I am 44 years old and I finished my training as a nurse in 1969. Subsequently I have been trained in administration, management and economics. By now I am head of The Nursing Home Marskgaarden. As you know, I am now living in Naestved, the 20'th biggest municipality in Denmark, counting 45,000 inhabitants.
Because of the social, cultural, political and economical differences between Japan and Denmark, it is difficult directly to compare our ways of caring for the senior citizens. I hope, that my presentation will contain views and ideas, that may inspire you in your discussions of policies concerning care of the senior citizens in Japan.
In Denmark it is an assignment for the public authorities to provide a variety of services to help the citizens solve their social problems and health problems. In Denmark it is not a private task to solve these problems. Recently a few private institutions are providing services within these areas, but they take up very little room in our sector.
The municipality of Naestved are for the time being in a time of unrest and upheaval, where the traditional methods for care and treatment are settled with. It is our political and administrative aim constantly to pro-vide resources for covering the material needs. The arrangements aiming at well-being are getting higher priority and the services should be delivered to the citizens in their homes.
It is an aim, that the threatening attitudes towards the citizens should be: the least possible intervention in the citizens' normal life. This rises as a consequence a demand on the citizens, for their own capacity socially and economically.
The service structure in the municipality is based on the idea, that the citizens should receive the same care and assistance, whether or not she is living in her own home or in a nursing home. Support are offered through a variety of remedial measures, by way of: home help, home nursing, around the clock home care, appliances for occupational therapy, changes to the outfit of the home, construction of special homes, physiotherapy and homes for handicapped people, special care homes, day-care institutions, day centers and relief homes.
In the municipality of Naestved are living 6,000 old-age pensioners over 67 years old. About 2,000 of these pensioners have more or less a need for public assistance.
In order for a pensioner to receive public services, an inspection of the pensioners' situation is performed. A team of case officers, nurses etc. are to decide whether or not needs and wishes of the pensioner fit the politically decided group.
The municipality has at disposal 7 nursing homes housing 291 residents, 21 protected homes, 42 collective homes and 307 homes special suitable for handicapped people.
Now I will concentrate on the nursing homes and describe the organization - the personal and service structure. I will touch the basis of our attitudes and the working principles that we employ. Selected procedures will be described and at the end, I will touch the treatment of senile people. 59.7% of the residents in Marskgaarden are senile demented.
It will lead too far to describe the complete political and administrative structure of the municipality. To show the organizational position of the nursing homes, I have prepared the following diagram (Figure 1).

Fig. 1 Marskgarden's Samarbejds-struktur


The town council is the topmost local authority and has appointed a series of specialist committees. The area of social welfare is dealt with by "The social committee", which is the nearest political authority for the nursing homes.
The social manager, who is the nearest administrative manager, has deviated the area of social welfare into four sectors (Figure 2). Children and youth, people engaged in active employment, senior citizens and pensioners and the administration.

Fig. 2

The nursing homes are placed under the senior citizens and pensioners sector and the administration.
The nursing homes co-operate with both sectors in order to coordinate the planning and the tasks, both the political directed and the admin-istrative tasks.
Marskgaarden is one of the seven nursing homes in the municipality. The buildings are 17 years old. Our physical settings are very good, with 72 care homes distributed over three buildings, each in two stocks. Each building is considered an apartment and contains 24 care homes. The area of each care home is 24 ?u comprising a 16 ?u living room, a small hall and a combined bath and toilet. Each care home has a terrace or a balcony connected. Each of the apartments (buildings) has common living room, dining room and a kitchenette placed in a family room.
Furthermore, in the nursing home we have an activity department, a kitchen, laundery, hair dresser and a kiosk in connection with a small cafe.
The nursing home is classified as a class A nursing home, which means that the nursing home is meant for citizens with great need for care, both physically and mentally. The classification reserves 60 care homes for people over 67 years of age and 12 care homes for people under 67 years of age. In reality we have 21 young residents placed in one of our apartments.
The apartments are partially autonomous. This creates a situation, where the three apartments have different milieus and differ in their views concerning nursing and care, even if it is the fact that two apartments are both inhabited by elderly people in the same care-category and the training background for the personal in all apartments are the same and that we all are functioning within the same municipality objective.
It is the objective of Marskgaarden to offer the residents the nursing and care, the security, the well-being, the inspiration and the being together needed by the individual to continue living with the least possible intervention in their personal liberty in spite of handicap.
Each year the town council draws up a budget for the nursing homes. In 1991 in total 90.5 million kroner was earmarked for the seven nursing homes. The share of Marskgaarden was 22.7 million kroner. The politicians have passed rules that roughly govern the way. the money may be spent. E. g. the budget of Marskgaarden is divided in four main groups (Figure 3).

