“ Care That Respects Individuality ” Provided to Elderly People with Dementia as Perceived by Japanese Dementia Carers Qualified

The objective of this study was to clarify the contents of “care that respects individuality” provided to elderly people with dementia living in group homes as perceived by dementia carers qualified. We interviewed 21 dementia carers qualified working at group homes in Prefecture A about the practical contents of and their thoughts on “care that respects individuality”. The data obtained from the interviews were analyzed using the modified grounded theory approach (M-GTA). As a result, 14 concepts regarding the contents of “care that respects individuality” provided to elderly people with dementia living in group homes as perceived by dementia carers qualified were generated in the following 4 categories: “placing emphasis on the individual”, “respecting feelings”, “eliciting strengths”, and “close mutual relationship”.


Introduction
The world's dementia population is estimated to be 46.8 million people in 2015, but it is projected to increase to 74.7 million people by 2030 and increase to 131.5 million people by 2050.The number of patients diagnosed with dementia is the largest in the Asian region, including Japan, with a total of 49% of 4.9 million people [1].
The importance of care that respects individuality is also being discussed in the context of care for elderly people with dementia [2].
In this study, "sonohitorashisa (personhood)" which is expression peculiar to Japan is referred to as "individuality" based on 8 categories borrowed from a study in the literature [3].In Japan's dementia care, the concept of "care that supports the dignity of elderly people", which forms the basis for geriatric nursing, is considered a factor behind the use of the term "individuality"."Care that supports the dignity of elderly people" is defined as care that allows an elderly person to lead the individual life that they wish even if they come to need long-term care [4].The term "individuality" has an important place in long-term care for the elderly.Furthermore, the expression "person-centered care" proposed by Kitwood is now used worldwide.The central concept behind this situation is "personhood," or "sono hitorashisa (individuality)" in Japanese.Personhood is the position and status bestowed to an individual by others that signifies the recognition, respect, and trust shown to an individual as a person 4).Some reports have also described how practices in person-centered care alleviate symptoms such as anxiety, disappointment, and depression, [5] [6] [7].The main theme of person-centered care is the maintenance of personhood.The current Japanese term "sono hitorashisa (individuality)" may therefore have the same meaning as personhood.
In our examination of previous studies regarding "individuality" in Japan, we found an article by Nagata [8] in which situations of care that respect "individuality" are described in terms of "self-selection and self-determination", "individualization", "enhancing quality of life", "self-expression", "self-actualization", and "independence."Haruki et al. [9] also list five elements of recognition of "individuality": "values and recognition", "hope, motivation, and enjoyment", "lifestyle", "role in society and groups", and "activities of daily living."We also examined previous studies regarding "individuality" in elderly people with dementia and found an article by Suwa et al. [10] that identified four categories of care techniques that respect the individuality of elderly people with dementia: "presenting interventions performed to date", "being where one belongs", "expressing self-existence", and "mutually communicating sympathy", which represented "the temporal nature of elderly people with dementia" and the "caring for elderly people with dementia".In addition, Tsuji et al. [11] noted that in order to maintain the individuality of an elderly person with dementia even after they are admitted to a group home, a pre-admission assessment regarding living habits immediately prior to admission, life history to date, manner of interacting with others, and personal hobbies and preferences should be carried out.These articles show that although studies regarding care techniques in "care that respects individuality" provided to elderly people with dementia and assessments to maintain this individuality have been conducted, no studies can be found that clarify the nature and contents of "care that respects individuality".Dementia care specialists are described in one report as being very active in caring for behavioral and psychological symptoms of dementia (BPSD) and in developing skills to communicate with people with dementia [12].Clarifying the contents of "care that respects individuality" provided to elderly people with dementia by dementia carers qualified could offer new insight into suitable care for BPSD and allowing people with dementia to continue living in their own way in a good environment and familiar community.

Purpose
The objective of this study was to clarify the contents of "care that respects individuality" provided to elderly people with dementia living in group homes as perceived by dementia carers qualified.

