Abstract
Objective
This study aimed to identify the events perceived by support staff as affecting older adults’ ability to live at home. It also explored the factors contributing to the perceptions of increasing overtime requirements among staff members supporting these individuals.
Materials and Methods
An anonymous online survey was conducted among staff members at community general support centers nationwide. The survey examined the content of decision-making support provided to older adults living alone and the factors that led to the interruption of home-based living.
Results
The most common events leading to interruption of home-based care were deteriorating health, emergency hospitalization, and reduced willingness to continue living at home. Factors associated with staff perceptions of increased overtime were greater anxiety about being responsible for supporting older adults living alone (odds ratio: 4.83, 95% confidence interval: 1.72–13.59, P=0.003) and the perception that being responsible for older adults living alone increases work outside regular duties (odds ratio: 22.0, 95% CI: 6.95–69.79, P<0.001).
Conclusion
As increased overtime may lead to higher turnover rates among staff, administrators should monitor staff anxiety about being assigned to older adults living alone and the increased workload involved, and take appropriate measures to address these issues.
Keywords: community general support centers, older adults living alone, decision-making support, care manager, overtime work
Introduction
The rate of population aging in Japan is unprecedented1), with the number of individuals aged 65 years or older projected to continue to increase until 2044. Japan’s “baby boomer” generation is expected to reach 75 years of age by 2024, resulting in a substantial increase in the late-stage older adult population (those aged ≥75 years). This demographic shift is notable, with the population aged ≥75 years projected to rise from 18.6 million in 2020 to an estimated 22.58 million by 2030. This represents a substantial increase of 21.4% over the decade2).
The growth in Japan’s aging population and the increase in the number of older adults living alone have substantially affected the social security system and local communities3). Older adults living alone have various risk factors, including isolation, dying alone, dementia, depressive symptoms, and a decline in physical and mental functions4,5,6), making their support an urgent issue. Community general support centers (CGSCs) play an essential role in providing the necessary assistance to older adults. The promotion of monitoring activities in collaboration with residents and the provision of individualized consultation support require protecting older people in their daily lives, respecting their wishes, and supporting their decision-making7, 8). However, the duties of CGSCs are diverse and include consultation support, care plan creation, and collaboration with medical institutions, making it challenging for the staff to dedicate sufficient time to each older adult. This is particularly because of the differences in patients’ individual health conditions and living environments, as well as the diverse backgrounds and knowledge levels of staff. In recent years, partly because of the increase in the number of older adults living alone, CGSC staff have struggled to provide decision-making support9, 10). As physical and mental functions decline with age, it becomes more challenging to consider the differing opinions and assessments of individuals, families, and supporters regarding the continuation of independent living11). Furthermore, many older adults living alone reject interference from others, and their highly specific circumstances make support complex and difficult4). Given the complexity of providing tailored support, it is essential to identify situations that can disrupt independent living in older adults and to respond promptly.
Recently, staff retention in the CGSCs has attracted attention as an important social concern. A survey by the Japan Foundation for Aging and Health indicated that approximately 80% of CGSC staff felt burdened by their workload, and approximately 70% reported experiencing staff shortages. Chronic understaffing leads to excessive individual workloads, which reduces the quality of work and increases mental stress12). Previous research identified several factors that increase the risk of turnover among local healthcare professionals, including reduced job satisfaction13), increased workload14, 15), and mental exhaustion16). Moreover, high job demands increase the risk of burnout17). A study by Sawada et al. on CGSC staff found that younger staff members were particularly prone to burnout and high turnover because of overwhelming workloads18). Kurioka et al. suggested that an imbalance between effort and rewards for tasks, together with excessive working hours, could increase the intention to leave work19).
Therefore, this study aimed to clarify the relationship between the risks faced by older adults living alone and the workload of the supporting staff. It identified events perceived by staff as affecting older people’s ability to live at home and clarified the underlying factors contributing to staff perceptions that managing these cases increases the requirement to work overtime. Therefore, this research provides insights into strategies that will help older people continue to live at home and reduce excessive staff workload.
Materials and Methods
Data collection
The study participants were staff members working at CGSCs nationwide. We conducted an anonymous self-administered web-based questionnaire survey. To select the target CGSCs, we calculated the population composition ratio for each prefecture based on the 2020 National Census. Using these ratios as a standard, we randomly sampled 1,002 CGSCs using Microsoft Excel. The survey questionnaire was developed for this study by drawing on reports on integrated community care and care management from the Ministry of Health, Labour and Welfare20, 21). The development process involved: 1) a comprehensive literature review; 2) selection of potential survey items; 3) researcher discussion and decision-making regarding item relevance, clarity, and alignment with research objectives; and 4) generation of a trial questionnaire administered with the cooperation of three CGSC staff members to refine the questionnaire content. The participants received an informed consent document via mail explaining the study purpose, methods, and anonymity. After providing consent, participants completed a web-based questionnaire using SurveyMonkey (San Mateo, CA, USA). The survey period was from July 11 to August 31, 2022.
