Abstract
The population of older adults will continue to grow rapidly in the United States and Japan over the next decade. With more than 28% of the population above the age of 65, the “super-aged” society in Japan is the oldest in the world (World Bank, 2022). In contrast, 17% of the population is above the age of 65 in the United States, a demographic that is projected to double in the next 20 years (O’Neill, 2023). In both countries, aging adults express a strong preference to remain in their homes or in the community rather than an institutional setting, a care approach that has been termed aging in place (AIP; Ahn, 2017). While Japan leads the United States in developing policies to address an aging population, structural and practical support for family members and caregivers who wish to accommodate AIP is insufficient to meet the demand in each country (Binette & Vasold, 2018; D’Ambrosio, 2020).
One underutilized approach to address AIP is workforce development for educators, clinicians, and researchers who focus specifically on the knowledge and skills needed to foster family-based solutions to AIP (Gruss & Hasnain, 2021). Given the ways in which Japan and the United States are approaching the care of older adults, we sought to explore creative solutions to address AIP by merging the knowledge and practices from these diverse cultures and health care systems via cross-cultural exchange. Drawing on the expertise and best practices of these two unique systems contributes to a broader and richer approach to advancing professional practice and programs to support AIP in each country.
Funded by the Japan Foundation of New York and with support from the International Family Nursing Foundation (IFNF) and the Japanese Association for Research in Family Nursing (JARFN), our cultural exchange program delivered two interactive, didactic seminars about existing models of care and services that exist in each country. These sessions were designed and presented by family health scholars with gerontological expertise in Japan and the United States and included small group discussions with participants from both countries to foster cultural exchange and engage practitioners, educators, and researchers from Japan and the United States in dialogue about their values, practices, and programs to support healthy aging. Here, we report briefly on our process and lessons learned in the hope that the framework we developed could serve as a launchpad for similar initiatives with family nursing and family health scholars worldwide.
The major activities of the project, which will inclusively be referred to as the Workshop, were to jointly develop a series of lectures about trends in aging and health, health care systems, programmatic approaches, and clinical practices for serving families caring for aging family members in the community in Japan and the United States. Our aim was to compare these two systems of care within these lectures so that participants might learn from the experiences in each country. Lectures were recorded and delivered sequentially via the IFNF website. After viewing the lectures, two small group interactive sessions were held using Zoom so that Workshop participants from the two countries could dialogue with each other and the content experts about the unique features of health care for aging community members in Japan and the United States. A third element of the Workshop was the contribution of an educational team from the International Family Nursing Association (IFNA) who designed a teaching plan for the lectures to aid dissemination and incorporation of the lecture content into educational and clinical systems in the United States and Japan.
Dialogue between scholars in the United States and Japan occurred at several levels during the yearlong project, particularly between content experts from the two countries who were learning about the institutional, programmatic, and clinical uniqueness of each health care system. These conversations in the planning group advanced everyone’s overall understanding of new developments in the care of older adults in Japan and the United States. Early planning meetings focused on exchanging ideas and information about the health care systems and programs, as well as clinical practices that served families caring for an older family member or caring for someone with dementia within Japan and the United States. Subsequent meetings focused on setting specific lecture goals, objectives, and intended outcomes and coordinating the content to be covered in the lecture series.
Two logistical challenges had a significant impact on how the Workshop was delivered. The first was language. While most Japanese participants were anticipated to have experience with and a working knowledge of English, the same could not be said of U.S. participants regarding Japanese. We approached this potential barrier for participation by recording the lectures in English and providing transcripts of the recordings in both English and Japanese. This allowed participants to view the recorded lectures prior to the interactive sessions, giving plenty of time to synthesize the content. This “flipped classroom” approach also addressed the second logistical challenge related to timing of the Workshop. Given the inclusion of so many time zones, the blending of asynchronous lectures with synchronous discussion aided in presenting the Workshop. Still, these time zone challenges limited the number of participants who could participate.
