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© 2013 by ARAHE Journal of ARAHE, Vol. 20(3), 2013

Influence of “Cooking within the Living Unit”

on Residential Homes for the Elderly
Terumi Aiba, Ai Niimi1, Keiko Tomita2,
Motoko Matsui1, Masaki Matsumura3, Kimiko Ohtani1
Faculty of Health Science, Kyoto Koka Women’s University, Kyoto, Japan
1
Graduate School of Life and Environmental Sciences, Kyoto Prefectural University, Kyoto, Japan
2
Faculty of Agriculture, Kinki University, Nara, Japan
3
Baku Architect & Associates, Kyoto, Japan

ABSTRACT

T
he effects of “cooking within the living unit” (CWLU) in “unit care type special nursing homes for the
elderly” on resident’s physical status and QOL have been clarified in previous reports. The purpose of this
study is to investigate and clarify the effects of CWLU introduced into “unit care type” residential homes
for the elderly, where residents are younger and healthier than those in the special nursing homes for the elderly.
We analyzed residents’ nutrient status using their case records kept by the registered dietitian, and conducted
a questionnaire study with residents and staff. Regarding malnutrition, the ratio of residents with “No risk”
increased. The subjective QOL evaluated by residents was worth acknowledging as residents had not felt
deteriorating despite the change in facility environment. Regarding the effect on residents’ evaluation about
their meal, the rating of meal satisfaction rose, and residents found participating in cooking enjoyable. Human
relationship improved because of the increase in conversation among residents, cooking staff, and care staff
through CWLU, while there was a decrease in the exchange of residents among the units, and a problem on
human relations among residents in small groups. Regarding the effect on staff evaluation, the meal service
improved as time went by. Dietitians could obtain information on residents regarding their meals from care staff
and cooking staff, and make the nutritional assessment effectively. The result suggests the importance of
widely disseminating the effects and challenges of CWLU to improve residents’ QOL, especially in the residential
homes for the elderly. (J ARAHE 20( 3) :135-146, 2013)

KEY WORDS: Cooking within the living unit (CWLU), QOL (Quality of Life), residential home for the elderly,
special nursing home for the elderly, unit care

fare Statistics Association, 2012). Their style of manage-

INTRODUCTION
There are many kinds of facilities in Japan collectively
referred to as “homes for the aged,” such as “special nurs-
ing homes for the elderly,” “homes for the aged with a
moderate fee,” “residential homes for the elderly,” “group
homes,” and “private residential homes” (Health and Wel-
Address for correspondence: Terumi Aiba, Department of
Health and Nutrition, Faculty of Health Science, Kyoto Koka
Women’s University, 38 Kadono-cho Nishikyogoku Ukyo-Ku,
Kyoto 615-0882, Japan
Tel: +81-75-325-5405 ∙ Fax: +81-75-325-5445
E-mail: aiba@mail.koka.ac.jp
ment varies, depending on whether the owners are a public
body, a private enterprise, a non-profit, or any other orga-
nization. However, according to one survey (Cabinet Of-
fice, 2011), 50% of people want to stay in their own home
when they start to experience a decline in health, the high-
est figure among preferred locations to receive care. In
our questionnaire survey on old age, ranging from the age
band of 40s through to 60s, it was observed that the ma-
jority of people do not wish to “live in a nursing home,”
an option that scored around 10% or less (Aiba et al.,
2011), but one survey (Ministry of Health, Labour and
Welfare, 2009) showed that around 420,000 people had