Survey items
1. Background characteristics of CGSC staff
The following data on staff background characteristics were obtained: sex, age, years of CGSC experience, and professional roles (nurse, public health nurse, certified social worker, chief care manager, and others).
2. Events triggering discontinuation of home-based living for older adults living alone
In response to 19 items on the issues of emergency hospitalization, regular hospitalization, increased number of hospital admissions and discharges, and worsening of chronic medical conditions, respondents chose from four response categories: does not influence, hardly influences, minimally influences, and influences. All the items are shown in Figure 1.
Figure 1.
Distribution of CGSC staff perceptions of key events leading to interrupted home living for older adults living alone.
CGSC: community general support center.
3. Decision-making for maintaining home living support provided by staff to older adults living alone
There were six survey items on topics covered when the support staff ascertained the wishes of older adults living alone regarding their living arrangements. These included “What kind of life do you wish to lead?”, “What serves as your ‛anchor’ in your daily life at home?”, and “Who would you like us to contact during an emergency?” There were 13 survey items on preparing and offering information to support individual decision-making. These included “Assessing cognitive function”, “Assessing financial status”, and “Selecting terminology tailored to the individual’s comprehension level”. There were seven survey items on the support content to facilitate decision-making for older adults living alone. These included “Share the need for self-decision-making with the individual”, “Share current daily life challenges with the individual”, and “Respect the individual’s decisions”. All these items had four response options: “No”, “Rarely”, “Somewhat”, and “Yes”. All items are listed in Table 1.
Table 1. Association between managing cases for older adults living alone and other variables (n=194).
| Managing cases for older adults living alone leads to increased overtime | ||||||||
|---|---|---|---|---|---|---|---|---|
| Items | Category | Total | No | Yes | ||||
| N | % | N | % | N | % | P-value | ||
| Topics covered when support staff ascertain the living arrangement wishes of older adults living alone | ||||||||
| What kind of life do you wish to lead? | No | 1 | 0.5 | 1 | 100.0 | 0 | 0.0 | 1.000a |
| Yes | 193 | 99.5 | 110 | 57.0 | 83 | 43.0 | ||
| What serves as your “anchor” in your daily life at home? | No | 15 | 7.7 | 10 | 66.7 | 5 | 33.3 | 0.441 |
| Yes | 179 | 92.3 | 101 | 56.4 | 78 | 43.6 | ||
| Who would you like us to contact in an emergency? | No | 12 | 6.2 | 9 | 75.0 | 3 | 25.0 | 0.199 |
| Yes | 182 | 93.8 | 102 | 56.0 | 80 | 44.0 | ||
| Do you have a religion you practice? | No | 123 | 63.4 | 72 | 58.5 | 51 | 41.5 | 0.625 |
| Yes | 71 | 36.6 | 39 | 54.9 | 32 | 45.1 | ||
| What concerns do you have about living alone? | No | 4 | 2.1 | 2 | 50.0 | 2 | 50.0 | 1.000a |
| Yes | 190 | 97.9 | 109 | 57.4 | 81 | 42.6 | ||
| What would you like to do if independent living becomes difficult? | No | 12 | 6.2 | 9 | 75.0 | 3 | 25.0 | 0.199 |
| Yes | 182 | 93.8 | 102 | 56.0 | 80 | 44.0 | ||
| Preparing and offering information to support individual decision-making | ||||||||
| Assessing cognitive function | No | 5 | 2.6 | 2 | 40.0 | 3 | 60.0 | 0.635a |
| Yes | 189 | 97.4 | 109 | 57.7 | 80 | 42.3 | ||
| Assessing financial status | No | 11 | 5.7 | 8 | 72.7 | 3 | 27.3 | 0.358a |
| Yes | 183 | 94.3 | 103 | 56.3 | 80 | 43.7 | ||
| Selecting terminology tailored to the individual’s comprehension level | No | 3 | 1.5 | 0 | 0.0 | 3 | 100.0 | 0.077a |
