Prospects for Introducing the

®
to Japan
ABSTRACT
To date, no elder care facilities in Japan have formally introduced the Eden Alternative® philosophy of
care. The purpose of this cross-sectional descriptive study was to identify the perceptions of care workers
and nurses regarding the lives of older adults in care facilities to consider the prospects for introducing
the Eden Alternative to Japan. The participants included 139 care workers and 41 nurses who responded
to a survey questionnaire based on Eden Alternative principles developed by the researchers for this
study. More than half of the participants indicated that they sometimes thought the older adults expe-
rienced feelings of helplessness, loneliness, and boredom and hoped for changes in the manner of care
to improve the lives of residents. Participants were also in favor of the residents having plants and visits
from children, but opinions about having animals on site were split. The fact that the survey respondents
noticed the problems indicated by the Eden Alternative suggests there is great potential for introducing
the Eden Alternative to Japan.

I
n Japan, the percentage of older adults
exceeded 20% of the population in 2000
and reached 22.1% in 2008. The aver-
age life expectancy is 79.2 for men and 86 for
women, and the aging of Japanese society is
unmatched anywhere in the world (Cabinet
Office, Government of Japan, 2009). The chal-
lenges brought about by Japan’s aging popula-
tion include an expansion of nuclear families,
older adults living alone, a rising population
of old-old adults, and increasing medical
costs. In particular, the number of older adults
living alone is expected to rise, and measures
are urgently needed to address who will care
for this population and where this care will be
provided. Since the implementation of Japan’s
long-term care insurance system in 2000, de-
signed to resolve such issues, the number of
older adults admitted to facilities where ev-
erything is covered by that insurance has been
increasing. Older adults with health problems
who cannot live independently at home usu-
ally decide to move to a facility for elders (FE)
to receive care. Long-term care insurance is
accepted in 9,327 facilities, with 690,358 older
people currently living in them (Japan Min-
© 2010/Stockphoto

Shizuka Otsuka, MSN, RN; Akiko Hamahata, PhD, RN; Misa Komatsu, PhD, RN;
Chizuko Suishu, MAED, RN; and Keiko Osuka, PhD, PHN, RN