Dialogue among Workshop participants occurred within small group interactive Zoom sessions where clinicians, educators, and scholars from Japan and the United States were able to describe their local situations for participants from other countries. These sessions were attended by participants in Japan and the United States, as well as individuals from the United Kingdom and Switzerland. The purpose of these interactive sessions was to engage participants in cross-cultural discussion of their roles within each health care system and to encourage reflections on the content of the lectures. Sessions began with an introduction and overview for all attendees. Breakout rooms were then used for small group discussions with a mix of participants from Japan, the United States, and two other countries. These small group discussions were co-facilitated by an English- and Japanese-speaking member of our team. Finally, all participants rejoined the larger group to share brief highlights from the small group discussions.
Participants were asked to identify surprising or new aspects of clinical and programmatic practices in each country and consider how they might apply ideas from the lectures and discussions to their current work role or institution. Participants from the United States were surprised by the extent of the care systems constructed in Japan to address the care of older adults within each community. Japanese participants were curious about the online and social network approaches to care being tested within the United States. Multiple questions about cultural differences in working with families in the two countries were explored. For example, Japanese participants emphasized the need to approach families incrementally, always recognizing that families were cautious about letting strangers, even professionals, inside the family. Japanese participants were curious about how frank the U.S. professionals’ discussions of end-of-life concerns might be. An evaluation of the workshop was sent to all participants shortly after the completion of the second interactive session. Responses suggest participants felt that they learned new information and were able to identify programmatic and clinical applications from what they learned.
Dialogue about the educational toolkit, and its relevance and potential uses in Japan and the United States, occurred both within the educational consultation team and the Workshop planning group. Recruited from IFNA Education Committee, a team of four individuals with curricular development expertise were asked to develop a Toolkit aimed at expanding dissemination of the Workshop content. They included Drs. Constance Kartoz, Norma Krumwide, Tammy Neiman, and Teresa Gutierrez Alelman. The Toolkit provides teaching strategies to accompany the Workshop lectures and is intended to increase the uptake of the Workshop by academic and/or clinical institutions beyond those who participated in the Workshop.
The Educational Team produced a learning plan for each lecture based upon Transparent Assignment Design principles. The new American Association of Colleges of Nursing (AACN) Essentials for Nursing Education (AACN, 2021), the IFNA Position Statement on Competencies for Family Nursing Practice (IFNA, 2015), and types of interactive learning activities were included in consideration. The team used Zoom and shared document drives to meet with each other and develop the Toolkit. The process unfolded in stages: understanding the scope and intent of the Toolkit, decisions about the framework for the Toolkit, development of the resource, and a final revision. The work was informed by continual feedback from Dr. Chesla and participation the interactive Workshop sessions.
The Educational Briefcase is the product of this effort. Elements of the Briefcase are available open access on the IFNF website including the four recorded lectures, English and Japanese transcriptions of each lecture, and a teaching guideline for potential users to structure experiences to engage students from varied educational and clinical settings in the content of the lectures using principles of transparent assignment design (Washington State University, 2020). Additional materials in the Briefcase include guidelines that can be used in small group discussions to stimulate conversation between learners about the lecture content. The Briefcase can be accessed from the IFNA website.
As with any new project, there are many lessons learned during the process of planning and execution. Logistical consideration, particularly time zone differences between the United States and Japan, drove many of the choices in design. In the end, these choices (e.g., asynchronous and synchronous components) made the dissemination of the final Briefcase easier and more complete. We relied on existing content expertise and technology (e.g., the IFNA YouTube channel) to make the Workshop a success, but considerable time went into developing and recording the lectures and preparing and translating the transcripts. In addition to the program developers’ activities, members of the Workshop planning group who are International Exchange Committee members of JARFN also coordinated practice sessions with Japanese participants to foster encouragement and build confidence in English-language skills. These extra steps to address language differences must be considered and time allotted.
The most exciting lessons learned were those related to the fostering of new ideas in the family-focused care of older adults, as well as the building of new international collaborations. Each person who contributed to the planning and delivery of the Workshop and Briefcase learned a great deal and the resulting educational materials will continue to serve students, clinicians, and scholars.
Footnotes
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J.G.A. and C.A.C. have contributed equally to this editorial.