| Yes | 191 | 98.5 | 111 | 58.1 | 80 | 41.9 | ||
| Providing explanations aligned with comprehension level | No | 1 | 0.5 | 0 | 0.0 | 1 | 100.0 | 0.428a |
| Yes | 193 | 99.5 | 111 | 57.5 | 82 | 42.5 | ||
| Forecasting future physical and mental conditions of older adults living alone | No | 9 | 4.6 | 7 | 77.8 | 2 | 22.2 | 0.958a |
| Yes | 185 | 95.4 | 104 | 56.2 | 81 | 43.8 | ||
| Explaining predicted future conditions to older adults living alone | No | 26 | 13.4 | 15 | 57.7 | 11 | 42.3 | 0.958 |
| Yes | 168 | 86.6 | 96 | 57.1 | 72 | 42.9 | ||
| Providing information to encourage decision-making | No | 2 | 1.0 | 1 | 50.0 | 1 | 50.0 | 1.000a |
| Yes | 192 | 99.0 | 110 | 57.3 | 82 | 42.7 | ||
| Providing information using visual aids | No | 37 | 19.1 | 21 | 56.8 | 16 | 43.2 | 0.95 |
| Yes | 157 | 80.9 | 90 | 57.3 | 67 | 42.7 | ||
| Presenting and explaining local social resources | No | 4 | 2.1 | 2 | 50.0 | 2 | 50.0 | 1.000a |
| Yes | 190 | 97.9 | 109 | 57.4 | 81 | 42.6 | ||
| Presenting and explaining realistic options | No | 11 | 5.7 | 6 | 54.5 | 5 | 45.5 | 1.000a |
| Yes | 183 | 94.3 | 105 | 57.4 | 78 | 42.6 | ||
| Explaining the advantages of options presented by support staff | No | 8 | 4.1 | 5 | 62.5 | 3 | 37.5 | 1.000a |
| Yes | 186 | 95.9 | 106 | 57.0 | 80 | 43.0 | ||
| Explaining the disadvantages of options presented by support staff | No | 11 | 5.7 | 7 | 63.6 | 4 | 36.4 | 0.761a |
| Yes | 183 | 94.3 | 104 | 56.8 | 79 | 43.2 | ||
| Explaining the risks of options presented by support staff | No | 15 | 7.7 | 9 | 60.0 | 6 | 40.0 | 0.821 |
| Yes | 179 | 92.3 | 102 | 57.0 | 77 | 43.0 | ||
| Content of support to facilitate decision-making for older adults living alone | ||||||||
| Share the need for self-decision-making with the individual | No | 41 | 21.1 | 22 | 53.7 | 19 | 46.3 | 0.604 |
| Yes | 153 | 78.9 | 89 | 58.2 | 64 | 41.8 | ||
| Share current daily life challenges with the individual | No | 7 | 3.6 | 5 | 71.4 | 2 | 28.6 | 0.701a |
| Yes | 182 | 93.8 | 106 | 58.2 | 81 | 44.5 | ||
| Collaboratively examine daily life challenges | No | 6 | 3.1 | 5 | 83.3 | 1 | 16.7 | 0.241a |
| Yes | 188 | 96.9 | 106 | 56.4 | 82 | 43.6 | ||
| Respect the individual’s decisions | No | 2 | 1.0 | 1 | 50.0 | 1 | 50.0 | 1.000a |
| Yes | 192 | 99.0 | 110 | 57.3 | 82 | 42.7 | ||
| Communicate the support staff’s opinions | No | 23 | 11.9 | 12 | 52.2 | 11 | 47.8 | 0.603 |
| Yes | 171 | 88.1 | 99 | 57.9 | 72 | 42.1 | ||
| Communicate the support staff’s wishes | No | 45 | 23.2 | 25 | 55.6 | 20 | 44.4 | 0.797 |
| Yes | 149 | 76.8 | 86 | 57.7 | 63 | 42.3 | ||
| Encouragement from support staff | No | 30 | 15.5 | 18 | 60.0 | 12 | 40.0 | 0.738 |
| Yes | 164 | 84.5 | 93 | 56.7 | 71 | 43.3 | ||
| Perspectives of support staff for older adults living alone | ||||||||
| The older adults living alone I support are able to make decisions about how they live their life | No | 9 | 4.6 | 5 | 55.6 | 4 | 44.4 | 0.918a |
| Yes | 185 | 95.4 | 106 | 57.3 | 79 | 42.7 | ||
| I believe I am respecting the preferences of the older adults living alone | No | 8 | 4.1 | 3 | 37.5 | 5 | 62.5 | 0.291a |
| Yes | 186 | 95.9 | 108 | 58.1 | 78 | 41.9 | ||
| Supporting older adults living alone involves substantial mental burden | No | 61 | 31.4 | 51 | 83.6 | 10 | 16.4 | <0.001 |
| Yes | 133 | 68.6 | 60 | 45.1 | 73 | 54.9 | ||
| I feel anxious about being responsible for supporting older adults living alone | No | 87 | 44.8 | 59 | 67.8 | 18 | 20.7 | <0.001 |
| Yes | 107 | 55.2 | 42 | 39.3 | 65 | 60.7 | ||
| Being responsible for older adults living alone increases work outside my regular scope of duties | No | 66 | 34.0 | 62 | 93.9 | 4 | 6.1 | <0.001 |
| Yes | 128 | 66.0 | 49 | 38.3 | 79 | 61.7 | ||
Results are from the χ2 test or Fisher’s exact test. aFisher’s exact test.
