The plight of migrant care workers in Japan: A qualitative study of their stressors on caregiving.

OBJECTIVE: This study explored the phenomenological experiences of migrant care workers working in the formal long-term care setting in Japan and identified their stressors on caregiving.
METHODS: We collected data using in-depth interviews among Filipino (n = 21), Indonesian (n = 6), and Vietnamese (n = 4) migrant care workers. We conducted the interviews in either their native language or in Japanese. All interviews were audiotaped and transcribed verbatim. We analyzed the transcripts using thematic analysis. We used qualitative data analysis software NVivo 10Ⓡ to code and manage the data.
RESULTS: Six key themes emerged that were related to stressors on caregiving. These include (1) coworker relationship, (2) language barrier, (3) work-life balance, (4) health concerns, (5) physical environment, and (6) patient relationship. Migrant care workers struggled with Kanji (Chinese characters) and verbal communication. Most of them shared having fatigue and chronic back pain. A few also mentioned about anxiety and depression. The low salary and heavy workload have made caregiving jobs unattractive to them. Workplace discrimination, patients' attitude, and a hostile work environment were part of their stressors at work. DISCUSSION: This study is the first step in highlighting the current issues being faced by migrant care workers in Japan. The stressors were the identified psychosocial issues of migrant care workers. The Japanese government is suggested to amend their care work policy and provide psychosocial support explicitly tailored for migrant care workers.

Introduction

The Asia-Pacific region is experiencing rapid demographic changes (United Nations, 2017). The aging process is changing at an unprecedented rate, and the timing and pace of this transition vary across the region. Japan is one of the first countries to be classified as a "super-aging society" in 2007 (Muramatsu and Akiyama, 2011). The country has the second-highest life expectancy globally, with an average of 84 years (World Bank, 2018). The percentage of older adults is projected to rise from 26.6% in 2015 to 38.4% in 2065 (National Institute of Population and Social Security Research, 2017). The aging population is one of the major causes for the rate of medical care in Japan to steadily scale up, comprising about 11.17% of the national budget in 2012 alone (Statistics Bureau, 2015). A rapid decline in the birthrate further complicates the aging situation. Thus, Japan's population is predicted to decrease to become less than 88.08 million by 2065, which is 70% of the current population (National Institute of Population and Social Security Research, 2017).

The high life expectancy partnered with a low fertility rate creates a severely compromised labor market. This condition prompted the Japanese government to mobilize new sources of care work. They have strengthened its international relations, especially among Asian countries, through bilateral Economic Partnership Agreement (EPA). Initially, the EPA started with the goal of improving the economic climate in the region (Ogawa, 2012). Later on, they allowed the transnational movement of nurses and care workers to Japan (Ogawa, 2012). Japan has now accepted nursing care professionals from Indonesia, Vietnam, and the Philippines to work as caregivers or nurses upon passing the national examination (Ballescas, 2010). Within this context, the care facilities play an essential role in integrating migrant care workers to Japan's global care chains. They are responsible for shouldering the candidate's Japanese language lesson and provide training and mentoring. The care facilities pay approximately four to six million yen per candidate (Tsubota et al., 2015).

Dementia has been identified as a significant health concern in Japan's aging population. The number of Japanese older adults with dementia has been steadily increasing (Miyamoto et al., 2010). Approximately 80% of the older adults admitted to care facilities in Japan are estimated to have dementia (Ministry of Health Labour and Welfare, 2015). This condition has resulted in an increased demand for long term care (LTC). Also, the availability of informal or family caregivers has diminished due to changes in family structure and decreased willingness to provide care (Eto, 2001; Kono, 2000). Consequently, the need for LTC facilities for older adults has grown, and the supply of formal care workers falls short of demand. Faced with a labor shortage, care workers had to work overtime and endure a heavy workload.

Caregiving job is considered to be the most demanding yet lowest paying career in Japan (Mizuho, 2016). Japanese people perceived caregiving as "hard, dirty, and dangerous." The Philippines, Indonesia, and Vietnam have been sharing a considerable portion of these migrant care workers. As of January 2019, a total of 3165 EPA care workers has been working in Japan (Izumi, 2020). The following scenarios can illustrate the relative demands and gravity of these jobs: (a) warrant a certain level of care for dementia patients, (b) perform overnight shifts for about four to six times a month whenever a shortage of workers is anticipated, and (c) tolerate a healthcare worker: patient ratio of 1:20–25 especially during night shifts (Mizuho, 2016). Such caregiving activities may increase the stress levels of care workers in LTC facilities.

There is a lack of exploratory and descriptive studies about the stressors of migrant care workers in Japan. An in-depth analysis of the plight of these migrant workers is presently unknown. This study will be the first to examine the narratives of Filipino, Indonesian, and Vietnamese care workers working in the formal long-term care setting in Japan. In this study, we aim to explore the phenomenological experiences of migrant care workers and identify their stressors on caregiving.