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136 / J ARAHE 20(3) : 135-146, 2013
made an application to special nursing homes for the el-
derly, and that many of them were unable to get swift ad-
mission but had to be placed on a waiting list. This num-
ber of applications reflects the fact that there are many
elderly people who have no choice but to apply for those
facilities because of their physical status, economic condi-
tion, and other difficult circumstances, despite their desire
to stay at home. In addition, it was considered that there
were various factors that influence the securing of a better
QOL (Quality of Life) for the elderly in nursing homes,
such as facility equipment, nursing care and medical ser-
vices, daily activities, and meal services. The reports
(Carrier et al., 2009; Mathey et al., 2001; Moroguchi et al.,
2010) emphasized the importance of the relationship be-
tween meal services and better QOL. This means that nurs-
ing homes need good quality in meal services for a better
QOL of the elderly.
A guideline for “unit care” was introduced (Ministry of
Health, Labour and Welfare, 2002) and a grant to renovate
existing facilities into “small living unit-type special nurs-
ing homes for the elderly” (also called “the new unit care
of geriatric welfare homes for the elderly”). The defini-
tion of “unit care” by the Ministry is as follows: “Nursing
care is to provide the users with a living environment simi-
lar to home so that each user can perform common daily
life activities in accordance with their individual charac-
ters and life rhythms while building human relationships
with others.” Under this concept, the residents are divided
into small groups, each of which lives in a living unit that
has the homely atmosphere of life with a small number of
people. Each unit is designed to have private rooms for
each resident and a common living area.
In recent years, the facilities are getting transformed
into the “unit care type” in order to improve residents’
QOL. The survey (Ministry of Health, Labour and Wel-
fare, 2011) showed the ratio of unit care type facilities to
be 28.9% (complete unit care type: 18.7%, partial unit
care type: 10.2%). Yamaguchi (2006) reported that the ef-
fects of unit care for the elderly with dementia were im-
provements in communication, enjoyment of meals, in-
creased motivation and energy, and improved group
dynamics. Another report (Joh & Yoshii, 2006), showed
that the move from group caring into unit care had a good
reputation but at the same time it had some problems, such
as the loneliness of individual residents, the insufficient
exchange among residents, and the difficulty of care staff
management working as a team.
In our previous paper (Ohtani et al., 2011), we reported
that the cooking method of “Cooking within the living
unit” (CWLU) was defined as follows: the cooking staff
cook the staple food, main dish, and side dish in the kitch-
en in the unit every day, and the residents can also take part
in cooking. We also reported that in the special nursing
home for the elderly where CWLU was introduced into
unit care, residents’ eating behaviors changed as the staff
could provide a home-cooked meal and individual care
quickly, and the nutrient and mental status were improved.
However, according to a preceding research (Miura et al.,
2008), with regard to the facilities with kitchen in a unit
that enables the residents to take part in cooking, only 4.9%
participated in CWLU. This indicates that although there
is a good appreciation for CWLU, actual implementation
is often seen to be difficult. As the residents in the special
elderly nursing home studied in preceding researches
were 65 years old or above, and were often in a substantial
physical or mental impairment condition, they required
full-time nursing care that was difficult to receive at home.
There might be the possibility that they would have some
difficulty participating in cooking.
In this research, a comparative study was performed
before and after CWLU was introduced, using question-
naire studies toward residents and staff in a residential
home for the elderly, where the shift to the unit care type
was made when the reconstruction work took place and
“CWLU” was introduced. We verified the effects and chal-
lenges of CWLU for the unit care type residential home
for the elderly. Residents in residential homes for the el-
derly are required by Article 11-(1)-(i) of the Elderly Wel-
fare Law to be 65 years old or more and have difficulty re-
ceiving nursing at home because of environmental and
(or) financial reasons. Residents in residential homes for
the elderly are younger and healthier than those in special
nursing homes for the elderly, and fewer of them have de-
mentia. In comparison with those in special nursing homes
for the elderly, the following effects are anticipated: the
experience of cooking for those in residential homes for
the elderly will contribute more to the improvement of QOL
through exercising the brain (Yamashita et al., 2006), the
comfortable condition provided by the home atmosphere,
and the improvement of nourishment that can be achieved
by identifying food preferences through communication
between residents and staff.
The government grant to renovate the facilities into the
unit care type is provided only to the special nursing homes