4. Perspectives of support staff for older adults living alone
Five items were used to assess the staff perspectives. These included “The older adults living alone I support are able to make decisions about how they live their lives”, “I believe I am respecting the preferences of the older adults living alone”, and “Supporting older adults living alone involves a substantial mental burden”. These items had four response options: “No”, “Not really”, “Somewhat”, and “Yes”. All items are listed in Table 1.
Statistical analyses
In the analysis, we included data from respondents who provided answers to all items on CGSC staff background characteristics, events triggering the discontinuation of home-based living for older adults living alone, the content of decision-making support for maintaining home living provided by staff for older adults living alone, and perspectives of support staff for older adults living alone. Age was categorized into two groups, <45 years and ≥45 years, according to the Ministry of Health, Labour and Welfare report20). Years of experience were also divided into two categories: <7 years and ≥7 years8). Regarding responses to items on the content of decision-making support, responses of “No” and “Rarely” were recoded as “No”, while responses of “Somewhat” and “Yes” were recoded as “Yes”. Similarly, for responses to items on support staff perspectives, responses of “No” and “Not really” were recoded as “No”, and responses of “Somewhat” and “Yes” were recoded as “Yes”.
First, we analyzed the distribution of scores for each item for events that triggered the discontinuation of home-based living. We used the χ2 test or Fisher’s exact test to examine the association between “Yes” responses to the statement that managing cases for older adults living alone leads to increased overtime and other variables. To identify the factors associated with managing cases of older adults living alone, which lead to increased overtime, we conducted a binary logistic regression analysis. The dependent variable was the perception that managing cases of older adults living alone leads to increased overtime (No: 1, Yes: 2). We used a forced entry method for potential confounding factors, including sex (Male: 1, Female: 2), age (<45 years: 1, ≥45 years: 2), years of experience (<7 years: 1, ≥7 years: 2), and professional role (Public Health Nurse/Nurse: 1, Certified Social Worker/Chief Care Manager/Other: 2). Variables that showed a significance level of <5% in the univariate analysis were also input into the model: “Supporting older adults living alone involves substantial mental burden” (No: 1, Yes: 2), “I feel anxious about being responsible for supporting older adults living alone” (No: 1, Yes: 2), and “Being responsible for older adults living alone increases work outside my regular scope of duties” (No: 1, Yes: 2). Before inclusion, we assessed all variables for multicollinearity using the variance inflation factor (values ≥10 indicated severe multicollinearity). Data entry, tabulation, and statistical analyses were performed using IBM SPSS Statistics Version 29 (Armonk, NY, USA). The significance level was set at 5%.
Ethical considerations
This research was conducted in accordance with the Declaration of Helsinki, 1995 (as revised in Seoul, 2008), and was carried out with the consent of the University Medical Research Ethics Review Committees at the authors’ universities (approval number: 22005). The participants were informed that their participation was voluntary, that they were free to withdraw their cooperation at any time, and that their anonymity and privacy would be protected. Submission of the web questionnaire was considered an indication of informed consent.
Results
Participant backgrounds
Of the 1,002 CGSC staff surveyed, 284 responses were received. Of these, 194 were included in the analysis, yielding a response rate of 68.3%. The participants’ mean age (standard deviation) was 46.0 years (8.7 years). Their average length of experience at a CGSC was 6.1 years (4.5 years). A total of 115 participants (59.3%) were female, and 79 (40.7%) were male. Participants’ professional roles varied, with certified social workers being the most common at 75 (38.7%), followed by chief care managers (64; 33.0%) and public health nurses (31; 16.0%) (Table 2).
Table 2. Participant characteristics (n=194).
| Managing cases for older adults living alone leads to increased overtime | ||||||||
|---|---|---|---|---|---|---|---|---|
| Items | Category | Total | No | Yes | ||||
| N | % | N | % | N | % | P-value | ||
| Age, mean (standard deviation) | 46.03 (8.73) | 0.342 | ||||||
| Years of experience at CGSC, mean (standard deviation) | 6.05 (4.51) | 0.597 | ||||||
| Age group | 45 years | 83 | 42.8 | 56 | 67.5 | 27 | 32.5 | 0.013 |
| ≥45 years | 111 | 57.2 | 55 | 49.5 | 56 | 50.5 | ||
| Years of experience category | <7 years | 119 | 61.3 | 73 | 61.3 | 46 | 38.7 | 0.143 |
| ≥7 years | 75 | 38.7 | 38 | 50.7 | 37 | 49.3 | ||
| Sex | Male | 79 | 40.7 | 42 | 53.2 | 37 | 46.8 | 0.344 |
| Female | 115 | 59.3 | 59 | 51.3 | 46 | 40.0 | ||
| Professional role | Public health nurse/Nurse | 48 | 24.7 | 27 | 56.3 | 21 | 43.8 | 0.876 |
| Public health nurse | 31 | 16.0 | ||||||
| Nurse | 17 | 8.8 | ||||||
| Certified social worker/Chief care manager/Other | 146 | 75.3 | 84 | 57.5 | 62 | 42.5 | ||
| Certified social worker | 75 | 38.7 | ||||||
| Chief care manager | 64 | 33.0 | ||||||
| Other | 7 | 3.6 | ||||||
Results are from the χ2 test. CGSC: community general support center.