Journal of Gerontological Nursing • Vol. 36, No. 3, 2010 47

istry of Health, Labour and Wel-
fare, 2009). Thus, FEs have become
increasingly important in Japan for
older adults and their families.
Background
FEs provide services focused on
improving the lives of older adults,
such as a unit care system that divides
residents into small groups for indi-
vidual care, year-long events, recre-
ational activities, and visiting volun-
teers. In FEs, daily living assistance
is provided by care workers (compa-
rable to certified nursing assistants
in the United States) and nurses, but
the ratio of three care workers to one
nurse is a standard set by law and
thus the number of care workers is
much greater. The position of the
care worker was introduced in 1987
The Eden Alternative®, established in the United
States, has focused on improving the quality of life of
nursing home residents by addressing the problems of
loneliness, helplessness, and boredom.
as a social welfare profession to as-
sist residents in FEs with activities of
daily living (Toyota, 2008). The role
of care workers is important, but
employment conditions such as long
hours and low pay are harsh, and
there is much stress among workers
(Mitoku, Morimoto, & Yano, 2008).
The high turnover of care workers
in FEs can negatively influence the
quality of life of residents.
The Eden Alternative®, established
in the United States, has focused on
improving the quality of life of nurs-
ing home residents by addressing the
problems of loneliness, helplessness,
and boredom (Bruck, 1997; Drew &
Brooke, 1999). Facilities that have ad-
opted the Eden Alternative typically
create an atmosphere reminiscent of
home, featuring plants, animals, and
regular visits from children. Because
the Eden Alternative is a departure
48
from the top-down approach to
management, both the staff and resi-
dents have a voice in decision making
(Hamilton & Tesh, 2002). As a result,
staff motivation improves markedly,
and turnover is reduced.
Since the Japanese branch of the
Eden Alternative was established in
2004, training for beginners and Cer-
tified Eden Associate Training has
been conducted. To date, no FEs in
Japan have been certified as Eden Al-
ternative facilities by the head office
in the United States; however, two
FEs have conducted workshops as a
preliminary stage for implementing
the Eden Alternative, and ground-
work is under way. Although some
facilities have introduced pet therapy
(Niiyama, 2003; Suzuki et al., 2002),
plant therapy (Kitade, 2003; Teraoka
& Harada, 2003), and programs of
volunteer visits from children (Ki-
tabatake, 2000; Miyake et al., 2001:
Sekido, 2001) to improve the lives of
their residents, they do not have the
Eden Alternative’s philosophical un-
derpinning.
Previous studies in Japan have
shown that many residents are dis-
appointed in the daily routine of the
facility, experience anxiety in estab-
lishing relationships with other resi-
dents, and have little chance to make
personal decisions (Komatsu, Hama-
hata, & Magilvy, 2007; Matsuoka &
Hamahata, 2004). Unfortunately,
such problems still remain largely
unresolved. Many cultural differenc-
es exist between Japan and Western
countries, such as ways of thinking,
lifestyles, attitudes toward aging,
and contrasts in the management of
FEs; however, the lives of residents
would almost certainly be improved
if the Eden Alternative were to be
introduced to FEs in Japan. In con-
sidering the possibility of adopting
the Eden Alternative, it is necessary
to understand the perceptions of care
workers and nurses, who would be
the driving forces in improving resi-
dent care under the Eden Alternative
philosophy. Therefore, the purpose
of this study was to identify the
perceptions of FE care workers and
nurses regarding the lives of older
adults in their facilities.
METHOD
Design and Sample
This study used a cross-sectional
quantitative descriptive survey to an-
swer the question “What are the per-
ceptions of care workers and nurses
working in FEs regarding the lives of
the older adults living there?” FEs
provide daily care services for frail
older adults and are supported by
long-term care insurance for which
the Japanese Ministry of Health,
Labour and Welfare has jurisdiction.
Five FEs were selected as a con-
venience sample for this study. The
condition for selection was that the
facilities be located in medium-sized
cities with similar local environ-
ments. Each facility was a midsize
nonprofit facility with 100 residents
and a care provider-resident ratio of
3 to 1. In each facility, all care work-
ers and nurses who assist in the daily
life of the residents were invited to
participate in the study.
Procedures
This study was approved by the
ethics committee of the participat-
ing university in Japan. In a pre-
liminary survey to develop measure-
ment tools, one FE was requested to
complete the survey. The researchers
went to the facility and explained the
study purpose and methods to the
head nurse. At the same time, written
requests that explained the study’s
purpose, methods, and voluntary in-
formed consent to the care workers
and nurses who would be participat-
Copyright © SLACK Incorporated
 Table 1
Demographic Characteristics of the Sample
Variable