Participants
The participants in this study were 21 dementia carers qualified working at 21 group homes who were referred to us by a dementia care research group in Prefecture A and who consented to take part in this study.

Study Period
This study (interview) was conducted from March to May 2016.

Method of Data Collection
We observed situations in which dementia carers qualified provided meal care to elderly people with dementia, and then conducted interviews with these dementia carers qualified.

Participant Observation
We chose to perform participant observation because we thought that we would be able to elicit contents of specific "care that respects individuality" by adopting contents identified from participant observation as themes to confirm the actual situation of care in the event that none of the participants gave answers regarding "individuality" or "care that respects individuality" during the interviews.
We also chose to observe situations of meal care because feeding, which is a basic desire, is an essential means of life support and is even emphasized as an activity to form mutual relationships and foster communication.Meals are also said to be the origin of subjective behavior in humans.Meal settings are therefore a particularly good instance in daily life for an individual to express their subjectivity.We consequently considered meal situations to be likely scenarios where individuality is expressed and "care that respects individuality" is easily provided.
During participant observation, we adopted as observational perspectives 8 categories borrowed from a study in the literature [3] on "care that respects individuality", as follows: "support of living habits", "understanding of life history", "care linking people and things", "environmental adjustment", "hoped ac-complishments", "respect for values", "support for role execution", and "assessment of capability."The contents of the observations were sorted into those before, during, and after meals, and subsequently described.Any contents of situations considered to be associated with the observational perspectives were described in detail.

Interviews
We conducted semi-structured interviews using an interview guide.The contents of the interview guide included thoughts on habitual dementia care, thoughts and practical details related to "individuality" and "care that respects individuality", and thoughts and practices related to "individuality" and "care that respects individuality" during meal care.All contents of situations considered associated with the observational perspectives were taken as themes from which to elicit contents of "care that respects individuality".Each participant was interviewed once in a private room at the group home where he/she worked.
The contents of interviews were recorded using an IC recorder with the permission of the participants.

Analytical Methods
Analysis in this study was conducted using the modified grounded theory approach (M-GTA) developed by Kinoshita.This analytical method involves the generation of concepts based on a deep understanding of the data, achieved by emphasizing understanding of the contextual properties of the data without sectioning.Kinoshita describes studies in which the M-GTA is suitable to use as those on social interaction in which humans directly communicate, those in the area of human services, and those where the phenomenon being investigated has a process-like nature [13].
In the present study, we focused on "care that respects individuality" provided to elderly people with dementia living in group homes by dementia carers qualified.The care itself involves interactions in which humans directly communicate and has process elements that change with the progression of symptoms and reactions of elderly people with dementia.In light of these factors, we deemed the M-GTA to be a valid analytical method.

Realities of Data Analysis
In our analysis using the M-GTA [14], the individuals on whom the analysis was focused were "dementia carers qualified working at group homes" and the analytical topic was "how do dementia carers qualified perceive and perform care that respects the individuality of elderly people with dementia living in group homes?" The analytical procedure is as follows.
1) Word-for-word interview transcripts were read again and again to develop an understanding of their contents and flow.Theoretical saturation was considered achieved at this point.
5) The generated concepts were compared, and related concepts were grouped into categories.
6) The relationship between categories was examined, and a results diagram showing the overall relationship and process was created.The concepts were briefly documented to produce storylines.
To guarantee the rigor of the analysis, the analytical results were shown to several study participants to confirm the validity of the details.During the process from generation of the concepts to creation of the results diagram, efforts were made to guarantee the reliability of the analysis under the supervision of a researcher skilled in qualitative research.

