker. Could I ask for this work?” Since this elicits feelings in the care receiver that he or she is helpful for somebody, it is easy to persuade the care receiver to start the work, even if he or she has severe dementia. In this case, staff members direct their attention to the care receivers by engaging in conversation; the aim of this is to observe how each care receiver is doing, that is, his or her pleasure to complete the task, ability to carry out the work, fatigue, safety, and so on. The staff may change the care receiver’s tool, chair, or cushion so that he or she can perform the work comfortably. When the staff observes that the care receiver is not willing to do the work despite efforts to engage him or her, the staff member lets the care receiver take a break or provides him or her with a new task.

This description demonstrates that Yuzu-OTP aims to make the facility comfortable for the care receiver. The staff at Yuzu-no-sato are not concerned with whether the care receiver completes his or her work. Rather, it is important for the care receiver to be willing to do the work and to develop a sense of accomplishment through the program. Furthermore, when the care receiver considers that his or her work is complete, the staff at Yuzu-no-sato teach him or her a method that the work becomes more expressive. Then, the work is brought to the next level and the care receiver’s sense of accomplishment increases [3].

Fig. 1.
figure 1

The staff talks to the care-receiver.

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Yuzu-OTP involves many kinds of work. However, painting is the first activity for a new care receiver to engage in, and therefore this activity will be the focus in this work. In such a task, he or she receives a sample (a painted picture) and a sketch (a picture that only includes outlines). Then, he or she adds colors to the sketch (this is called “Iro nuri” or “Nurie” in Japanese). We analyzed what the staffs of Yuzu-no-sato observe in care receivers’ work [3]; here, we provide a summary of what happens as the care receiver does Iro nuri. The following are questions that the staff members consider during the task:

  • Can the care receiver understand what he or she is doing?

  • How does he or she hold a color pencil?

  • How does he or she paint the color on the sketch? Is the color different from the sample?

  • What direction do his or her eyes follow when the staff member points during their conversation?

  • How does he or she respond when the staff talks to him or her?

  • Is he or she tired of the work?

  • Does he or she have a bad posture?

  • Is he or she doing the work with pleasure?

  • Can he or she develop a feeling of accomplishment?

The staff member considers the care receiver’s cognitive ability, grip, pressure on the pen, skill, visual/auditory ability, fatigue, pleasure, and sense accomplishment. These items are not meant to evaluate the care receiver’s ability with numerical value; rather, the intention is to find the most suitable work for the individual care receiver.

4 Analysis of the Staff Meeting for Reflection

4.1 Aim

We sought to establish the importance of the meeting by analyzing the staff’s conversation. We want to find how the staff verbalize their notice in the work program at the meeting.

4.2 Method

One of the authors participated in an evening staff meeting at Yuzu-no-sato and recorded it. Then, we analyzed the utterances of the staff. This study was approved by the Independent Ethics Committee of Faculty of Medicine at Saga University. We also obtained the consent of the hospital director at Sodegaura Satsukidai Hospital.

4.3 Transcript Symbols

We use the following transcript symbols [9] to express the staff utterances:

  • A left bracket ([) indicates the point of overlap onset;

  • An equals sign (\(=\)) indicates no break or gap;

  • Numbers in parentheses (0.0) indicate elapsed time by tenths of seconds;

  • A dot in parentheses ((.)) indicates a brief interval;

  • Colons () indicate prolongation of the sound immediately prior. The longer the row of colon, the longer the prolongation;

  • Parenthesized words ((word)) indicates that the transcriber was not really sure about what was said;

  • Empty parentheses (( )) indicate that the transcriber was unable to hear what was said;

  • Parenthesized “h” indicates plosive; and

  • Dollar signs ($ $) indicate that the speaker was smiling during the utterance.

4.4 Result

Excerpt 1 from the meeting, given below, is from the discussion of a novice occupational therapist (OT), an expert care worker (ES), the other staff (S), and the staff leader (SL) on how Care Receiver-A performed. “R” represents a staff member who was not present at this meeting. Although OT was a novice, she assumed the role of planning the next activity for each care receiver based on the reflection in the meeting. She tackled this role while receiving the leader and other staff members’ instructions.

figure a
figure b

In this meeting, first, OT talked about how Care Receiver-A appeared before the program started (L.01–07). ES agreed with OT’s opinion and reported that she had observed the same thing, while SL listened and nodded. Then, SL asked OT how Care Receiver-A appeared during the activity (L.08). Because SL was also monitoring Care Receiver-A’s appearance at this time, she wanted to report her opinion to others (L.10, 14, 16, 18, 20, 22). SL suggested that OT should reflect on Care Receiver-A’s behavior while planning the next program activity (L.19). However, OT did not answer (gap six seconds); therefore, SL gave OT a clue to plan the next work (L.31–34).