Mean age in years (SD)
Gender
Women
Men
Years working in current facility
<1
1 to 5
6 to 10
>11
Note. Percentages may not total 100 due to rounding.
ing in the study were organized into
envelopes with the self-administered
survey questionnaires, and the head
nurse was asked to distribute them.
After this preliminary survey, the
questionnaire was revised, and the
study officially began.
Like the preliminary survey, re-
searchers for the main survey went to
each facility to explain the study and
asked the head nurse to implement it.
Written requests and questionnaires
for a total of 210 care workers and
nurses at five facilities were put into
envelopes. The questionnaires were
distributed in envelopes that could
be sealed so the respondents could
not be identified. Collection boxes
were arranged in each facility, and
the researchers went to the facilities 3
weeks later to collect the responses.
Survey Instrument
The survey questionnaire was de-
veloped by the researchers for this
study on the basis of a pamphlet
obtained by one of the researchers
during introductory training for the
Eden Alternative, as well as a ques-
tionnaire by the Japan branch of the
Eden Alternative used to survey
the daily lives of older adults who
receive care in Japanese FEs. This
Journal of Gerontological Nursing • Vol. 36, No. 3, 2010
Care workers (n = 139) Nurses (n = 41)
n (%)
41 (13.3)
105 (75.5)
34 (24.5)
23 (16.5)
66 (47.5)
38 (27.3)
12 (8.6)
questionnaire contains 14 questions
and consists of four subscales: per-
ception of residents’ life, percep-
tion of own work, perception of
environment in the facility, and per-
ception of work relationships. De-
mographic characteristics collected
included age, gender, type of work,
and number of years working in the
current facility.
In the preliminary survey, 33 care
workers and 7 nurses responded.
The reliability for this sample (n =
40) was acceptable with an over-
all Cronbach’s alpha coefficient of
0.81; coefficients for the four sub-
scales were 0.96, 0.75, 0.82, and 0.73,
respectively.
Perceptions about helplessness,
loneliness, boredom, decision mak-
ing, and aspirations in residents’ lives
were queried. For example, for the
question, “Do you feel the residents
suffer from helplessness?”, respon-
dents answered using a 4-point scale
(4 = always feel, 3 = sometimes feel,
2 = do not feel, 1 = not applicable).
Perceptions of environment in-
cluded questions about having ani-
mals, plants, and visits from chil-
dren. For example, for the question,
“Do you agree with keeping ani-
mals such as dogs, cats, or birds?”,
Total (N = 180)
n (%) n (%)
47.3 (1) 42.1 (13.1)
40 (97.6) 145 (80.6)
1 (2.4) 35 (19.4)
8 (19.5) 31 (17.2)
17 (41.5) 83 (46.1)
10 (24.4) 48 (26.7)
6 (14.6) 18 (10)
responses were given on a 3-point
scale (3 = agree, 2 = disagree, 1 =
not applicable), and the reasons for
responding agree or disagree were
requested.
Perceptions of one’s own work
included questions on changes in
the manner of care and the value of
work, with responses given on a 4-
point scale (4 = always feel to 1 =
not applicable). The respondents
who chose always feel and some-
times feel about value in their work
were asked for the reasons. Respon-
dents were also asked if they would
like to live in the facility where they
worked (e.g., “Do you think you
would enjoy living in the facility if
you were in the same situation as the
residents?”). Responses were given
on a 3-point scale (3 = yes, 2 = no,
1 = not applicable), and reasons for
no responses were requested.
Perceptions of work relationships
were also queried (e.g., “Does your
opinion differ from that of your
superior?”) on a 4-point scale (4 =
always, 3 = sometimes, 2 = never, 1 =
not applicable).
Data Analysis
Descriptive statistical values
were calculated based on the num-
49
 Table 2
Respondents’ Perceptions of Residents’ Life
Care Workers Nurses Total
(n = 139) (n = 41) (N = 180)
Variable n (%) n (%) n (%)
Helplessness
Always think residents feel helpless 13 (9.4) 8 (19.5) 21 (11.7)
Sometimes think residents feel helpless 84 (60.4) 16 (39) 100 (55.6)
Do not think residents feel helpless 10 (7.2) 3 (7.3) 13 (7.2)
Not applicable 32 (23) 14 (34.1) 46 (25.6)
Loneliness
Always believe residents are lonely 10 (7.2) 5 (12.2) 15 (8.3)
Sometimes believe residents are lonely 96 (69.1) 26 (63.4) 122 (67.8)
Do not believe residents are lonely 7 (5) 0 (0) 7 (3.9)
Not applicable 26 (18.7) 10 (24.4) 36 (20)
Boredom
Always believe residents are bored 31 (22.3) 15 (36.6) 46 (25.6)
Sometimes believe residents are bored 96 (69.1) 18 (43.9) 114 (63.3)
Do not believe residents are bored 3 (2.2) 1 (2.4) 4 (2.2)
Not applicable 9 (6.5) 7 (17.1) 16 (8.9)
Decision making
Always feel residents make their own decisions 17 (12.2) 4 (9.8) 21 (11.7)
Sometimes feel residents make their own decisions 55 (39.6) 19 (46.3) 74 (41.1)
Do not feel residents make their own decisions 20 (14.4) 7 (17.1) 27 (15)
Not applicable 47 (33.8) 11 (26.8) 58 (32.2)
Residents’ aspirations
Caregiver knows very much what residents want 6 (4.3) 1 (2.4) 7 (3.9)
Caregiver knows some things residents want 52 (37.4) 12 (29.3) 64 (35.6)
Caregiver does not know what residents want 12 (8.6) 4 (9.8) 16 (8.9)
Not applicable 69 (49.7) 24 (58.5) 93 (51.7)