Example of Concept Generation: "Developing an Environment
Tailored to the Life Functioning and Lifestyle Rhythm of Each Person" In this article, participants' words are indicated by "bold text in double quotation marks", participant numbers are given in parentheses, e.g. ( 1), parts emphasized during analysis are underlined, omissions are indicated by […] and concepts are represented as "text in single quotation marks".This concept was generated from participant (1) and 11 specific examples (variations) were subsequently collected from seven cases.This abundance of specific examples collected allowed us to judge this as a valid descriptive concept.The specific examples were, "Which spoon should be chosen?Which chopsticks should be chosen?The right spoon, chopsticks, and cup are different for each person.[…] I choose items such as the spoon and chopsticks that are easiest for that person to hold and the cup that is easiest for them to drink out of." (1) "I accept a person as they are; for example, they wake up when they want to wake up, they sleep when they want to sleep, they do what they like to do when they want to".( 15) "I believe that a person can eat in any manner they like, so long as they are able to savor their food.It is therefore okay to eat with one's hands.In such cases, I make food in a form that is okay to eat by hand, such as rice balls.[…] For those who do not eat by hand, I provide heavy tableware so that it does not move".(20) "I made sure to provide meals at any time because we offer 24-hour care.I thought to provide this kind of care because meals are most delicious when a person is hungry and they eat properly.[…] This manner of eating is most characteristic of the person and is most suited to the person's diet and senses; I therefore wish to cherish this".(7) The participants spoke accordingly of how they accepted and addressed the various situations of elderly people with dementia.This concept was therefore defined as "providing care tailored to changing the functioning and lifestyle rhythm of a person influenced by aging and dementia without compulsion".The following concepts were generated using the same procedure.

Ethical Considerations
This study was approved by the Committee of Medical Ethics of Hirosaki University Graduate School of Medicine, Hirosaki, Japan (approval number: 2015-039).Candidate participants were given explanations about the study purpose and methods, details that would be requested, protection of privacy, the voluntary nature of participation and freedom to discontinue the study, the means by which data would be stored and managed, and other aspects.Interviews were conducted once candidates had confirmed their willingness to participate and had provided written informed consent.Verbal or written consent was also obtained from the group home administrators and elderly people with dementia receiving support in meal settings or their family member before interviews.

Summary of Participants
The participants were 4 men and 17 women aged from their 30s to 60s.All participants had been working in dementia care for 7 to 25 years.3 had renewed their certification as dementia carers qualified twice, 10 had renewed their certification once, and 8 had never renewed their certification.The most common qualifications held by the participants other than dementia care specialist were certified care worker and care manager, followed by nurse, midwife, and middle school teacher, which were far less common (Table 1).

Storyline for "Care That Respects Individuality" Provided to Elderly People with Dementia Living in Group Homes by Dementia Carers Qualified
The 14 concepts and 4 categories were generated from the investigation in accordance with the analytical procedure based on the M-GTA.While the associations between concepts and categories were examined, storylines were also described by presenting "care that respects individuality" provided to elderly people with dementia living in group homes by dementia carers qualified as a results diagram (Figure 1).
Over the long process of caring for elderly people with dementia living in group homes, dementia carers qualified "placing emphasis on the individual" by simultaneously "assessing and caring for physical symptoms" of each individual elderly person, paying attention to "developing a comfortable environment" and "developing an environment tailored to the functioning and lifestyle rhythm of each person" and by "sharing information from each perspective without making assumptions" through "valuing each person's personal space in interactions." Using this care as the foundation, dementia carers qualified "respecting feelings" by "providing various stimuli to elicit inner aspects" of elderly people with dementia, "respecting feelings at different times", and "understanding feelings towards others arising from camaraderie" in elderly people with dementia attempting to develop harmony with their surroundings.Dementia carers qualified Figure 1."Care that respects individuality" provided to elderly people with dementia living in group homes by dementia care specialists.
also "eliciting strengths" in elderly people with dementia, such as by "gaining an understanding of life histories and making efforts to use these in current lifestyles", "pursuing interests and concerns and actively encouraging these", "encouraging the ability for self-determination", and "discovering capabilities and continuing these".During this process, a "close mutual relationship" was established between the elderly person with dementia and the dementia carers qualified when the specialist provided various forms of encouragement to the elderly person with dementia, such as "assessing and caring for needs from emotional expressions associated with the aggravation of dementia" and providing care tailored to the progression and status of dementia, including making use of "means of communicating with people who have difficulty with verbal communication".
However, "placing emphasis on the individual" "respecting feelings" "eliciting strengths" and "close mutual relationship" demonstrated a mutual relationship, such as reflecting on mutual care, in cases where care could not be carried out smoothly because of various factors, including the status of surroundings, and physical state, such as progression of dementia, aging, and disease.