for the elderly. The residential home for the elderly we
took up in this questionnaire study was a unique case, who
renovated their facilities into the unit care type using oth-
er sources of funding but not the government funding as
they were not eligible for the government grant.
METHODS
Facility
The facility surveyed in this study is a residential home
for the elderly located in Kyotango City, Kyoto Prefecture,
Japan. The facility can cater for 60 residents. The break-
down of staff composition is as follows: 1 director, 1 doc-
tor (part-time employee), 2 life consultant social workers
(care manager as an additional post), 12 care staff, 1 nurse,
1 registered dietitian, 1 dietitian, and 9 cooking staff. The
facility was converted into private rooms of the unit care
type in June 2008, and CWLU began at the same time as
the completion of the reconstruction work, in June 2009.
Before the reconstruction, the cooking was done as a
large-scale cooking in a large kitchen and all residents
took meals in a large dining room together. After the re-
construction, 6 living units were erected, each of which
has the capacity for 10 people. In each unit, there are a
kitchen and a sink near the dining table that enable the
residents to take part in washing dishes and doing simple
preparation for cooking. The height of the sink is low
enough for wheelchair users. Moreover, as the kitchen fa-
cility faces toward the living room, the staff can cook and
wash dishes while watching the residents. Breakfast is
cooked in each kitchen, while lunch and supper are cooked
together in one of 2 neighboring kitchens, and dishes are
served in each kitchen.
Period of survey and subjects
The study was conducted in 6 episodes (4 questionnaire
surveys and 2 case record analyses); a year before the in-
troduction of CWLU (June 2008), 6 months before (De-
cember 2008), the starting month (June 2009), 1 month
after the introduction of CWLU (July, 2009), 3 months
after (August 2009), and 6 months after (November 2009).
We compared those 6 occasions to analyze various factors
before and after the introduction of CWLU.
The questionnaire studies were conducted at 1 year be-
fore and 1 month after the introduction of CWLU for 12
Aiba et al.: Influence of Cooking within the Living Unit / 137
or 16 residents. The questionnaire surveys were also con-
ducted at 3 months after and 6 months after the introduc-
tion of CWLU for 9 care staff, 7 cooking staff, 1 registered
dietitian, and 1 dietitian. The case record analysis was con-
ducted at the starting month and 6 months after the intro-
duction of for 51 residents (15 males, 36 females).
Residents’ nutrient states
Changes in weight as a measure of residents’ nutrient
states were analyzed using the facility’s case record, refer-
ring to the Nutritional Improvement Manual (Ministry of
Health, Labour and Welfare, 2011). If the weight decrease
rate during the past 6 months was 10% or more, they were
classified as “high risk.” If either the BMI was less than
18.5, or weight decrease rate was 3% or more but less than
10%, they were classified as “medium risk.” If the BMI
was 18.5 or more but less than 20, they were classified as
“low risk.”
Questionnaire study for residents
Evaluation of subjective QOL by residents
The questionnaire study of subjective QOL was conduct-
ed by interviewing 12 residents individually (4 males, 8
females). These residents were judged by staff as having
no problem with dementia or mental status and as able to
answer the questionnaire survey.
“QOL questionnaire for the elderly subject in a commu-
nity” was developed by Ota et al. (2001) and consists of 6
subscales, such as daily activity, satisfaction with health,
and satisfaction with human support, as it was considered
necessary to approach QOL of the elderly from a range of
perspectives.
In this study, residents’ subjective QOL was comprehen-
sively measured using 3 methods: “Health subjective out-
look using VAS (Visual Analogue Scale),” the “Face scale,”
and “Subjective happy feeling” by “PGC (Philadelphia
Geriatric Center) morale scale.” VAS, which is included
in EuroQol (Japanese EuroQol Translation Team, 1998),
was used for the first method, “Health subjective outlook,”
to show subjects’ condition on the scale. In this study, the
question “Do you think you are healthy?” was asked, with
responses measured on a 5-point scale as 5 points for “Very
healthy”, 4 for “Relatively healthy”, 3 for“Neither”, 2 for
“Not so healthy”, and 1 for “Not healthy”.
The second method, the “Face scale,” is used to provide
138 / J ARAHE 20(3) : 135-146, 2013
Fig. 1. Face scale: Which face best represents your feel-
ing now? Scale goes from smiling face (5 points) through
to crying face (1 point).
an index on QOL, which was developed by Lorish &
Maisiak (1986). This is a method that displays 20 illustrat-
ed faces from score 1, showing the state of crying, through
to score 20, showing that of smiling. The subjects were
asked to select the most suitable one for their feeling. They
found the correlation between the face score and other stan-
dardized measurements of mood. In this study, the scale
was modified as shown in Fig. 1, with 5 faces clearly dis-
tinguishable from each other because the subjects do not
in general pay attention to the subtle differences implied
by the use of 20 faces.
The “PGC morale scale” for the elderly developed by
Lawton was used as the third method. In this scale, “sub-
jective happy feeling” is measured by 17 questions or state-
ments relating to 3 factors: “agitation,” “attitude toward
own aging,” and “lonely dissatisfaction” (1975). In this
study, we used 2 from each factor, given residents’ life
background and feeling (6 items shown in Table 3). The
responses to “I have as much pep as I had last year,” “I
am as happy now as when I was younger,” and “How sat-
isfied are you with your life today?” were graded as 1
point for “yes,” -1 point for “no,” and 0 point for “nei-
ther.” The responses to “Little things bother me more this
year,” “I sometimes worry so much that I can’t sleep,”
and “I have a lot to be sad about” were graded as -1 point
for “yes,” 1 point for “no,” and 0 point for “neither.”
Evaluation of meals by residents
The questionnaire study of meal satisfaction was con-
ducted by the residents, whose subjective QOL had been
evaluated before and after the introduction of CWLU. In-
dividual interviews were used to discuss meal satisfac-
tion. The questionnaire study about eating behavior and
meal service was also conducted by interviewing 16 resi-
dents individually (5 males, 11 females).
The meal satisfaction dealt with 7 items, among which
were 5 items referred to by Adachi et al. (1988): “Is the
meal delicious?” “Is meal time pleasant?” “Can you eat
what you want to eat?” “Can you hardly wait for meals?”
and “Is the atmosphere of the meal lively?” We added 2
items: “Do you eat the amount of food you want to eat?”
and “Do you have a good appetite?” Responses were
measured on a 4-point scale.
Regarding the changes in eating behavior, 7 items were
examined as showed in Table 5. Those items were mea-
sured according to a 5-point scale that compared the situ-
ation before and after CWLU was introduced.
The evaluation of the meal service was examined ac-
cording to 8 items as showed in Table 6. The responses
were measured according to a 5-point scale. In addition,
residents’ opinions were sought about the effects and fu-
ture challenges of CWLU.
Questionnaire study for staff
Evaluation of residents’ eating behavior by the staff
Three months and 6 months after the introduction of
CWLU, we conducted questionnaire studies during indi-
vidual interviews with the 9 care staff concerning their
evaluation of residents’ eating behavior. The questionnaire
consisted of 12 items (7 items for positive dietary behav-
ior and 5 items for negative dietary behavior as shown in
Table 7). Responses were measured according to a 5-point
scale.
Evaluation of the meal service by the staff and their
consciousness
We also conducted a questionnaire study with the 16
staff in the facilities (9 care staff and 7 cooking staff)
through individual interviews, concerning their evaluation
of the meal service, 3 months and 6 months after the in-
troduction of CWLU. The questionnaire consisted of 11
items: The same 8 items used for residents plus 3 extra:
“Assistive care for eating,” “Provision of meal on an indi-
vidual basis,” and “Diet modification.” Responses were
measured according to the same 5-point scale as the eval-
uation of the meal service for residents. In addition, we
asked both the care staff and cooking staff about their con-
sciousness toward their work.
Meal service administration and nutritional care
management by the dietitians
To clarify the influence of CWLU, individual interviews
were carried out with a registered dietitian and a dietitian
from the facilities concerning meal service administration
and nutritional care management.
 Aiba et al.: Influence of Cooking within the Living Unit / 139