Note. Percentages may not total 100 due to rounding.

bers of care workers and nurses, as
well as their years of working in
the facility and mean age. The fre-
quency distribution of individual
perceptions about the daily lives
of residents, relationships at work,
and the introduction of plants,
animals, and children visiting the
facility was calculated based on
the numbers of care workers and
nurses. Analyses were performed
using SPSS version 12.0 for Win-
dows.
RESULTS
The demographic characteristics
of the respondents are listed in Table
1. A total of 210 questionnaires were
distributed, and 180 were returned,
for a response rate of 85.7%. The
respondents included 139 care work-
ers and 41 nurses. The overwhelming
majority of respondents were wom-
en (care workers = 75.5%, nurses =
97.6%). Most respondents indicated
they had worked at the current facil-
ity for 1 to 5 years.
The care workers’ and nurses’
perception of the life of residents are
shown in Table 2. The majority some-
times thought the older adults in the
facility experienced feelings of loneli-
ness (67.8%), boredom (63.3%), and
helplessness (55.6%), but approxi-
mately one third of respondents did
not know whether residents were able
to make their own decisions. In addi-
tion, more than half of the respon-
dents were not sure of the residents’
aspirations (51.7%).

50 Copyright © SLACK Incorporated

 Table 3
Respondents’ Perceptions of facility environment
Care Workers Nurses Total
(n = 139) (n = 41) (N = 180)
Variable n (%) n (%) n (%)
Having animals in facility
Agree 47 (33.8) 16 (39) 63 (35)
Reasons for agreeing a

• Animals make residents comfortable 39 (83) 12 (75) 51 (81)

• Animals relieve residents of loneliness 29 (61.7) 11 (68.8) 40 (63.5)
• Animals change residents’ daily life 22 (46.8) 9 (56.3) 31 (49.2)
Disagree 44 (31.7) 13 (31.7) 57 (31.7)
Reasons for disagreeing a

• Residents may have infectious disease 35 (79.5) 12 (92.3) 47 (82.5)

• Some residents simply do not like animals 33 (75) 8 (61.5) 41 (71.9)
• Caregivers may spend too much time caring for the animals 27 (61.4) 7 (53.8) 34 (59.6)
Not applicable 48 (34.5) 12 (29.3) 60 (33.3)
Having plants in facility
Agree 97 (69.8) 31 (75.6) 128 (71.1)
Reasons for agreeing a

• Plants make residents comfortable 79 (81.4) 25 (80.6) 104 (81.3)

• Natural environment improves morale of all involved 43 (44.3) 18 (58.1) 61 (47.7)
• Residents would be able to care for a living object 40 (41.2) 15 (48.4) 55 (43)
Disagree 13 (9.4) 1 (2.4) 14 (7.8)
Reasons for disagreeinga
• Plants pose an obstacle to ambulatory residents 8 (61.5) 1 (100) 9 (64.3)
• Caregivers spend too much time caring for the plants 5 (38.5) 0 (0) 5 (35.7)
• Plants may introduce infections 4 (30.8) 1 (100) 5 (35.7)
Not applicable 29 (20.9) 9 (22) 38 (21.1)
Visits from children
Agree 84 (60.4) 18 (43.9) 102 (56.7)
Reasons for agreeing a

• Residents enjoy such visits 70 (83.3) 14 (77.8) 84 (82.4)

• Children relieve residents’ loneliness 46 (54.8) 10 (55.6) 56 (54.9)
• Residents feel encouraged in daily life 38 (45.2) 6 (33.3) 44 (43.1)
Disagree 16 (11.5) 9 (22) 25 (13.9)
Reasons for disagreeing a

• Children may cause accidents 14 (87.5) 7 (77.8) 21 (84)

• Children may spread infections 10 (62.5) 7 (77.8) 17 (68)
• Some residents simply do not like children 9 (56.3) 2 (22.2) 11 (44)
Not applicable 39 (28.1) 14 (34.1) 53 (29.4)

Note. Percentages may not total 100 due to rounding.

a
Respondents were allowed to choose more than one answer.