Respective Categories and Concepts
The generated categories and their concepts are explained in detail as follows: 1) "Placing emphasis on the individual" (

Sharing information from each perspective without making assumptions
Sharing and comprehensively viewing information on a person from various perspectives, including one's own perspective, the family's perspective, and the staff's perspective, without making assumptions regarding the person from a single viewpoint.
I try not to make assumptions.I ask someone else from my team to take a look because I believe that other staffs see things that I cannot.There are also scenes that are not shown to me, so teamwork is indeed important.(20)

Valuing each person's personal space in interactions
Not encroaching on the space of people who value their own space and time without permission.
Because I must not place myself in this person's shoes, I draw a clear line in my contact with them.Just because their dementia has advanced does not mean that they cannot say "excuse me" when they knock on a door and enter a room without hearing an answer.(14) This category represents basic care provided to elderly people with dementia living in group homes.Dementia carers qualified "placed emphasis on the individual" by simultaneously "assessing and caring for physical symptoms" of each individual elderly person, paying attention to "developing a comfortable environment" and "developing an environment tailored to the functioning and life-style rhythm of each person", and "sharing information from each perspective without making assumptions" through "valuing each person's personal space in interactions".
"Assessing and caring for physical symptoms" involved assessing or preventing symptoms common to elderly people, such as loss of hearing, cataracts, con- side, so you can be at ease'".(5)."Developing an environment tailored to the functioning and lifestyle rhythm of each person" involved providing support tailored to the changing functioning and lifestyle rhythm of each person resulting from aging and dementia without compulsion.Participants spoke of the need to choose items such as spoons and chopsticks tailored to individual function.Participants also described developing an environment tailored to every possible situation of elderly people with dementia, such as "I believe that a person can eat in any manner they like, so long as they are able to savor their food.
It is therefore okay to eat with one's hands.In such cases I make […] rice balls." (20) "I accept a person as they are; for example, they wake up when they want to wake up, they sleep when they want to sleep, they do what they like to do when they want to." (15).When providing care, "sharing information from each perspective without making assumptions" involved sharing and comprehensively viewing information on a person from various perspectives, including one's own perspective, the family's perspective, and the staff's perspective, without making assumptions regarding the person from a single viewpoint.Participants' spoke of the importance of teamwork based on various perspectives and recognized the importance of sharing information and not making assumptions about elderly people with dementia based on a single image when providing "care that respects individuality".Valuing each person's personal space in interactions involved not encroaching on the space of people who value their own space and time without permission.Participants spoke of the importance of being courteous in their contact with elderly people with dementia.In providing "care that respects individuality", dementia carers qualified properly shared information without making assumptions about elderly people with dementia based on a single image and provided care by "placing emphasis on the individual" with courtesy.
2) "Respecting feelings" (Table 3) This category represents respecting the feelings that elderly people with dementia have difficulty expressing.Dementia carers qualified "respected feelings" by "providing various stimuli to elicit the inner aspects" of elderly people with dementia, "respecting feelings at different times", and "understanding feelings towards others arising from camaraderie" in elderly people attempting to develop harmony with their surroundings.
"Providing various stimuli to elicit inner aspects" involved providing a variety of stimuli, such as changing the setting, in order to elicit other aspects of a person.Participants spoke of providing stimuli by increasing opportunities to go on outings in order to elicit inner aspects."Respecting feelings at different times" They become more restless."( 17) "Even the things that they like change after one week.Sometimes they become unable to do something that they like and no longer want to do it."(13)."Understanding feelings towards others arising from camaraderie" involved understanding that elderly people with dementia make an effort to adapt to those around them out of camaraderie, and that difficulties developed as the progression of dementia led to stress.Participants also made an effort to adopt an individual approach to eliminate this stress and spoke of concerns associated with the feelings and symptom progression of elderly people with dementia.
3) "Eliciting strengths" (Table 4) This category represents the focus placed on the strengths of elderly people with dementia.Dementia carers qualified "elicited strengths" in elderly people with dementia, such as by "gaining an understanding of life histories and making efforts to use these in current lifestyles", "pursuing interests and concerns and actively encouraging these", "encouraging the ability for self-determination,' and "discovering capabilities and continuing these".
"Gaining an understanding of life histories and making efforts to use these in current lifestyles" involved actively obtaining information from family members and others to learn about the life history of a person, such as their lifestyle at home, their position, and their growing environment, including memories of childhood, and then using this information to form an image of the person's past situation in an effort to utilize this image in the person's current lifestyle.Participants described efforts made to use life histories in current lifestyles, including guessing a person's thoughts from their life history, such as "I ask the family about a person's life history, such as the environment the person grew up in, and make an effort to understand the person and connect this to their current lifestyle.This is the most important thing."(3) "Pursuing interests and concerns and actively encouraging these" involved gaining an understanding of the things

