Review of Care communication: Making a home in a Japanese eldercare facility

It is no news that Japan has a fast-growing population of older adults, and the surrounding sociopolitical issues have been discussed extensively in the media as well as in academia. As a relatively new trend after the establishment of the Long-Term Care Insurance System in 2000, older people who live in residential care facilities, rather than at home, are increasing (to the total of 900,000 in 2014, according to the 2016 Japanese Ministry of Health, Labor and Welfare report cited by Backhaus). However, little is generally known about residents’ daily life at care facilities, especially in regard to how they communicate with people who provide care to them in such an institutional environment, away from their homes and families. In his new book, Care Communication: Making a Home in a Japanese Eldercare Facility, Peter Backhaus, a sociolinguist, eloquently details the verbal interaction between the residents and the care workers at a public residential geriatric health care facility near Tokyo. His earlier experience, working as a care assistant for 15 months after high school in Germany to fulfill his ‘civilian service,’ adds general insights to his research findings of linguistic communication between residents and staff in the Japanese context. Backhaus and his collaborators tape-recorded the interactions for 6 weeks in 2007, focusing on the morning period when many care activities are performed. From quantitative and qualitative analyses of his data, he found three major traits of the eldercare communication in the morning tasks: they are (1) task focused, (2) asymmetrical, and (3) done in a hurry. Being a frequent contributor to the language column in The Japan Times, Backhaus, not surprisingly, elucidates these findings in a delightfully clear expository style, which can easily be followed and enjoyed by experts and nonexperts alike. The book also includes extensive references to relevant previous studies, which provide useful resources for future researchers as well as a good foundation for interpreting the current subject matter the book discusses.

The book consists of eight chapters and the foreword by Heidi E. Hamilton, an esteemed authority on verbal communication of older adults. Chapter 1 (Introduction) is an overview of the book, in which the author also points out the larger questions of institutional eldercare communication, such as ‘how to cope with growing dependence and loss of autonomy,’ and ‘how to navigate institutional and personal identities.’

In chapter 2, Backhaus describes the background and previous research of the study in terms of sociopolitical aspects and of care communication. He gives the important observation that the target of the study is a communication impaired environment, not simply due to the physical condition of the residents, but because of the task-oriented nature of the communication and the power asymmetry between the residents and the care workers – a theme that repeatedly appears throughout the book.

Chapter 3 provides detailed descriptions about his data and methodological considerations. During 18 working days among the 6 weeks of the data collection period, 107 dyadic interactions between a care worker and a resident, amounting to 38 h, were audio-recorded. There were 4 female and 2 male care workers, and 14 female and 11 male residents. The recording started at a resident’s room in the morning wake-up task of a care worker. The main motivation for conducting this research, Backhaus states, ‘is to get a better overall understanding about the nature of communication in Japanese institutional eldercare settings,’ (p. 24) but he rightly narrows the research question to describing ‘the basic characteristics of resident-staff interaction during the morning care activities in Edogawa Care [the pseudonym of the facility where the study was conducted].’ Two prominent methodologies used for the analysis are conversational analysis, which provides a useful tool to examine how utterances are sequenced, and interactional sociolinguistics, which illustrates the dynamic of interaction between the speakers in the sociocultural context.

Detailed analyses of the data are discussed in chapters 4–8. Chapter 4 focuses on the use of so-called honorifics, particularly terms of address, speech-level, and referent honorifics. One of the highlighted findings from the Edogawa Care data is that the use of different speech levels and referent honorific expressions does not straightforwardly indicate linguistic politeness but reflects more complex interactional strategies. This is consonant with what has been reported in studies examining style shifts in various contexts (e.g. Jones & Ono, 2008). It is interesting that the form ‘last name + san’ is predominantly used by the care workers to address the residents (what Backhaus calls a vocative use) and used much less by the residents to the workers. This difference may often be overlooked but is revealing of the nature of the verbal interactions at issue being unequal in power and task oriented. The specific residents’ attention is requested (or demanded) by the care workers but not vice versa. Another interesting point observed is that the fictive use of kinship terms, such as obaasan ‘grandmother,’ to address older nonfamily member adults, which has in other work been found to be patronizing (e.g. Usami, 1999), was almost nonexistent in his data (except for one use of okaasan ‘mother’), possibly suggesting the care workers’ sensitivity to such concerns. The fourth chapter also provided extremely useful and extensive references to previous studies, although with the omission of one notable reference: Takao Suzuki (1973, 1978 English translation), which includes illustrations of Japanese terms of address, including the fictive use of kinship terms.