Journal of Gerontological Nursing • Vol. 36, No. 3, 2010 51

 Table 4
Respondents’ Perceptions of their work
Care Workers Nurses Total
(n = 139) (n = 41) (N = 180)
Variable n (%) n (%) n (%)
Would like to see changes in manner of resident care
Always want to change care 33 (23.7) 5 (12.2) 38 (21.1)
Sometimes want to change care 80 (57.6) 27 (65.9) 107 (59.4)
Do not want to change care 6 (4.3) 1 (2.4) 7 (3.9)
Not applicable 20 (14.4) 8 (19.5) 28 (15.6)
Feel there is value in their work
Always feel a value 41 (29.5) 5 (12.2) 46 (25.6)
Sometimes feel a value 90 (64.7) 23 (56.1) 113 (62.8)
Reasons for always or sometimes finding value in their work a

• Residents keep smiling 109 (83.2) 22 (78.6) 131 (82.4)

• Residents express appreciation for caregivers’ help 92 (70.2) 15 (53.6) 107 (67.3)
• Residents trust caregivers 85 (64.9) 15 (53.6) 100 (62.9)
• Residents’ performance of activities of daily living improve 71 (54.2) 14 (50) 85 (53.5)
Do not feel a value 2 (1.4) 0 (0) 2 (1.1)
Not applicable 6 (4.3) 13 (31.7) 19 (10.6)
Would like to live in the facility in which they work
Yes 13 (9.4) 2 (4.9) 15 (8.3)
No 83 (59.7) 18 (43.9) 101 (56.1)
Reasons for no responses a

• Caregivers are always very busy 61 (73.5) 11 (61.1) 72 (71.3)

• Residents’ privacy is not respected 35 (42.2) 14 (77.8) 49 (48.5)
• Residents are bound by rules 34 (41) 8 (44.4) 42 (41.6)
• Residents are bothered by other residents 34 (41) 4 (22.2) 38 (37.6)
Not applicable 43 (30.9) 21 (51.2) 64 (35.6)

Note. Percentages may not total 100 due to rounding.

a
Respondents were allowed to choose more than one answer.

Table 3 lists respondents’ per-
ceptions of their facility’s envi-
ronment. Opinions about having
animals such as dogs, cats, or birds
in the facility were almost equally
divided between agree, disagree,
and not applicable. One third of
respondents agreed to having ani-
mals in the facility (35%), stating
that animals are a source of com-
fort for residents (81%), relieve
residents’ loneliness (63.5%), and
bring changes to the residents’ daily
life (49.2%). In addition, respon-
dents thought that animals would
motivate residents to go on living
and that the residents would enjoy
having animals. On the other hand,
one third of respondents (31.7%)
did not agree, citing concerns about
residents having an infectious dis-
ease (82.5%), the fact that residents
simply do not like animals (71.9%),
and that caregivers would have to
spend too much time taking care of
the animals (59.6%).
The majority (71.1%) of care
workers and nurses were in favor
of having plants in the facility be-
cause they thought plants would be
a source of comfort for residents
(81.3%) and that it would be good
for residents to care for a living ob-
ject (43%). Approximately half of
the respondents (47.7%) respond-
ed that a natural environment im-
proves the morale of all involved.
The reasons why some respon-
dents disagreed (7.8%) were that

52 Copyright © SLACK Incorporated

 Table 5
Respondents’ Perceptions of work relationships
Care Workers Nurses Total
(n = 139) (n = 41) (N =180)
Variable n (%) n (%) n (%)
Experience a difference in opinion with superiors
Always 20 (14.4) 3 (7.3) 23 (12.8)
Sometimes 72 (51.8) 27 (65.9) 99 (55)
Never 16 (11.5) 1 (2.4) 17 (9.4)
Not applicable 31 (22.3) 10 (24.4) 41 (22.8)
Experience a difference in opinion with coworkers
Always 10 (7.2) 7 (17.1) 17 (9.4)
Sometimes 89 (64) 25 (61) 114 (63.3)
Never 6 (4.3) 0 (0) 6 (3.3)
Not applicable 34 (24.5) 9 (22) 43 (23.9)
Have the opportunity to discuss problems with coworkers
Always 30 (21.6) 12 (29.3) 42 (23.3)
Sometimes 87 (62.6) 25 (61) 112 (62.2)
Never 13 (9.4) 1 (2.4) 14 (7.8)
Not applicable 9 (6.5) 3 (7.3) 12 (6.7)

Note. Percentages may not total 100 due to rounding.