Concept Concept definition Variation
Gaining an understanding of life histories and making efforts to use these in current lifestyles Actively obtaining information from family members and others to learn the life history of a person, such as their lifestyle at home, their position, and their growing environment, including memories of childhood, and using this information to form an image of the person's past situation in an effort to utilize this image in the person's current lifestyle.
It is best if the person can continue living their preferred life that they have led at home.I make sure they can continue this life somehow while picturing what lifestyle they had, what work they did before, their position, whether they were a mother and whether they were in the position of a mother.( 1)

Pursuing interests and concerns and actively encouraging these
Gaining an understanding of the things that a person likes or values, such as watching their expressions or the target of their gaze, and actively encouraging the pursuit of these things. To Encouraging the ability for self-determination Providing support that does not ignore a person's feelings so that the person can make choices and act in order to avoid falling into a situation where they are forced to do something.
I allow them to choose.For example, I ask if they want their tea to be hot or cold.Some people prefer cocoa.Others do not drink tea immediately after eating, are first to clean up, or clean up after watching the morning serial drama on television.I allow them to make their own decisions as much as possible without settling on one thing.(

Discovering capabilities and continuing these
Imparting confidence by continuing to discover capabilities with a long-term view.
When a person has confidence, they discover what they are capable of.Instead of asking a person to do something they cannot do and saying, "Oh, so you cannot do that after all?", you should properly assess that person.[…] I want to properly elicit the things that people are good at.(4) what I can do by myself, so all of the staff share information and frequently ask questions to family members."(8)."Encouraging the ability for self-determination" involved providing support that does not ignore a person's feelings so that the person can make choices and act in order to avoid falling into a situation where they are forced to do something.Participants spoke of situations in which they created settings where choices could be made in daily life."Disco- vering capabilities and continuing these" involved imparting confidence by continuing to discover capabilities with a long-term view.Participants spoke of the importance of properly assessing individual elderly people with dementia.Participants also described caring for individual elderly people with dementia by carefully watching them so that capabilities could continue to be discovered with a long-term view, such as, "Until yesterday, they were able to fold laundry and other items into squares, but today they are unable to do so, and tomorrow they may be able to fold again; I do not suddenly force them to stop.I would like to elicit what they are good at."(4).
4) "Close mutual relationship" (Table 5) This category represents the close relationship between a dementia carers qualified and an elderly person with dementia.When providing various forms of encouragement to elderly people with dementia, dementia carers qualified established a "close mutual relationship" with the elderly person with dementia by "assessing and caring for needs from emotional expressions associated with the aggravation of dementia" and by providing care tailored to the progression and status of dementia, including making use of "means of communicating with Table 5. Concepts, concept definitions, and variations of "close mutual relationship".