Statistical analysis the total, of which 76.5% had been there for 3 years or
more. About half of the residents were disabled, 35.3%
Data analysis was performed using the statistical soft- had dementia, and 9.8% had possible dementia according
ware SPSS 10.0J for Windows. We used the Wilcoxon to Dementia Aged Daily Life Degree of Autonomy (Min-
signed-rank test to compare data from before and after the istry of Health, Labour and Welfare, 2006). Independent
introduction of CWLU. residents (“Requiring support” only in terms of long-term
care) accounted for 66.7%. Residents at residential homes
Ethical considerations for the elderly generally stay a longer period, and over
half of them have some degree of independence compared
In this study, under the approval of the ethical commit- with those at special elderly nursing homes, as reported
tees of Graduate School of Kyoto Prefectural University, by our previous paper (Ohtani et al., 2011).
we explained the outline of research to the director of fa-
cilities and obtained in advance his agreement and that of Change in residents’ nutrient states
the residents and staff to take part.
Fig. 2 shows the change in the range of BMI before and
RESULTS AND DISCUSSION after the introduction of CWLU, analyzed using the case
records provided by the facilities. Little change in the BMI
Attributes of the residents was observed 6 months after the introduction of CWLU.
As shown in Table 2, there was also no significant differ-
Table 1 shows the attributes of 51 residents of the facil- ence among the risk levels before and after the introduction
ity in this study. The female residents were about 70% of of CWLU. However, regarding the risk level of malnutri-
tion, the ratio of residents with “Some risk” has decreased
and the ratio with “No risk” has increased.
Table 1. Attributes of residents (n=51)
n %
Male 15 29.4 Evaluation of CWLU by the residents
Sex
Female 36 70.6
Less than 70 years old 4 8 Influence of CWLU on residents’ subjective QOL
70-80 years old 13 25.5 In this study, subjective QOL by residents as evaluated
Age
80-90 years old 23 45.1 by residents themselves was measured by “Health subjec-
90 years old or more 11 21.6 tive outlook using VAS,” the “Face scale,” and “Subjective
Less than 1 year 4 7.8 happy feeling using PGC morale scale.” Table 3 shows the
Period as resident 1-3 years 8 15.7 results. There was little difference on mean values of health
3 years or more 39 76.5 subjective outlook before and after the introduction of
None 28 54.9
Mental disease 7 13.7
Intellectual disability 8 15.7
Disability 0% 20% 40% 60% 80% 100%
Visual impairment 5 9.8
Disability 2 3.9
Hearing impairment 1 2.0 Less than 18.5
Starting month
Normality 28 54.9 18.5-20
20-25
Dementia Possible dementia 5 9.8
25 or more
Dementia 18 35.3
Independence 34 66.7
Care level 1 2 3.9 6 months after

Stage of long-term Care level 2 7 13.7

care level Care level 3 4 7.8
Care level 4 2 3.9
Fig. 2. Change on range of BMI after the introduction of
Care level 5 2 3.9 CWLU (n=51).
140 / J ARAHE 20(3) : 135-146, 2013

CWLU. Although there was a decreasing tendency on the there was no difference in the “PGC morale scale.” Ac-
“Face scale,” it could occasionally be influenced by resi- cording to one report (Ogura, 2000), when the residents at
dents’ feelings at the time the questionnaire was carried one special elderly nursing home started living there, they
out. There was almost no change in all items. Moreover, felt difficulty and anxiety because of the facility’s charac-
teristics. Maintenance of positive feeling was a hard task
for them. In addition, Irichijima (2002) reported that the
Table 2. Change in risk levels of malnutrition after the in- facility environment stress factor influences levels of men-
troduction of CWLU (n=51)
tal health among the elderly in geriatric facilities. We
Starting month 6 months after p-value
thought that the result shown in Table 3 was worth evalu-
n % n %
ating as there was no noticeable difference in residents’
Some risk 22 43.1 19 37.3
No risk 29 56.9 32 62.7
0.366 feelings that their physical and mental conditions were
High risk 00 00.0 01 02.0
deteriorated even though residents’ facility environment
Medium risk 17 33.3 09 17.6 had changed.
0.233
Low risk 05 09.8 09 17.6
No risk 29 56.9 32 62.7 Influence of CWLU on the residents’ meals
Wilcoxon signed-rank test Table 4 shows how residents’ meal satisfaction changed