In the next conversation, the staff discussed Care Receiver-B, who had painted a water color during the program. This discussion is given in Excerpt 2.

figure c
figure d

Care Receiver-B’s spirits were high when she was painting a water color (L.20). However, she painted the same space repeatedly, and she was unaware that there were spaces that had not yet been painted (L. 02, 03, 06, 08, 09, 13, 14). The staff members who participated in the meeting spoke rapidly, and many utterances overlapped. Each staff member observed how Care Receiver-B was painting and how she externalized her awareness. Although most staff member reported that Care Receiver-B painted only one area of the picture, SL had a different viewpoint from the other staff members, as shown when she commented, “But, she was painting neatly, wasn’t she? (L.04),” “But, there was a taste in her painting, wasn’t there? (L.11),” and “It was all right. We can consider that it is such a work, can’t we? (L.16).” Thus, SL accepted Care Receiver-B’s work and asked the other staff members to appreciate it as well. At this point, ES reported that Care Receiver-B could paint by herself (L.19), and S reported that painting made Care Receiver-B happy (L.20). Finally, ES concluded that Care Receiver-B did not hate painting, even if she could not carry out all aspects of the task.

OT, who had to plan the next activity for Care Receiver-B, asked ES and E whether Care Receiver-B could put color on the paintbrush from the palette by herself (L.25, 27, 29). ES and S did not say that Care Receiver-B was unable to do it; rather, they gave OT some ideas about how to set up the water-color painting activity for Care Receiver-B (L.28, 30–36, 38). Then, SL proposed that OT create a team - “the water-color team (L.43)” - consisting of care receivers who painted water colors. One of the staff members would attend to this team and assist them to paint.

5 Discussion

The Yuzu-OTP at Yuzu-no-sato day care involves scheduling each day based on the work process shown in Fig. 2. The steps involved in organizing this therapy are discussed below.

Fig. 2.
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Work process in Yuzu-OTP.

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Preparation. :

First, the staff plan the type of work to be carried out by each care receiver. They arrange each care receiver’s work based on his or her cognitive state, tastes, interests, job experience, and so on. On the day that the task is to be carried out, they set articles on tables and regulate the work environment. Moreover, the staff confirm a way of correspondence to each care receiver and risk to hide behind in each work. Then, the staff estimate how each care receiver will do his or her individual work.

Execution. :

During the work program, the staff members sit close to the care receivers, perform some works together, talk to them, and observe how they are carrying out their tasks (see Sect. 3) [3, 6]. The staff write down their awareness [10] on the prepared sheet.

Reflection. :

After the care receivers leave the day care, the staff members attend a staff meeting. They report on how each care receiver did and reflect on his or her state. The staff’s reflection leads to the next plan of the work that each care receiver can manage with enthusiasm and a greater feeling of accomplishment.

 

In the reflection step, the staff reported their observations in detail (see Sect. 4). Some staff jotted down what they had seen in about one sentence when they had a bit of free time. It is useful for the reflection meeting when staff write down their observations in advance; in this study, we found that these memos were sometimes discussed in the meetings. However, our previous research showed that in terms of the care staff at facility X, care staff receivers could not write down their observations [6]. Therefore, as future work, we are seeking to address how the system can be made more useful when it comes to allowing staff to write down their perceptions and connect to the reflection step (the meeting).

In the meetings, since the individual’s perspective was conveyed to the other staff members, they could share their viewpoints, support the steps another co-worker had taken to encourage the care receiver, and create new thoughts and suggestions. Nonaka [11] showed that there are four patterns in the dynamic interaction of “tacit and explicit knowledge,” namely socialization, externalization (or articulation), combination, and internalization. Externalization is the process of converting tacit knowledge into explicit knowledge. People use metaphors, analogies, concepts, hypotheses, models, and so on to translate their tacit knowledge for other people to understand [11]. In the case of Care Receiver-B, initially, some staff members thought that she could not paint well. However, after the leader (SL) indicated her opinion using an analogy, saying “Aji noaru sakuhin” [There is taste in her painting], other staff members’ opinions became more positive. This relates to the Yuzu-OTP’s emphasis on the care receiver’s pleasure in carrying out a task and his or her sense of accomplishment when determining what type of work should be set up for the care receiver. In this way, during the meetings, the staff members generated new knowledge concerning what each care receiver should do during the next occupational therapy session to elicit enthusiasm; thus, they engaged in reflection.

6 Conclusion

In this paper, we analyzed meetings at the “Yuzu-no-sato [1]” day care facility for individuals with severe dementia. We found that the staff became aware of what they have observed, experienced, and felt during the work occupation sessions. In the meetings, staff members could share their viewpoints and create new thoughts and suggestions. In the future, we intend to construct a system that allows staff at other day care facilities to externalize their awareness easily. Moreover, we will record utterances that emerge not only in meetings but also when Yuzu-no-sato’s staff are carrying out the preparation and the execution steps. We will then clarify features of Yuzu-OTP based on a conversation and gesture analysis [12].