Concept definition Variation
Assessing and caring for needs from emotional expressions associated with the aggravation of dementia Understanding and responding to the feelings behind emotional expressions, such as a person's personality, expressions, words, and actions, associated with the extent of aggravation of dementia.
When a person says that they want to die or uses violent language, I wonder whether they are in a state of intense fear from not knowing what to do about their fading identity.When I spend a bit more time in providing care or go somewhere quiet with the person to talk one-on-one, I consider how I can respond to that particular situation, such as by encouraging them to take a nap to give their mind a rest from the confusion that will not abate from talking.( 10)

Means of communicating with people who have difficulty with verbal communication
Using a variety of communication methods, including patiently waiting for responses, touching, and making eye contact with people who have difficulty communicating verbally.I leave greetings until last.Once, I approached a person, placed my hand on their knee and waited until our eyes met to say, "Good morning, Mrs. XX."When I looked down at my hand, it took that person a little while to reply with, "Good morning." People with dementia never reply immediately.One must wait a bit.
When I looked at my hand, I thought, "Sorry, I looked at my hand without waiting for you, Mrs. XX."I felt it was unforgivable to do that when Mrs. XX was trying her best to answer me.(10) people who have difficulty with verbal communication." "Assessing and caring for needs from emotional expressions (deliberately falling down, shouting, violent language, grimacing, etc.) associated with the aggravation of dementia" involved understanding and responding to the feelings behind emotional expressions, such as a person's personality, expressions, the person can move their body and utter words, but the words spoken do not appear to follow any linguistic meaning, which is why I try a variety of things until the person's expression softens."(13).Dementia carers qualified therefore adopted various practices to satisfy the feelings and wishes of elderly people with dementia.