the plants would pose obstacles
for ambulatory residents (64.3%),
caregivers would have to spend
too much time caring for the plants
(35.7%), and that the plants might
introduce infections in the facility
(35.7%).
More than half (56.7%) of care
workers and nurses welcomed visits
from children to the facility, stating
that the residents enjoy such visits
(82.4%), that residents’ loneliness
would be relieved (54.9%), and the
residents would feel encouraged in
daily life (43.1%). A few respon-
dents thought it was good for the
children to get to know people
much older and more experienced
than themselves. However, 13.9%
of respondents disagreed, stating
that children may cause accidents
(84%) or spread infections to the
residents (68%), and because some
residents simply do not like chil-
dren (44%).
Respondents’ perceptions of their
work are shown in Table 4. More
than half (59.4%) of the respondents
indicated that they sometimes want-
ed changes in the manner of care that
would improve the life of residents.
More than 88% of respondents al-
ways or sometimes had a positive
view of the value of their work. This
was felt especially when the residents
would keep smiling (82.4%), express
appreciation for their help (67.3%),
express trust in them (62.9%), and
when the condition of the residents’
activities of daily living was improv-
ing (53.5%). Slightly more than half
(56.1%) of the respondents did not
think they would enjoy living in
the facility where they worked if
they were in the same situation as
the residents. Some of the reasons
why they did not want to live there
were that caregivers were so busy
with other tasks they had no time to
properly devote themselves to the
residents’ well-being (71.3%), that
the residents’ privacy was not re-
spected (48.5%), that the residents
were bound by rules (41.6%), and
that some residents were bothered
by other residents (37.6%).
Table 5 lists respondents’ per-
ceptions of relationships at work.
More than half of the respondents
expressed that their opinions some-
times differed from those of their
superiors (55%) and their cowork-
ers (63.3%). However, many of them
(62.2%) also responded that they
sometimes had opportunities to dis-
cuss problems with colleagues and
other professionals.
DISCUSSION
Looking at the respondents’ at-
titudes toward the lives of older
adults, more than half of both care
workers and nurses responded that
FE residents were helpless, lonely,
and bored. One third of respondents

Journal of Gerontological Nursing • Vol. 36, No. 3, 2010 53

 logical effect on facility residents,
but that they also have positive
keypoints effects on cognition and immune
The Eden Alternative in function (Sugihara et al., 2006). At-
tempts to incorporate a natural en-
Japan vironment for its soothing effect on
residents are likely to increase.
Otsuka, S., Hamahata, A., Komatsu, M., Suishu, C., & Osuka, K. (2010). Prospects for
Introducing the Eden Alternative to Japan. Journal of Gerontological Nursing, 36(3), 47-
The majority of respondents
55. in this study also favored bring-
ing children to visit the facility, an

1 The Japanese branch of the Eden Alternative® was first estab-

lished in 2004, yet only two elder care facilities have entered the
preliminary stage for formally implementing the Eden Alterna-
activity the residents enjoyed. The
reasons given were that children’s
visits eases residents’ loneliness
tive. and invigorates their lives. How-

2 Facilities for elders have become increasingly important for older ever, respondents were split on the
adults and their families in Japan; however, the lives of residents idea of keeping animals. Those who
have not improved. supported the idea said that animals
have a soothing effect on residents

3 Care workers and nurses noticed the problems in the lives of old-
er adults indicated in the Eden Alternative, such as helplessness,
loneliness, and boredom, and hoped to improve the current man-
and bring change to residents’ lives,
whereas those against the idea cit-
ed problems with infection, that
ner of care. Respondents also welcomed the placement of plants animals are not liked by all older
and visits from children, but opinions on having animals on site adults, and that caring for animals
were split. was troublesome. Pet therapy has