CGSC staff perceptions of key events leading to interruptions in home living for older adults living alone
The CGSC staff’s perceptions of the extent to which various factors led to the interruption of independent home living for older adults living alone are summarized below. The factor most frequently perceived as “influencing” the interruption of home living was “Worsening of chronic medical conditions”, cited by 81.4% of staff (17.5% selected “Minimally influences”). This was followed by “Emergency hospitalization” at 77.8% (19.6% selected “Minimally influences”) and “Decreased motivation to continue living at home” at 68.0% (27.8% selected “Minimally influences”). Other notable factors included “Increased incidents of fire mismanagement” and “Decline in cognitive function”. The overall distribution of these perceptions is shown in Figure 1.
Factors associated with increased overtime when managing cases of older adults living alone
Eighty-three participants (42.8%) indicated that managing cases of older adults living alone led to increased overtime. The remaining 111 participants (57.2%) did not perceive such an increase. The univariate analysis identified several factors significantly associated with a “Yes” response to increased overtime (Table 2). Specifically, participants aged ≥45 years were significantly more likely to agree with this statement (n=56, 50.5%; P=0.013). Furthermore, a strong association was observed between the perception that supporting older adults living alone involves a substantial mental burden (n=73, 54.9%; P<0.001) (Table 1). Similarly, feeling anxious about being responsible for supporting older adults living alone was significantly associated with increased overtime (n=65, 60.7%; P<0.001). Finally, the belief that being responsible for older adults living alone increased their work outside their regular scope of duties, showing a significant association (n=79, 61.7%; P<0.001).
Predictors of increased overtime associated with supporting older adults living alone: binary logistic regression analysis
A binary logistic regression analysis identified two variables that were significantly associated with the perception that supporting older adults living alone led to increased overtime (Table 3). These were “I feel anxious about being responsible for supporting older adults living alone” (Yes response: odds ratio [OR]: 4.83, 95% confidence interval [CI]: 1.72–13.59, P=0.003) and “Being responsible for older adults living alone increases work outside my regular scope of duties” (Yes response: OR: 22.0, 95% CI: 6.95–69.79, P<0.001). Additionally, age group and professional role had significant confounding effects on the perception of increased overtime owing to supporting older adults living alone. Specifically, being aged ≥45 years (OR: 4.83, 95% CI: 1.93–12.08, P<0.001) and being a nurse or a public health nurse (OR: 4.00, 95% CI: 1.61–9.98, P=0.003) were also significantly associated with the perception of increased overtime.
Table 3. Factors explaining increased overtime in managing cases of older adults living alone: binary logistic regression results (n=194).
| Items | Category | OR | 95% CI | P-value | |
|---|---|---|---|---|---|
| Lower limit | Upper limit | ||||
| Sex | Female/Male | 0.69 | 0.30 | 1.60 | 0.391 |
| Age group | ≥45 years / <45 years | 4.83 | 1.93 | 12.08 | <0.001 |
| Years of experience at CGSC | ≥7 years / <7 years | 1.89 | 0.83 | 4.31 | 0.132 |
| Professional role | Public health nurse, Nurse/Certified social worker, Chief care manager, Other | 4.00 | 1.61 | 9.98 | 0.003 |
| Supporting older adults living alone involvessubstantial mental burden | Yes / No | 1.73 | 0.56 | 5.37 | 0.344 |
| I feel anxious about being responsible forsupporting older adults living alone | Yes / No | 4.83 | 1.72 | 13.59 | 0.003 |
| Being responsible for older adults living alone increases work outside my regular scope of duties | Yes / No | 22.0 | 6.95 | 69.79 | <0.001 |
CGSC: community general support center; OR: odds ratio, 95% CI: 95% confidence interval.
Discussion
This study identified several events that the CGSC staff frequently perceived as influencing older adults’ ability to continue living alone at home. The most frequently identified events were worsening of chronic medical conditions, emergency hospitalization, decreased motivation to continue living at home, increased incidents of fire mismanagement, and decline in cognitive function. A notable proportion of the CGSC staff perceived that supporting older adults living alone leads to increased overtime, and our findings suggest that this perception is associated with factors such as anxiety about being responsible for these cases and an increase in work outside regular duties. Furthermore, the results suggest that perceptions of increased overtime work differ according to age and professional role.