The Constituent Details of "Care That Respects Individuality" Provided to Elderly People with Dementia
The level of expression of BPSD is closely related to the physical state and manner of daily life of each individual elderly person with dementia.The extent of BPSD is therefore a major factor decreasing the quality of life of the person with dementia and their caregiver.According to a previous study on the prevention and alleviation of BPSD, inadequate assessment of physical status, including pain, could facilitate BPSD [15].Some reports state that the provision of care and programs that take individuality into account serves to reduce BPSD in elderly people with dementia [16] These care practices are the same as those involving "placing emphasis on the individual", such as "assessing and caring for physical symptoms" and "developing an environment tailored to the functioning and lifestyle rhythm of each person", which were established in the present study, and are therefore a fundamental rule of basic dementia care [17].Accordingly, "placing emphasis on the individual" is associated with preventing and alleviating the expression of BPSD, and is even considered a foundation of "care that respects individuality."If basic care for dementia is not properly provided, "care that respects individuality" that focuses on each individual cannot be practiced.Elderly people with dementia have highly transparent minds, bodies, and "lifeworlds" (living environments.)Understanding the feelings of each individu-al experiencing dementia by considering their psyche must therefore necessitate a full understanding of everything about that individual's physical state and lifestyle as well as their psyche.The foundational position of the practice of "placing emphasis on the individual" must consequently mean that dementia care specialists are capable of "respecting feelings", by "providing various stimuli to elicit inner aspects" of elderly people with dementia, "respecting feelings at different times", and "understanding feelings towards others arising from camaraderie".
Furthermore, the concept of "understanding feelings towards others arising from camaraderie" generated in this study is thought to represent a peculiar national characteristic of the Japanese whereby a person values themself as part of a group instead of as an individual.The dementia carers qualified.in the present study appeared to consider the strong sense of camaraderie, the adaption to surroundings instead of following their own way of doing things, and adaptation difficulties associated with the progression of dementia as factors linked to stress in elderly people with dementia.The thinking that "one must adapt to one's surroundings" is characteristic of the Japanese, and understanding the frustration and stress that arise from a person losing their ability to adapt to their surroundings as their dementia progresses may lead dementia carers qualified to provide "care that respects individuality" to elderly people with dementia.
Respecting the independence and self-determination of elderly people [17] has been cited as a principle of dementia care.These care practices are considered the same as those identified in the present study and that are involved in "respecting feelings", such as "respecting feelings at different times" in elderly people with dementia, and in "eliciting strengths", such as "encouraging the ability for self-determination", which take place after "providing various stimuli to elicit inner aspects.""Respecting feelings" and "eliciting strengths" are therefore practices of person-centered nursing care that could lead to a reduction in the inconveniences felt by elderly people with dementia.Taft et al. [18] also proposed a psychosocial model of dementia care that presents the need to provide opportunities for choices and activities based on individual life histories in line with a person's interests.This psychosocial model of dementia care posits care formed of psychological and social care elements that protects the dignity of elderly people with dementia; however, "eliciting strengths" is also a form of care that protects the dignity of elderly people with dementia, suggesting similar care content.Practices of "eliciting strengths", such as "gaining an understanding of life histories and making efforts to use these in current lifestyles", "pursuing interests and concerns and actively encouraging these", "encouraging the ability for self-determination", and "discovering capabilities and continuing these", become methods of allowing elderly people with dementia to acknowledge their own capabilities, are associated with self-confidence, and enable self-actualization.
The practice of "eliciting strengths" therefore occupies an important position in "care that respects individuality" provided to elderly people with dementia and is considered core care content.
Taft et al. [18] also wrote about the need for empathetic care for building relationships, including mutual relationships, and for constantly held anxieties in their psychosocial model of dementia care.The establishment of a "close mutual relationship" by "assessing and caring for needs from emotional expressions associated with the aggravation of dementia" and by using "means of communicating with people who have difficulty with verbal communication" is similar in content to the empathetic care and building of mutual relationships proposed by Taft et al. [18] and is considered care that protects the dignity of elderly people with dementia.Without the establishment of a "close mutual relationship", a dementia care specialist would not be able to provide care tailored to the progression of dementia and various situations of elderly people.
Amidst the repetitive cycle of practices from "placing emphasis on the individual" to "respecting feelings" and "eliciting strengths", a close relationship, or "close mutual relationship", is established between the elderly person with dementia and the dementia care specialist.This is considered to result in the provision of "care that respects individuality."

Comparison with Person-Centered Care
The concept of person-centered care proposed by Kitwood has long been considered different in meaning from the "care that respects individuality" used in Japan.We therefore compared the contents of "care that respects individuality" provided to elderly people with dementia identified in the present study with those of person-centered care and discuss the details of "care that respects individuality" in Japan.
Person-centered care is defined as the equal balance of four elements: V (value; accepting values), I (individualized approach; respecting the identity of the individual), P (perspective of the person; seeing things from the viewpoint of the person), and S (social psychology; satisfying psychological needs and providing a social environment through mutual support) [19].
The practice of "placing emphasis on the individual" identified in the present study appears to have similarities with I (individualized approach; respecting the identity of the individual) in person-centered care."Respecting feelings" and "close mutual relationship" appear to have similarities with S (social psychology; satisfying psychological needs and providing a social environment through mutual support).Meanwhile, to establish a "close mutual relationship", P (perspective of the person; seeing things from the viewpoint of that person) is needed, thereby suggesting an association."Eliciting strengths" is the practice of encouraging self-determination, wishes, and capabilities in elderly people with dementia and appears to differ from the constituent elements of person-centered care.While we did not identify any concepts with the same content as V (value; accepting values) of person-centered care in the present study, as discussed in part 1 of the Discussion, "placing emphasis on the individual", "respecting feelings", "eliciting strengths", and "close mutual relationship" are principles of de-mentia care that pertain to care that protects the dignity of elderly people with dementia.Protecting the dignity of elderly people is regarded as an absolute value in the existence of all people, regardless of age or cognitive ability.The element of V (value; accepting values) in person-centered care is therefore a concept related to the overall content identified in the present study.Person-centered care emphasizes that all four elements are of equal weight [19].
However, the practices of "placing emphasis on the individual", "respecting feelings", "eliciting strengths", and "close mutual relationship" identified in the present study are characterized by processes and mutual relationships between each of the categories, and their associations are coordinated.In other words, the contents of "care that respects individuality" identified in the present study include all the contents of person-centered care, although "eliciting strengths", in which the self-determination, wishes, and capabilities of elderly people with dementia are encouraged, is considered an original concept that differs from the structure of person-centered care.