4 The Eden Alternative would rapidly improve the care of older
adults and make work more meaningful for caregivers.
did not know whether the residents
were able to make their own de-
cisions, and almost all wanted to
change the current manner of care.
From these findings, it seems that
care workers and nurses identify
problems in the lives of the older
adults for whom the Eden Alter-
native is intended, and that they
are not satisfied with the care that
is currently provided (Ike, 2008).
However, more than half of the
respondents had no opinion about
what the residents actually want-
ed. Thus, even if the caregivers see
problems in the residents’ lives,
they have not discovered specific
care methods the residents desire.
The majority (88%) of care
workers and nurses said they felt
value in their work when residents
smiled often, thanked the caregiv-
ers, and expressed trusted in them.
This indicates that care workers
and nurses have person-to-person
interactions with residents, and that
they feel their work is meaningful
when residents are satisfied with the
care. The employment conditions
for care workers in FEs in Japan
are poor, and a high percentage of
workers leave the profession when
they lose a sense of meaning of
their work (Care Work Foundation,
2007). If residents can lead energetic
and satisfying lives in FEs using the
Eden Alternative, caregivers’ sense
of doing valuable work would also
likely increase. For care workers to
work with a sense of meaning, care
needs to be provided so that resi-
dents feel satisfied with life in the
facility (Takeuchi, 2007). Introduc-
ing the Eden Alternative as a spe-
cific means of improving care in the
facility may lead to both better lives
for residents and a sense of doing
something worthwhile among care
workers and nurses.
A majority of care workers and
nurses agreed with the idea of hav-
ing plants in the residents’ living
environment. Research has shown
that plants have not only a psycho-
been shown to have a positive ef-
fect on older adults (Ando, 2001),
but there is still much concern
about the problem of hygiene.
Opinions against plants, animals,
and children in the facility were
based on reasons such as infections,
the responsibility of caring for
them, residents’ preferences, and
potential accidents, but these are
thought to be due to the busyness
of caregivers and the environmen-
tal characteristics of facilities in Ja-
pan. Land is scarce and expensive
in Japan, so there are few single-
story FEs. Most are buildings of
three or more stories, with 25 to 30
people per floor and limited to 100
residents. The first floors are usu-
ally offices and day service facili-
ties, with residential rooms on the
second and higher floors. It is rare
for facilities in cities to have gar-
dens, and there is no space to keep
small birds or dogs. Ornamental
plants are placed in the first-floor
entryway, but these are simply in-
terior decorations. Most of the
residential rooms are crowded with
four people to a room, so there is
no space for plants. Japanese FEs

54 Copyright © SLACK Incorporated

do not encourage small children to
visit their grandparents, and so it is
rare to see children in these facili-
ties. In winter, many residents are
infected with norovirus or influ-
enza. These viruses spread rapidly
through facilities, all of which are
cautious about infection preven-
tion measures.
CONCLUSION
The results of this study indicate
that many care workers and nurses
believe that FE residents are help-
less, lonely, and bored, and the re-
spondents could not decide on what
residents actually wanted. However,
these caregivers would like to im-
prove the current manner of care.
Opinions were split on keeping
animals in the facility, but most re-
spondents welcomed the placement
of plants and visits from children.
This indicates that care workers and
nurses in Japan want to improve the
lives of FE residents and are search-
ing for ways to do so.
Currently, junior high school
students in Japan can experience
caring for older adults in FEs dur-
ing summer vacation as part of their
classwork, and new FEs are being
built next to kindergartens or nurs-
ery schools to provide occasions
for contact between FE residents
and children. The notion of keep-
ing animals in facilities is still not
discussed, but there are times when
volunteers bring dogs to facilities as
a special event for the enjoyment of
residents. Attempts are being made
in Japan to improve the lives of
older adults from various aspects,
and it may be that the introduction
of ideas such as the Eden Alterna-
tive would rapidly improve the care
of older adults and make the work
more meaningful for caregivers.
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About the Authors
Ms. Otsuka is Assistant Professor,
and Dr. Hamahata is Professor, Seirei
Christopher University, School of
Nursing, Hamamatsu, Shizuoka, Dr.
Komatsu is Director, Seijyuji Nursing
College, Mie County, Mie, Ms. Suishu is
Professor, Wakayama Medical Univer-
sity, School of Health and Nursing Sci-
ence, Wakayama City, Wakayama, and
Dr. Osuka is Professor, Aichi Gakuin
University, Faculty of Psychological and
Physical Science, Department of Health
Science, Nissin, Aichi, Japan.
The authors disclose that they have
no significant financial interests in any
product or class of products discussed di-
rectly or indirectly in this activity. The
authors acknowledge research support
from their universities.
Address correspondence to Shizuka
Otsuka, MSN, RN, Assistant Professor,
Seirei Christopher University, School
of Nursing, 3453 Mikatahara, Kita-ku,
Hamamatsu, Shizuoka, Japan 433-
8558; e-mail: shizuka-o@seirei.ac.jp.
Received: April 24, 2009
Accepted: October 29, 2009
Posted: February 22, 2010
doi:10.3928/00989134-20100202-03
55
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