The identification of worsening chronic medical conditions, emergency hospitalization, and cognitive function decline as factors influencing the continuation of home living in older adults corroborates previous research on these factors21,22,23) and suggests the need for early detection and appropriate intervention. Previous research suggests that reduced motivation and desire to continue living at home among older adults living alone, particularly those with dementia, reduces the likelihood of continuing to live at home24, 25). The causes of this reduced motivation are not limited to a decline in cognitive function or worsening physical conditions, but also involve a complex combination of psychosocial factors, such as feelings of loneliness, helplessness, and changes in the living environment26, 27). Therefore, both medical and psychosocial support are essential to address reduced motivation, necessitating interprofessional collaboration and tailored responses to each individual’s specific circumstances. However, we suggest that because age-related changes in physical and mental functions are unavoidable, it is important to consider that all older adults, and not just those living alone, experience these risks.
CGSCs establish support systems for older adults living alone by collaborating with residents and related organizations. However, in recent years, there has been an increasing demand for highly specialized observational and judgment skills to address complex issues such as the shortage of support personnel, reduced motivation among older adults living alone, depressive symptoms, and social isolation28). Studies on the monitoring and support services for older adults living alone have reported a tendency to prioritize emergency responses over daily monitoring29). Furthermore, staff involved in home support for older adults living alone reported increased psychological burden owing to long working hours and on-call duties30). Therefore, caring for older adults living alone may require a substantial amount of additional work beyond regular duties, potentially leading to a considerable increase in overall workload. Caring for individuals receiving home-based medical care often requires knowledge and skills outside a professional’s primary area of expertise, as many patients have multiple chronic conditions or complex medical needs31). This situation likely increases the mental burden and anxiety of the staff, which contributes to the perception of increased overtime. Furthermore, the absence of cohabitants for older adults living alone may lead to a wider range of concerns and more unpredictable situations, potentially increasing the workload (including decision-making support) beyond regular duties. Previous research has indicated an association between overtime and increased workload, staff burnout, and intention to leave work18, 19). Therefore, we suggest that CGSC managers prioritize management strategies that specifically address staff anxiety about taking on cases involving older adults living alone and concerns about workload increases outside their regular range of duties. This suggests that strengthening the support system for older adults could be a key strategy with a dual benefit; it will directly contribute to the well-being of older adults and may also improve the working conditions of valuable CGSC staff, thereby reducing turnover.
Regarding the confounding effects of age and professional role on the perception of increased overtime, because of their extensive experience with older adults living alone, older workers may be able to predict the workload involved more realistically. Similarly, professionals with medical expertise, such as nurses and public health nurses, may have a deeper understanding of the complexity and evolving nature of older adults’ conditions, allowing them to anticipate an increase in their workload. However, further research is required to investigate these hypotheses.
This study had several limitations. Owing to budget constraints and other factors, we did not calculate the required sample size before surveying 1,002 CGSCs nationwide. Furthermore, because of the low effective response rate and potential bias in participant attributes, the findings may not accurately reflect the entire population, requiring caution when interpreting the results. Because the survey requests were directed at managers, who then asked their staff for cooperation, it is possible that the staff may not have accurately answered the questions regarding overtime. The questions regarding increased overtime were based on staff self-perceptions and not on objective measurements of working hours. Therefore, there may have been a discrepancy between perceived and actual overtime. Finally, because this was a cross-sectional study, causal relationships between the variables could not be established.
Conclusions
The study findings suggest that staff perceptions of increased overtime owing to supporting older adults living alone are associated with anxiety about being responsible for these cases and the belief that such support leads to an increase in work outside regular duties. Furthermore, staff background factors such as age and professional role may influence this perception. Therefore, CGSC managers need to understand the reasons for and nature of this anxiety to implement measures for anxiety reduction in staff. Specifically, this could involve establishing environments for regular consultations and facilitating co-responses among experienced staff members. Additionally, it is essential to investigate the nature of potential out-of-scope tasks arising from these responsibilities, clarify job scopes, and address these issues accordingly. Ultimately, these findings underscore a significant dual benefit: measures designed to stabilize the lives of older adults are also effective ways to improve the working environment of CGSC staff and reduce the turnover of essential support staff.
Conflict of interest
The authors declare that they have no conflicts of interest.
Funding
This work was supported by a KAKENHI JSPS Grant-in-Aid for Scientific Research© [19K11132].
Ethics approval and consent to participate
This research was conducted in accordance with the Declaration of Helsinki, 1995 (as revised in Seoul, 2008) and was carried out with the consent of the Himeji University School of Nursing Ethics Review Committee (IRB approval code: 22005). Informed consent was obtained from all the participants involved in this study.