Table 3. Changes in residents’ QOL after the introduction of CWLU by residents’ evaluation (n=12)
1 year before 1 month after
Evaluation Evaluation p-value
(mean±SE) (mean±SE)
Health subjective outlook 3.4±0.4 3.4±0.4 0.861
Face scale 3.8±0.2 3.1±0.4 0.086
Subjective happy feeling by PGC Factor 1 (agitation)
① Little things bother me more this year 0.8±0.1 0.5±0.1 0.180
② I sometimes worry so much that I can’t sleep 0.8±0.1 0.6±0.1 0.157
Factor 2 (attitude toward own aging)
③ I have as much pep as I had last year 0.5±0.1 0.6±0.1 0.564
④ I am as happy now as when I was younger 0.5±0.1 0.7±0.1 0.414
Factor 3 (lonely dissatisfaction)
⑤ How satisfied are you with your life today? 1.0±0.0 1.0±0.0 1.000
⑥ I have a lot to be sad about 0.8±0.1 0.8±0.1 0.655
Total 4.3±0.4 4.1±0.4
Points for ③, ④, ⑤: 1: yes, -1: no, 0: neither. Points for ①, ②, ⑥－1: yes, 1: no, 0: neither
Wilcoxon signed-rank test

Table 4. Changes in residents’ meal satisfaction after introduction of CWLU by residents’ evaluation (n=12)
1 year before 1 month after
p-value
Evaluation (mean±SE) Evaluation (mean±SE)
Is the meal delicious? 2.8±0.1 03.0±0.0 0.157
Is meal time pleasant? 2.9±0.1 02.9±0.1 1.000
Can you eat what you want to eat? 2.0±0.3 02.8±0.2 0.041*
Can you hardly wait for meals 1.6±0.3 01.8±0.2 0.558
Is the atmosphere of the meal lively? 2.8±0.1 02.7±0.3 0.705
Do you eat the amount of food you want to eat? 1.9±0.4 02.9±0.1 0.040*
Do you have a good appetite? 2.8±0.1 02.7±0.2 0.480
Total 16.9±0.7 18.8±0.5
4-point scale: 3: very, 2: moderately, 1: slightly, 0: not at all
Wilcoxon signed-rank test. *: p＜0.05

by serving a homely meal along with the introduction of
CWLU. The high score suggests that they were mostly
satisfied with the meal. Two items in particular, “Can you
eat what you want to eat?” (p=0.041) and “Do you eat the
amount of food you want to eat? (p=0.040), showed sig-
nificant differences between before and after the introduc-
tion of CWLU.
The change in residents’ eating behavior is also shown
in Table 5. After the introduction of CWLU, the residents’
behavior became much better in “Taking part in cooking
and washing dishes,” “Conversation with the cooking
staff,” “Willingly coming to the dining room,” “Expres-
sions of concern about the meals,” and “Conversation
among the residents”, The residents felt however there
was little difference in “Expression of concern about the
dining room,” and “Conversation with the care staff.” Re-
garding “Taking part in cooking and washing dishes,”
“Conversation with the cooking staff,” and “Willingly
coming to the dining room”, there was a distinct difference
between male and female residents.
A brief questionnaire study was conducted with the res-
idents about their “Desire to take part in cooking” before
the introduction of CWLU. The study showed that 58%
of residents (11 out of 19) answered that they wished to
participate. According to the research conducted after the
introduction of CWLU, 6 residents actually took part in
the cooking, which led us believe that it had some relation
to the improvement shown in Table 5. Moreover, when
we asked residents about the feelings of pleasure experi-
enced when taking part in the cooking, some residents an-
swered that they felt pleasure in the exchanges with other
residents and cooking staff, for example, “It is pleasant to
cook while talking.” Some residents answered that they
Table 5. Change in residents’ eating behavior after the
introduction of CWLU by residents’ evaluation (n=16)
Evaluation
(mean±SE)
Taking part in cooking and washing dishes 1.2±0.2
Conversation with the cooking staff 0.8±0.2
Willingly coming to the dining room 0.7±0.2
Expression of concern about meals 0.6±0.2
Conversation among the residents 0.5±0.2
Self intake 0.3±0.2
Expression of concern about the dining room 0.3±0.2
Conversation with the care staff 0.3±0.2
2: much better, 1: a little better, 0: no change
-1: a little worse, -2: much worse
Aiba et al.: Influence of Cooking within the Living Unit / 141
enjoyed the cooking itself, such as using a peeler and cut-
ting vegetables. Those taking part in the cooking are com-
paratively active among the residents. By contrast, some
of the residents who did not take part in the cooking said
they had forgotten how to cook or that it was easier to eat
meals supplied by others, while others who were unable
to cook felt uncomfortable because they relied on others.
It is therefore necessary to give some consideration to-
ward those who are unable to take part, for one reason or
another, so that they should not feel regret at being left out.
Regarding residents’ evaluation of the meal service, “At-
mosphere of the dining room,” “Atmosphere of the table,”
and “Serving temperature” became better, as shown in
Table 6. Concerning “Atmosphere of the table,” there were
some residents who answered, “We can eat with the same
members,” which shows that they prefer to be able to eat
with familiar members within the unit. By contrast, other
residents answered, “Although we eat together with the
same members, we do not get on well each other” or “We
do not talk, and everyone just eats quickly.” Such state-
ments reveal the difficulty arising from the poor compati-
bility among the residents. As for “Serving temperature,”
many residents answered that the temperature of boiled
rice and miso soup became better. This is the advantage
of having the kitchen close to the living room in the unit.
Regarding other items, there was little change in their an-
swers. In addition, there was little difference between male
and female residents. However there were comments on
the advantages of CWLU such as “The cooking staff lis-
tened to my food preferences without delay,” “The cook-
ing staff avoided serving those foods I don’t like,” “It is
very good that the dining room is close to the residents’
private room,” “It would be better to eat near the private
Table 6. Changes in residents’ evaluations of meal ser-
vice after introduction of CWLU (n=16)
Evaluation (mean±SE)
Atmosphere of dining room 0.9±0.3
Atmosphere of table 0.6±0.2
Serving temperature 0.5±0.2
Taste 0.4±0.2
Grasp of food preference 0.3±0.1
Dishing up 0.3±0.1
Tableware 0.2±0.1
Serving time 0.1±0.1
2: much better, 1: a little better, 0: no change
-1: a little worse, -2: much worse
142 / J ARAHE 20(3) : 135-146, 2013