The Limitations and Future Research
This study focuses only dementia carers qualified working at group homes for generalization of the result.It is necessary to conduct an actual condition survey of all types of dementia carers working at group homes in future.Furthermore, it is necessary to conduct survey interview of senior dementia carers qualified and Certificated Nurse in Dementia Nursing for theory formation.

Conclusion
The contents of "care that respects individuality" provided to elderly people with dementia living in group homes as perceived by dementia carers qualified are organized into "placing emphasis on the individual", "respecting feelings", "eliciting strengths", and "close mutual relationship".

2 ) 3 )
Participants considered to have an abundance of interview contents related to the analytical topic were chosen as the analytical focus individuals, and work was started to generate concepts by focusing on areas related to the analytical topic.In generating the concepts, an analytical worksheet was created in which concept names, definitions, specific examples (variations), and theoretical memos were listed.Other specific examples were concurrently identified in the data and added.Concepts for which many specific examples were identified were deemed valid and adopted.During generation, the concepts were examined in terms of similar and counter examples as a means of continuous comparison and analysis.4) The analytical focus individuals were added sequentially to generate concepts.Generation of concepts was complete once specific similar examples had been exhausted and a data check of counter examples was deemed sufficient.
stipation, and dehydration, and providing treatment to prevent exacerbation of chronic diseases such as diabetes.Participants spoke of situations in which individual physical symptoms were difficult to assess.Participants also described providing basic care to adjust physical symptoms, such as "Because the elderly person does not voice the discomfort they feel from constipation or other symptoms, I have them eat yogurt two to three times a week.This is really effective."(4)."Developing a comfortable environment" involved creating an environment where elderly people with dementia could engage in physically memorized patterned behaviors, spend time with like-minded companions, have someone to listen to them at any time, and enjoy a seating arrangement that protects them from censure from those around them.Participants spoke of the development of patterns in behavior whereby elderly people with dementia felt a sense of security in physically memorizing the same seating location.Participants also described developing environments from both a physical and a human perspective, such as "I begin by chiming in with, 'That's right.'It's like saying, 'I'm by your that a person likes or values, such as by watching their expressions or the target of their gaze, and actively encouraging the pursuit of these things.Participants spoke of situations in which they noticed interests and concerns even in people who had developed difficulty with verbal communication.Participants also described difficulty in noticing things that elderly people with dementia like, such as, "It is pretty difficult to discover what a person likes.Dementia progresses and eliciting what a person is thinking or considering what the current actions or expressions of a person mean is a process of trial and error.There are limits to

T.
Nakagawa et al.DOI: 10.4236/ojn.2017.7110891240 Open Journal of Nursing words, and actions, associated with the extent of aggravation of dementia.Participants spoke of their various responses, including acknowledging emotional expressions and making an effort to consider things from the standpoint of the elderly person with dementia."Means of communicating with people who have difficulty with verbal communication" involved using a variety of communication methods, including patiently waiting for responses, touching, and making eye contact with people who have difficulty communicating verbally.Participants spoke of the various facts of communication with elderly people with dementia who have difficulty with verbal communication.Participants also described situations where they practiced various forms of nonverbal communication as dementia progressed, such as "When dementia becomes quite advanced,

Table 1 .
Summary of the study participants.

Table 2 .
Concepts, concept definitions, and variations of "placing emphasis on the individual".