Consent for publication
All authors consented to the publication of this manuscript in Journal of Rural Medicine.
Author contributions
Conceptualization, H. Nakai and K. Ishi; Methodology, H. Nakai and K. Ishi; Validation, H. Nakai and K. Ishi; Formal analysis, H. Nakai; Investigation, K. Ishi; Resources, H. Nakai and K. Ishi; Data curation, H. Nakai and K. Ishi; Writing—original draft preparation, H. Nakai; Writing—review and editing, H. Nakai and K. Ishi; Visualization, H. Nakai; Supervision, H. Nakai; Project administration, H. Nakai. All the authors have read and agreed to the published version of the manuscript.
Acknowledgments
We thank Diane Williams, PhD, from Edanz (https://jp.edanz.com/ac) for editing the draft of this manuscript.
Data availability
The datasets generated during this study are not publicly available to ensure the privacy of participants but are available from the corresponding author upon reasonable request.
References
- 1.2024 World Economic Forum. More than 1 in 10 people in Japan are aged 80 or over. Here’s how its ageing population is reshaping the country. World Economic Forum. 2023. https://www.weforum.org/agenda/2023/09/elderly-oldest-population-world-japan/ Accessed September 11, 2024.
- 2.Yusuke S. Impact of Japan’s aging population in 2030—focusing on the effect on the social security system and local economies—. Mitsui & Co. Global Strategic Studies Institute Monthly Report. 2023. https://www.mitsui.com/mgssi/en/report/detail/__icsFiles/afieldfile/2023/08/30/2307k_suzuki_e_2.pdf Accessed September 11, 2024.
- 3.Yamada M, Arai H. Long-term care system in Japan. Ann Geriatr Med Res 2020; 24: 174–180. doi: 10.4235/agmr.20.0037 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Sugisawa H. Challenges faced by older adults living alone: underlying factors and necessary interventions (in Japanese). Japan Foundation for Aging and Health. 2017. https://www.tyojyu.or.jp/net/topics/tokushu/koreisha-koritsu/dokkyokoreisha.html. Accessed September 14, 2024.
- 5.Noguchi T, Saito M, Aida J, et al. Association between social isolation and depression onset among older adults: a cross-national longitudinal study in England and Japan. BMJ Open 2021; 11: e045834. doi: 10.1136/bmjopen-2020-045834 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Iamtrakul P, Chayphong S. Exploring the influencing factors on living alone and social isolation among older adults in rural areas of Thailand. Int J Environ Res Public Health 2022; 19: 14572. doi: 10.3390/ijerph192114572 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Yamagata Z. FY2018 Ministry of Health, Labour and Welfare Administrative Policy Promotion Research Project Subsidy (Regional Healthcare Infrastructure Development Promotion Research Project). Guidelines for supporting individuals without relatives who have difficulty making decisions regarding hospitalization and medical care (in Japanese). 2019. https://www.mhlw.go.jp/content/000516181.pdf. Accessed September 13, 2024.
- 8.Ministry of Health, Labour and Welfare. Guidelines for decision-making support for individuals with dementia in daily and social life (in Japanese). 2018. https://www.mhlw.go.jp/file/06-Seisakujouhou-12300000-Roukenkyoku/0000212396.pdf. Accessed September 13, 2024.
- 9.Saito E, Kanzaki Y, Omote S, et al. [Characteristics of ethical dilemma and behavior in the support process of older adults and their families among nurses at a community general support center in Japan]. Nihon Koshu Eisei Zasshi 2023; 70: 836–842 (in Japanese). [DOI] [PubMed] [Google Scholar]
- 10.Ju Y, Sato E, Izumune M, et al. Difficulties in dementia support for professionals belonging to the Community General Support Centers in a Prefecture and Countermeasures. J Faculty and Graduate School of Nursing, University of Yamanashi Prefecture. 2020; 6: 9–19 (in Japanese). [Google Scholar]
- 11.Petriwskyj A, Gibson A, Parker D, et al. Family involvement in decision making for people with dementia in residential aged care: a systematic review of quantitative literature. Int J Evid-Based Healthc 2014; 12: 64–86. doi: 10.1097/XEB.0000000000000003 [DOI] [PubMed] [Google Scholar]
- 12.General Incorporated Association Longevity Development Center summary report: a survey on daily challenges faced by community general support center staff in performing their duties (in Japanese). 2023. https://nenrin.or.jp/research/pdf/research/20230512_04.pdf. Accessed September 15, 2024.