room,” “It is nostalgic to hear the sound and smell of
cooking,” “Getting a smell of cooking can bring a rhythm
to life,” “It is helpful to have the cooking staff close by.”
The issues on CWLU, as seen from the residents’ per-
spective, were the human relations among the residents in
small group, the mental pressure on residents unable to
participate in cooking, and fewer opportunities to commu-
nicate with residents who stay in other units of the facility.
The importance of deliberately deepening the level of ex-
change with other units is highlighted by this last response.
Evaluation of CWLU by the staff
Evaluation by the staff concerning residents’ eating
behavior
Table 7 shows the result of the questionnaire study on
the influences concerning eating behavior of residents af-
ter the introduction of CWLU with 9 care staff who had
been working more than 6 months before the reconstruc-
tion. They answered that all items on “Positive eating be-
havior” were improved except “Expression of concern
about the dining room.” In particular, the scores for “Con-
versation with the cooking staff,” “Conversation with the
care staff,” “Willingly coming to the dining room,” and
“Taking part in cooking and washing dishes” received a
high mark of 1.5 or more. Regarding “Conversation with
the care staff,” there was a significant difference (p=
0.031) between that of 3 months and 6 months after the
introduction of CWLU, and it improved as time went by.
However, Table 5 shows a difference in attitudes concern-
ing improvement between the care staff and the residents,
who did not give such a high mark. As for “Negative eat-
ing behavior,” there was little change, whereas “Leftovers
from meals” was improved. There were specific episodes
mentioned by the care staff as follows: “A female resident
started talking about her family history and her own life
to the staff who were in the unit,” “Despite the initial
thought of the care staff that the residents would be un-
able to cook, some of them cooked skillfully,” “It was a
good opportunity for residents to talk to each other when
they gathered together to help with cooking,” and “There
was a resident for whom cooking and dishwashing be-
came daily tasks.” Such episodes mentioned by the staff
show the beneficial effects of CWLU on residents’ eating
behavior because there was a kitchen near their rooms
and they saw the staff cooking. As for “Expressions of con-
cern about the dining room”, although little change was
observed from the residents who took part in cooking,
some of them started expressing opinions such as, “It
would be better if a duster and a towel were here.”
Evaluation by the staff concerning meal service and
change in staff’s consciousness toward their work
We asked both the care staff and the cooking staff about
their evaluation of the meal service to residents after the
introduction of CWLU. The results are shown in Table 8.
The scores for “Grasp of food preferences”, “Serving,”
and “Tableware,” at 6 months after the introduction of

Table 7. Change in residents’ eating behavior after the introduction of CWLU by staff’s evaluation (n=9)
3 months after 6 months after
p-value
Evaluation (mean±SE) Evaluation (mean±SE)
Positive Taking part in cooking and washing dishes 1.8±0.2 1.6±0.2 0.557
Conversation with the cooking staff 1.9±0.1 2.0±0.0 0.317
Willingly coming to the dining room 1.3±0.3 1.7±0.2 0.252
Expression of concern about meals 0.9±0.3 1.0±0.3 0.793
Conversation among the residents 1.0±0.3 1.1±0.3 0.750
Self-intake 1.0±0.3 1.2±0.3 0.480
Expression of concern about the dining room 0.4±0.2 0.6±0.3 0.655
Conversation with the care staff 0.6±0.4 1.9±0.1 0.031*
Negative Refusal to eat 0.3±0.3 0.1±0.4 0.683
Playing and eating behavior 0.4±0.3 0.3±0.2 0.655
Eating something inedible (Pica) 0.7±0.3 0.3±0.2 0.180
Unbalanced diet 0.0±0.0 0.3±0.2 0.083
Leftovers from meal 1.0±0.2 1.4±0.3 0.102
2: much better, 1: a little better, 0: no change, -1: a little worse, -2: much worse
Wilcoxon signed-rank test. *: p＜0.05
 Aiba et al.: Influence of Cooking within the Living Unit / 143