Chapter 5 extends an established topic in conversational analysis to discuss in detail the opening and closing of verbal interactions during morning care. As speakers, we may not be aware how we generally open and close our conversational interaction, but as studies in conversational analysis have painstakingly shown conversations are conducted in sequential phases. Backhaus illustrates that the opening sequence in eldercare interaction similarly has phases, such as the preparations, summons, greetings, and references to the reason for a care worker to attend a resident. The closing is also done sequentially yet, as Backhaus points out, the exchange in care situations can be ended at the moment of task completion and the interactional flow is largely determined by the care workers. This asymmetry is not surprising given the task-oriented nature of the interaction. However, Backhaus also draws our attention to two examples in which the turn structure is reversed, indicating more agency and control by the residents. He states that ‘these [power] asymmetries [between the care workers and the residents] are subject to negotiation in the interactional give and take’ (p. 84). These are somewhat reminiscent of the findings of Marsden and Holmes (2014), mentioned in chapter 2, which illustrates interaction in care facilities in New Zealand, where warmth and friendliness and the display of solidarity rather than power are observed in certain notable instances. Backhaus’ study does not track interactional patterns of individual care workers and residents, but a further interactional sociolinguistic investigation with that focus may be revealing of stylistic differences and their varied degrees of effectiveness in communication styles.

This last point is also relevant to the discussion in chapter 6 on ‘task-talk’ (transactional talk) and ‘non-task talk’ (relational talk, small talk). Following the discussion of the opening and closing part of the morning care interaction, this chapter elucidates with quantitative and qualitative analyses the substantial segment of the interaction between the care workers and the residents. Transcribed examples of extended exchanges between the participants and the author’s explanation about them bring readers to the scene of morning care, even without sound and visuals. In task-talk, the care workers clearly have control over the content and the direction of the verbal act. On the other hand, the 163 non-task talk sequences found in the 107 interactions were initiated almost equally by either party of the interaction, and cover a variety of topics: 86 (53%) were started by the residents; 77 (47%) by the care workers. Noting that, while it is understandable to stipulate that tasks can be performed more efficiently if talk is restricted to the task, and that non-task talk by care workers may appear non-professional, the author concludes, consonant with some previous studies (e.g. Coupland, 2000), that ‘it is not likely the best way of giving and receiving care when the participants have nothing else to say during tasks’ (p. 122).

Chapter 7 ‘Tempo’ delves into the question of how care workers’ speech in interaction gives the impression of being hurried. Backhaus employs the conversational analytical method to uncover three contributing factors, which are rarely related to the individual speaker’s interactional speech tempo per se. One factor is overlap – the resident’s response to the care worker’s first part of the interactional sequence overlaps with the worker’s other utterance that closes the sequence or with the beginning of a new interactional sequence. The author aptly calls this ‘rear-end collision’ of different sequential stages (p. 138). Another factor is ‘multiple sayings’ by the care workers – within-turn repetitions typically of a single word (e.g. ashi, ashi ‘foot, foot’), calling for the resident to immediately perform a desired action. The third factor, identified as ‘subsequent versions,’ is similar to multiple sayings but refers to a (slightly) reworded version of the first utterance by the care workers. The care workers’ understandable intention is to move ahead efficiently in the limited time allocated to accomplish tasks, but Backhaus points out that his data show that these factors altogether are responsible for further slowing down the process.

Chapter 8 ‘Conclusion’ includes, after a concise summary and a useful discussion of the findings in 8.1, two sections dealing with ‘two larger sociolinguistic topics,’ i.e. gender (8.2) and politeness (8.3). The last two sections may be an unnecessary addition to the already informative volume, which presents a clear focus and lucid arguments without them. Especially with regard to the gender issue, the author appears to view certain linguistic elements as belonging to separate male and female grammars in Japanese. For example, the utterance by a male worker, Sm1: natte mo shoo ga nee no yo, ‘It’s no use however much you ring,’ is given as a salient example of ‘gender ambiguity,’ created by ‘a rather complex hybrid of “female grammar” delivered in a male voice’ (p. 147). The author’s explanation is that the particular negation form, nee, is marked a ‘stereotypically male speech,’ while the particles no and yo belong to female speech. However, such a one-to-one association of linguistic elements and the speaker’s gender is questionable since any such association is mediated by cultural ideology (often referred to as an issue of ‘indexicality,’ e.g. Ochs, 1992; Silverstein, 1985) and is variable. Many recent studies on language and gender in Japan have also supported the variability of styles (e.g. papers in Okamoto & Shibamoto-Smith, 2004). Further, the speech style that Sm1 presents is strongly reminiscent of the well-known male protagonist, Tora-san, in a popular series of films, Otoko wa tsurai yo ‘(lit.) It’s hard to be a man’ by Yoji Yamada. Backhaus’s point that the female-dominant work environment may influence the speaker’s style choices is interesting, and such investigation would be worth pursuing further in a more holistic and nuanced way.

Overall, Backhaus’ work is a superb testimonial, supported by meticulous quantitative and qualitative analyses of verbal data, for the importance of verbal communication in eldercare facilities. Numerous studies that he incorporates in his discussions not only validate the work but also provide valuable references to researchers. His compassion toward people in elderly care hidden behind his clear and objective analyses will undoubtedly touch readers.