Fig. 3

Staff expenses 19.0 mill. kr.
Building expenses 1.5 mill. kr.
Food 1.0 mill. kr.
Remaining expenses 1.2 mill. kr.
It is among other things my task to keep the budget according to current rules and guidelines.
Marskgaarden has 98 employees who is organized as follows (Figure 4) .

Fig. 4 Alle Afdelinger Har Elever

The head of the nursing home together with the three ward sisters and the catering officer constitutes the leading group.
Under each leading group member we have the employees in the departments. The three ward sisters are each leading 25 employees, consisting of nurses, nursing home assistants, nursing aides and domestic helpers. The catering officer has 12 employees consisting of catering assistants, kitchen and domestic helpers.
Directly under the head, not including the leader-group, there is a craftsman, activity department personal, hair dresser, chiropodist and a secretary.
Looking in at the co-operational structures, there is no doubt that Marskgaarden is a democratic workplace, where the residents as well as the employees have participation in the decision making and joint influence. The residents by means of a residents council. The employees by means of a joint council, consisting of an equal number of leaders and non leaders. Within each profession the employees elect a shop steward, who is automatically a member of the joint council. The head selects the leader representatives, and the number of leaders is not allowed to exceed the number of other employees.
The purpose of the joint council is to enhance the interest of the individual, the interest for an effective and responsible work, and to improve the working environment. This way of managing implies the delegation of responsibility and authority to the individual staff member or group of employees. Concerning the development of the daily co-operation, it is the duty of the joint council to respect laws in force, regulations, conventions, collective agreements, and arrangements which are made superior. With the joint council, the leader group and other legal committees, I will try to outline the structure of co-operation:
The total staff in each of the departments has a central position in the co-operation. The staff in each individual department plans, organizes and holds meatings. Rules are drawn up which are going to be followed in the department concerned. Of course certain superior norms and rules are passed by the joint council and/or the leader group. The rules in total form the decision basis of each individual department. I have chosen to place the joint committee in connection with its subcommittees in the periphery of the staff. The safety organization consists of employees who takes on to ensure that the safety rules on the working place are observed. Furthermore they develop instructions and methods to prevent working injuries.
The joint council has set up a course committee which arranges all courses in Marskgaarden. The joint council may form subcommittees to solve specific problems, e.g. programs for introducing new personal.
The leadergroup is placed in the lower part of the diagram to show, that the main task for this group is to manage and allocate work, and to work out management policies in close co-operation with the staff, the residents council and the shop stewards. No label or box may prevent a co-operation across.
The staffing in Marskgaarden is assigned based on the fact that no voluntary helpers exist to assist in nursing and caring tasks. The staffing is assigned to cover all 24 hours every of the seven days in the week.
The staffing is 75.65 full time jobs. A full time job is 37 hours per week. The full time jobs are distributed to 98 employees and are divided in four main groups: administration, nursing and care, catering and other employees.
The administration group consists of 1.00 head of nursing home. 0.78 secretary, in total 1.78 full time jobs.
The nursing and care group consists of 3.00 ward sisters, 7.58 nurses, 4.10 nursing home assistants. 36.77 nursing aides and 6.64 domestic helpers, in total 58.09 full time jobs.
The catering group consists of 1.00 catering officer, 1.70 catering assistants, 1.50 kitchen helpers and 6.77 domestic helpers, in total 10.97 full time jobs.
The last group, other employees, consists of 2.56 occupational therapist's helpers, 0.36 chiropodists, 0.49 hair dresser, 1.40 craftsmen, in total 4.81 full time jobs.
Converted into nursing hours the 75.65 full time jobs constitute for each individual resident 4.2 nursing hours each 24 hours. Therefore it is of great importance that the staff is working in a flexible and rational manner (Figure 5).