CWLU were significantly higher than those at 3 months
(p=0.046, 0.048, 0.002). Moreover, “Serving tempera-
ture”, “Taste,” and “Serving time,” tended to be higher
(p=0.058, 0.076, 0.061). This suggests that the staff felt
the items concerning meal service became better as time
went by. The items of “Serving temperature,” “Grasp of
food preferences,” and “Provision of meals on an individ-
ual basis” had high scores of 1.0 or more for both 3 and 6
months after the introduction of CWLU. The staff felt that
these items had been continuously improving. The specif-
ic responses are shown below. As for the score of “Atmo-
sphere of the table” was less than 0.5 after both 3 and 6
months. The care staff said they did not put items on the
table because the residents could knock them over. They
felt that in general it was hard to change the atmosphere
of the table. By contrast, as shown in Table 6, the residents
felt there was an improvement because they understood
“Atmosphere of the table” in a different context, seeing it
as referring to members who ate at the same table. With
regard to “Serving temperature,” there was an improve-
ment according to the evaluation, both by the staff and by
the residents, because the meal was served immediately
after serving in the kitchen within the unit. The cooking
staff answered that the response time to handle consider-
ations for individual diets was improved, and the care staff
answered that cooking staff could warm up meals with
the cooking stove or microwave oven again if residents
were late for meal time. With regard to “Taste,” the expert
cooking staff started having confidence and became able
to cook good meals. Although there had been differences
in experiences and skills among the cooking staff, depend-
ing on the units they cooked for, improvement was ob-
served. The care staff also answered, “The cooking staff
watched the food waste every day, and they kept improv-
ing it” and “The care staff were also able to taste it and
comment about it.” In other words, the cooking skills of

Table 8. Change in staff’s evaluations of meal service after introduction of CWLU (n=16)
3 months after 6 months after
p value
Evaluation (mean±SE) Evaluation (mean±SE)
Atmosphere of dining room 0.9±0.2 1.1±0.2 0.490
Atmosphere of table 0.4±0.2 0.4±0.2 0.748
Serving temperature 1.4±0.2 1.8±0.1 0.058
Taste 0.1±0.2 0.8±0.3 0.076
Grasp of food preference 1.3±0.2 1.8±0.1 0.046*
Serving 0.4±0.3 1.1±0.3 0.048*
Tableware 0.2±0.1 1.1±0.2 0.002*
Serving time 0.3±0.2 0.9±0.2 0.061
Assistive care for eating 0.6±0.2 1.1±0.2 0.131
Provision of meal on an individual basis 1.1±0.2 1.5±0.2 0.119
Diet modification 0.8±0.3 0.7±0.3 0.805
2: much better, 1: a little better, 0: no change, -1: a little worse, -2: much worse
Wilcoxon signed-rank test. *: p＜0.05

Table 9. Change in staff’s consciousness after introduction of CWLU (n=16)

3 months after 6 months after
p-value
Evaluation (mean±SE) Evaluation (mean±SE)
Rewarding work 1.1±0.2 1.6±0.2 0.102
Information exchange with other occupations 1.8±0.1 1.6±0.2 0.234
Quality of cooking work (Cooking staff only, n=7) (-0.5±0.3) 0.7±0.4 0.039*
Convenience of the environment on meals 0.3±0.3 0.6±0.3 0.412
Cooking time (Cooking staff only, n=7) 0.3±0.3 0.0±0.4 0.705
Tiredness from work (-0.8±0.3) (-0.8±0.3) 0.952
Amount of work (-1.1±0.2) (-1.3±0.2) 0.357
2: much better, 1: a little better, 0: no change, -1: a little worse, -2: much worse
Wilcoxon signed-rank test. *: p＜0.05
144 / J ARAHE 20(3) : 135-146, 2013
cooking staff have improved through the efforts of cook-
ing staff, and the exchange of opinions with the care staff.
Moreover, the cooking staff observed that the job had be-
come more like cooking at home, and it became easier
to season because of the smaller amounts being cooked.
About “Grasp of food preferences,” responses from the
cooking staff included, “I got information on each resi-
dent’s preferred food and amount” and “I now understand
with precision the residents in the unit.” It was observed
that the cooking staff understood residents’ food prefer-
ences clearly as time went by. “Serving,” both cooking
staff and care staff gave answers at 3 months along the
lines of “The residents could not serve food easily, though
we showed them how to serve” and “Food was not evenly
divided when served by the residents themselves.” How-
ever, 6 months after the introduction, an improvement was
noticeable from the answers, such as “The residents used
to just serve food without any intelligence before, but they
are able to exercise their intelligence now” and “The resi-
dents became able to serve their preferred amounts exact-
ly and skillfully as they got used to serving.” This suggests
that residents became good at serving over time. More-
over, 6 months after the introduction of CWLU, the cook-
ing staff had come to consider the dietary intake of each
resident, judging from their responses, such as “I am serv-
ing the right amount of food for each resident and notic-
ing the leftovers from meals.” With regard to “Tableware,”
some pieces were donated and others were brought by in-
dividuals after the introduction of CWLU, and this led to
some improvement. With regard to “Serving time,” the
staff answered at 3 months that, depending on each unit,
there was either an indicative time or a definitive time to
start and finish the meal. At 6 months, however, food was
being served once cooking was finished and the meal was
ready or else the serving time was flexible. Care staff said
that one improvement concerning “Serving time” was that
each resident fixed his or her own seat and was able to eat
at a preferred speed, both after 3 months and 6 months.
We asked about changes in the consciousness of the staff
after the introduction of CWLU, which is shown in Table
9. They felt “Quality of the cooking work,” “Rewarding
work,” “Information exchange with other occupations”
became better after the introduction of CWLU. However,
“Tiredness from work” and “Amount of work” became
worse. Both the care staff and the cooking staff felt that
those items had been deteriorating continuously. As for
the reasons for the deterioration, the cooking staff an-
swered that, “It became necessary to have a deeper rela-
tionship with the residents,” “It became necessary to take
responsibility for the cooking by myself alone.” “Amount
of work” of the cooking staff was increased because of
“Transportation of foods” and having to go “Up and down
stairs” as the kitchen in each unit was separated from other
units and also the main kitchen. “Amount of work” of the
care staff was increased because of their participation in
cooking in the unit.
Influence on meal service administration and nutri-
tional care management
Meal service administration by the registered dietitian
and the facility dietitian became different after the intro-
duction of CWLU. As the cooking staff had to cook alone
in the unit, “Menu plan” tended to be an easy menu, espe-
cially for lunch, to reduce their workload. The dietitians
devised menus that involved paring and cutting food ma-
terials such as vegetables so that residents could take part
in the cooking. In addition, both the registered dietitian
and the facility dietitian were required to plan the menu for
the kitchen in the unit, which is different from large-scale
cooking. With regard to “Cooking management”, direct
guidance of cooking by the registered dietitian and the fa-
cility dietitian decreased. The cooking staff started to hold
meetings among themselves to exchange opinions at lunch-
time so that each member could improve their cooking
skills, which improved the cooking staff’s forward think-
ing and sense of responsibility. Concerning “Documenta-
tion management”, there were too many documents to ar-
range and to store in each unit because the cooking staff
were tasked to record the sanitary management checklist.
It is therefore suggested that the cooking staff, the regis-
tered dietitian, and the dietitian in each unit use the comput-
er network system to manage CWLU smoothly, to commu-
nicate among the units more efficiently, to check the cooking
guidance and stored foods, and to browse the documents.
In addition, it was assumed that the overall cooking costs
would rise because the cooking costs would vary from unit
to unit and that the waste of food and residents’ intake
would increase. The total cost evaluation from the per-
spective of “Business management of the facility” is not
clear as yet because there is still room for improvement and
it is just a short period of time since the program started.
Concerning “Nutritional care management”, it became
clear that the registered dietitian and the facility dietitian