- 13.Wang H, Jin Y, Wang D, et al. Job satisfaction, burnout, and turnover intention among primary care providers in rural China: results from structural equation modeling. BMC Fam Pract 2020; 21: 12. doi: 10.1186/s12875-020-1083-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Yoshida T. A study on support system of long-term care support specialists and mental stress in designated in-home long-term care support providers. Jpn J Human Relations. 2012; 18: 1–10 (in Japanese). [Google Scholar]
- 15.Kitila KM, Wodajo DA, Debela TF, et al. Turnover intention and its associated factors among health extension workers in Illubabora zone, South West Ethiopia. J Multidiscip Healthc 2021; 14: 1609–1621. doi: 10.2147/JMDH.S306959 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Green AE, Miller EA, Aarons GA. Transformational leadership moderates the relationship between emotional exhaustion and turnover intention among community mental health providers. Community Ment Health J 2013; 49: 373–379. doi: 10.1007/s10597-011-9463-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Iguchi A. [Job demand and job resources related to the turnover intention of public health nurses: an analysis using a job demands-resources model]. Nihon Koshu Eisei Zasshi 2016; 63: 227–240 (in Japanese). [DOI] [PubMed] [Google Scholar]
- 18.Sawada Y, Ishikawa H, Ooji M, Matsuoka K.A study on burnout and social support among professionals at community general support centers. J Health and Welfare Statistics 2014; 61: 26–32 (in Japanese). [Google Scholar]
- 19.Kurioka S, Kuroko M, Hara K. Study on the intention of resignation and job relation factors among the staff of the regional comprehensive support center—investigation of ways to improve job retention of care workers—. Social Security Studies 2017; 2: 366–378 (in Japanese). [Google Scholar]
- 20.Ministry of Health, Labour and Welfare. FY2018 Research project report on the actual work conditions of community general support centers, under the Ministry of Health, Labour and Welfare subsidy for elderly health care business promotion expenses (Elderly Health and Health Promotion Projects) (in Japanese). 2019. https://www.murc.jp/wp-content/uploads/2019/04/koukai_190410_7.pdf. Accessed September 20, 2024.
- 21.Ayabe A.Factors affecting the perspective of caregivers on assisting elderly living at home. J Jpn Academy of Nursing Sci 2007; 27: 2_43-2_52 (in Japanese). doi: 10.5630/jans.27.2_43 [DOI] [Google Scholar]
- 22.Karasawa K, Inayoshi K. A study on the factors compromising elderly persons’ ability to continue living alone. Bulletin of Iida Women’s Junior College. 2008; 25: 21–33 (in Japanese). [Google Scholar]
- 23.Ohnuma T, Makizako H, Abe T, et al. [Predictors of interruptions to living at home in elderly people enrolled in a home visit rehabilitation service]. Nihon Ronen Igakkai Zasshi 2012; 49: 214–221 (in Japanese).doi: 10.3143/geriatrics.49.214 [DOI] [PubMed] [Google Scholar]
- 24.Inuyama A, Suwa S. Factors about older people with dementia living alone that impact their ability to continue living at home. J Chiba Academy of Nursing Science 2019; 25: 37–46 (in Japanese). [Google Scholar]
- 25.Nakashima T, Ohbayashi Y. How do people with dementia living alone confront daily challenges of aging? J Care and Behavioral Sci for the Elderly 2022; 27: 39–49 (in Japanese). [Google Scholar]
- 26.Perissinotto CM, Stijacic Cenzer I, Covinsky KE. Loneliness in older persons: a predictor of functional decline and death. Arch Intern Med 2012; 172: 1078–1083. doi: 10.1001/archinternmed.2012.1993 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Payne L, Harris P, Ghio D, et al. Beliefs about inevitable decline among home-living older adults at risk of malnutrition: a qualitative study. J Hum Nutr Diet 2020; 33: 841–851. doi: 10.1111/jhn.12807 [DOI] [PubMed] [Google Scholar]
- 28.Ministry of Internal Affairs and Communications, Administrative Evaluation Bureau. Survey report on monitoring activities for elderly people living alone (in Japanese). 2023. https://www.soumu.go.jp/main_content/000892187.pdf. Accessed September 18, 2024.
- 29.Koike T, Fukaya T, Nonaka K, et al. [Usage conditions and intentions to use monitoring services for the elderly living alone]. Nihon Koshu Eisei Zasshi 2013; 60: 285–293 (in Japanese). [PubMed] [Google Scholar]
- 30.Nübling M, Vomstein M, Schmidt SG, et al. Psychosocial work load and stress in the geriatric care. BMC Public Health 2010; 10: 428. doi: 10.1186/1471-2458-10-428 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Frost R, Rait G, Wheatley A, et al. PriDem Study project team.What works in managing complex conditions in older people in primary and community care? A state-of-the-art review. Health Soc Care Community 2020; 28: 1915–1927. doi: 10.1111/hsc.13085 [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated during this study are not publicly available to ensure the privacy of participants but are available from the corresponding author upon reasonable request.