Fig. 5 Personalenormeringen (1991)

Due to the fundament of attitude in the care systems, the cultures in the departments differ according to the used working principles. It is of great importance, that the initiative and independence of the residents and the staff are utilized. This is best achieved by accepting, that knowledge is more than professional training, such as life experience and the ability to familiarize oneself. Among other things, it is the task for the staff to involve the residents in their personal care to prevent passivity and incapability.
We are trying to use the following attitudes as a starting point. The staff consider broadly the differences, the action possibilities and the living conditions of the residents. It is therefore allowed the apartments to develop their own distinctive mark. That means, that no decided combination of working principles exists, to be considered the only right one. Not every apartment fits any one of the residents. Therefore sometimes it happens, that a resident move to another apartment.
Working with human beings demands that you like people and demands the necessary insight, knowledge and training. At the same time you have to be flexible and have the freedom to give priority to your own tasks. Taking these attitudes as a starting point, we are moving away from the medical dominated attitude and towards an attitude, where we focus on the residents and not on the sicknesses.
As a main working principle the residents are given joint influence through their participation in the Residents Council. The council is com-posed of residents, members of the resident's family and staffing members. The purpose of the council is to enforce the co-operative relations between the residents, their family and the staff. The council discus questions influencing the daily life at Marskgaarden. Through relevant information the members of the council are motivated to be active, and thereby achieving real influence on the formulation of frameworks and rules in the house.
We expect the residents to be self-determined, eventually assisted by their family. The residents decide, which of their private furniture, curtains and carpets, they want to use in their care homes. The arrangement of the living room is the residents' own business. Here the staff has one claim. that the resident must use a special nursing bed, if assistance from the staff is needed for the personal care. It is for the resident to decide, who is going to be their doctor, dentist, specialist and so on. We can talk a long time about self-determination. One more thing has to be mentioned. That is, the food is not served for the residents in fixed portions. The food is served on dishes, making it possible for everybody him- or her- self to decide the sizes of their own portions of food. This is a tiny, but very important detail.
Help them so that they can help themselves, is a very important working principle used in the everyday life. The staff is conscientiously working with the aim to assist the resident, where the resident needs it. This means that the starting point for assistance is the residents' own ca-ability. In the situations, the resident cannot handle him- or herself, the needed support will be assigned. This implies that the amount of assistance assignet to each resident is individual. For every resident the assistance and support is negotiated between the resident and the staff and is written to a care plan.
Between every resident and the staff a written communication takes place in the form of a communication book; we call it a kardex.
The kardex is also used as a mean of communication between the staff members concerning the resident. The book contains information such as the resident's name, age, date for moving to the nursing home, former occupation, former home address, a resume of the pathological history of the resident and the cause for moving to the nursing home.
The function level of the resident is described, and the agreements concerning assistance and support are recorded. The contents of the book is revised when needed.
The communication book serves several functions since it is used by all members of the staff, who is working with and around the resident, to ensure an equal level of information. Futhermore it serves to keep the agreements. If caused by illness or handicap the resident is unable to participate in the dialog, the information is obtained from the family and the family members enter into the agreements.
When a citizen is admitted to a nursing home and there is a vacant apartment, the nursing home receives information about the citizen from the Admittance Committee. In Marksgaarden the moving process is per-formed in a series of steps. First the citizen and eventually his or her family is contacted to arrange a visit at the citizens home or eventually at the hospital. During this visit agreements are entered between the citizen, the family and the staff concerning all practical procedures. Futhermore as much information as possible is collected concerning the physical, mental and social life of the citizen. All relevant information is recorded in the kardex in co-operation with the citizen or the family. Based on these information a written agreement is drawn up, describing where the citizen needs help and the habits and requirements to be taken into consideration. The staff obtains concurrently all relevant information within the social and welfare sectors, e.g. the citizen's doctor, home care, hospital and so on. Not two movings to nursing home are alike, because every moving to nursing home is based on an agreement between the citizen. the family and the staff.