were able to carry out nutritional assessments more easily.
This was because they could obtain information on resi-
dents’ meal intake situations from both the cooking staff
and the care staff, and through the relationship with the res-
idents being much closer than that before the introduction
of CWLU.
CONCLUSION
This study examined the effects and challenges of CWLU
in one of unit care type residential homes for the elderly.
We analyzed residents’ nutrient status using their case re-
cords kept by the registered dietitian, and conducted a
questionnaire study with residents and staff. The study
found that the number of residents who were at the risk of
malnutrition decreased. As a result of evaluating residents'
QOL, it was noted that the residents’ physical and mental
conditions had not deteriorated in spite of the change of
their living environment.
From examining residents’ responses concerning their
meals, the study found that the rating of meal satisfaction
had risen and that residents felt it enjoyable to take part in
cooking and in washing dishes. As for human relationships,
it became easier to carry out individual nursing care be-
cause of the increase in conversation among residents,
cooking staff, and care staff through CWLU. However,
the study also identified problems regarding relationships
among group members and a decrease in contact between
residents of different units. It also found that residents who
were unable to take part in cooking suffered psychologi-
cally as a consequence.
The evaluation of the meal service by the staff became
better after 6 months, in comparison with that of after 3
months, and improved as time went by. In addition, the ex-
perience of everyone working together in the same place
increased each other’s understanding and cooperation.
CWLU had a substantial influence on staff, in particular,
toward forward thinking and a sense of responsibility among
the cooking staff improved through their meetings. On the
other hand, the amount of work increased, and it became
necessary to manage safety and sanitation when the resi-
dents cooked. It is therefore necessary to increase the num-
ber of staff when CWLU is introduced.
Another effect of CWLU was that the dietitians were
able to have more information on residents regarding their
meals from both the care staff and the cooking staff, and
to make nutritional assessments more effectively.
Aiba et al.: Influence of Cooking within the Living Unit / 145
According to the research on the introduction of the unit
care system (Jung & Kuroda, 2008), the implementation
of unit care systems could be an effective measure for the
improvement of the overall quality of care work and care
environment. Although the negative perceptions about
care (as measured by Burnout Inventory) continued for
some time after the care system was established, it gradu-
ally started to diminish once the system became operation-
al properly. Regarding the facilities we researched, the staff
felt it hard work to manage because they started the unit
care system without any experience before and they had
to carry out CWLU at the same time. It is therefore very im-
portant to disseminate the know-how on CWLU widely
among the facilities that are implementing them.
In this study, the result indicated the effect of CWLU on
the cooking staff and on the residents who took part in the
cooking under the homely environment of the unit care in
the residential home. In order for the CWLU to become
really effective in improving residents’ QOL, it is neces-
sary to enhance the utilization of IT among all the units to
share information, and above all to change the conscious-
ness of the staff to cooperate with one another. Although
the government is promoting the introduction of unit care
method in special nursing homes for the elderly, it is clear
from this study that, to promote the unit care system and
furthermore the CWLU, it is highly desirable for the gov-
ernment to provide some grants to residential homes for the
elderly, where most of residents are comparatively healthy
in terms of physical and mental conditions.
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