Marskgaarden has many senile demented residents, 59.7%. 33% of these residents demands a special pedagogical effort and increased assignment of personel. In 1990 I established a steering and working group. whose task was to analyze and describe the problem areas concerning the care of senile demented residents and to suggest solutions for solving the problems.
The steering and working group has in total spent one year describing the project, preparing an activity plan and carrying out the tasks. There was suggestions to change the physical environment, the information to the staff members, residents, family, the social and health administration and the political special committee.
We were aware that, if it should be necessary to apply for additional grants, brakes would be put on the development work, caused by the communality's saving efforts. Therefore, the demand to the project group was that all expences needed by the proposed solutions should be kept within the budget of Marskgaarden.
The hard senile demented gradually gave rise to so big problems in the care departments, that it was necessary to start a restructuring. The majority of the problems was caused by lacking tolerance among the other residents and lacking knowledge in the staff. Often conflicts arose, which was difficult to solve. The staff felt powerless.
The project aims in all its simplicity at distinguishing between the degree of senility instead of distinguishing between the types of senility. We distinguish between mild, medium and hard senile demented people. The effort executed within the project are only aimed at the hard senile demented. The mild and medium senile demented residents are integrated into the other departments. The philosophy behind the project is, that we try to mitigate the symptoms, to improve the life quality through an individually adapted social pedagogically effort, within a narrow physical framework, where the residents accept each other in spite of the often very peculiar actions.
Two groups, each sharing half a department, and each group with six people, are established. Each resident has his or her own apartment in connection with common rooms. The number of residents in each group are chosen to be six, since it gives a clear group, both for the residents and for the staff.
The sharing groups or the "protection units", as we call them, are placed on the second floor. There is an elevator and a staircase. The last is barred by a gale equipped with a simple locking mechanism, that everybody except the senile demented can open. This gate is placed to protect the resident from falling down the stairs, and to prevents them from leaving the home without surveillance. None of the hard senile demented would be able to take care of themselves. The elevator is unlocked, because none of the hard senile demented would any longer be able to operate it. We use no further means of protection.
Some of the residents, that beside the state of senility also are paranoic, receives a minimum of neuroleptica. In case the resident suffer from compulsory actions, a pedagogical effort is applied to reduce or hopefully stop them. E.g. a long corridor or a large room may motivate a compulsory walk. This walk may be hindered or prevented by placing obstacles in the room, such as a folding screen. Around the sharing group is created an environmem which considers the needs of the senile demented residents. The environment is easy to overlook and is reasonably predictable, which creates peace and confidence. We may offer the resident the necessary and meaningful occupational therapy, which enforces the capabilities and the identity feeling of the resident. The low pace makes it possible for the senile demented to work up thoughts, feelings and sense impressions. Being together in close social relationships is possible. All disturbing sense impressions are reduced and replaced by adapted stimulation. The environment is marked by positive expectations and is respecting and accepting. That is to say, life quality is improved and the daily life becomes more meaningful. The milieu makes it possible to get close to the family, facilitating a natural guidance. The working environment has changed, the staff is released from the feeling of being powerless and having a bad conscience. All parties concerned has learnt to accept the situation, where a resident cannot any longer be reached by treatment.
In order to give our old residents a care with dignity, it is necessary for the staff to be in possession of knowledge and insight as well as training aimed at weak, handicapped and elderly people. The educational system in Denmark, in the area of care for senior citizens, was divided into a series of specialized training programs. each covering a specific area of the work.
This educational system gave rise to many problems in the daily work, caused by the variety of trade unions. The demarcations were sharp, often resulting in conflicts. From January the 1 . 1991 the educational system has been changed with the aim to blur the demarcations. It is yet too early to make a statement about the effect, but I have positive expectations to the new system.

I would like to finish my lecture by quoting the famous Danish philosopher Soren Kierkegaard, who may have borrowed it from Sokrates:
"That the relationship between the helper and the one who needs help has to be of the kind - that you, if you should succeed in leading a fellow human being to a given place, have to first of all take care of meeting him where he is and to start from there. This is the secret of the art of helping".
Thank you for your attention!