Methods

Study design

This study was exploratory and qualitative and drawn on the interpretive paradigm. We obtained narratives from the care workers regarding their experiences and perspectives of caregiving in Japan. The study focused on understanding their perspectives on topics, situations, and events related to elderly care.

Study area

We conducted the study in ten out of forty-seven prefectures in Japan. We selected the ten prefectures because of the large number of EPA care workers in those areas. We interviewed care workers living in Tokyo, Osaka, Kanagawa, Hyogo, Chiba, Shizuoka, Saitama, Ibaraki, Akita, and Hokkaido.

Study participants

The study involved migrant Filipino, Indonesian, and Vietnamese care workers working in a formal long-term care setting in Japan. Care workers should be at least 20 years old, with or without Japanese descent, and have a valid visa and work permit. Trainees (e.g., under the EPA program) were included in the study. We excluded those who work in adult day care centers and in-home respite services.

Data collection

We conducted the data collection with 31 migrant care workers from January 2019 to May 2019. We employed a snowball sampling method to select migrant care workers (Handcock and Gile, 2011). We used this method because migrant care workers were hard-to-reach populations and considered as minority groups in Japan. Using social media, we approached 11 community and online groups of Filipino, Indonesian, and Vietnamese care workers living in Japan. We also attended their social and church events. Through referrals, we were able to identify and recruit the care workers. Then, we conducted in-depth interviews, either face-to-face or online. For Kanto residents, we met them in person and had interviews at a café or restaurant. For non-Kanto residents, online interviews at home were more suitable considering their location and availability.

Care workers had the option to respond in English, Japanese, or their local language. We hired an interpreter during interviews with Indonesian and Vietnamese care workers. We audiotaped all interviews to ensure accurate information. Additionally, we took notes to facilitate the review of the main ideas or insights shared by the care workers. The topic guide (Appendix A) consisted of five sections about care workers' (1) sociodemographic characteristics, (2) work situation, (3) perceived stressors and burden of caregiving, (4) perceived need for psychosocial support, and (5) rewards and benefits of caregiving. The topic guides ensured the inclusion of formerly identified essential issues (Bowling, 2014). We added probes to get further information on key aspects. Interviews lasted for about an hour. We conducted data collection while simultaneously analyzing the data. After 31 interviews, no new themes emerged, and we confirmed that the data saturation had been reached (Fusch and Ness, 2015).

Data analysis

All 31 interviews were audio-recorded and transcribed verbatim in either Filipino or English. Two authors (EA and RRC) read the transcripts several times to achieve immersion and full familiarity with the data. They interpreted the whole data. Then, the transcripts were analyzed using a thematic approach (Braun and Clarke, 2006; Vaismoradi et al., 2013). We used qualitative data analysis software NVivo 10Ⓡ (QSR International, Burlington, MA, USA) to manage and code the data. We analyzed the transcripts in the following manner. First, we assigned codes to phrases and sentences that described the meaning of the text segment. Next, we assigned texts with a similar meaning under the same code; otherwise, we gave them a new code. We continued the entire process until no new code was extracted from the transcript. After that, we gathered similar codes into more conceptual categories. Lastly, we identified themes by bringing together categories.

We validated the coding and themes through continuous dialog among co-researchers and peer debriefing to interpret results with healthcare professionals (gerontologist and psychologists) (Graneheim and Lundman, 2004). We provided feedback to the care workers (member check) by giving them a summary of the findings before we finalize the main themes and categories. The care workers helped check the accuracy of our findings whether it resonates with their experience, helping us refine our findings further. After reaching consensus, the identified themes and quotations to support themes were translated into English.

The qualitative methods and reporting of results adhered to the Consolidated Criteria for Reporting Qualitative Studies (COREQ) guidelines (Tong et al., 2007) and Standards for Reporting Qualitative Research (SRQR) (O'Brien et al., 2014). We included the complete COREQ checklist as a supplementary file (Appendix B).

Ethical considerations

The study was approved by the Research Ethics Committee of Sophia University. We informed the care workers about the purpose of the study and secured written informed consent before the interview. All interviews were conducted at their convenient time and chosen venue. We also ensured the confidentiality of the care workers' responses. We strictly protected their privacy, as we did not use personally identifiable information in this study. We used pseudonyms for quotations.

Results

General characteristics of participants

Table 1 shows the sociodemographic characteristics of migrant care workers. Of 31 care workers, 21 (68%) were from the Philippines, followed by Indonesia (19%) and Vietnam (13%). Their mean age was 33.3 years [standard deviation (SD) 8.6], and the majority of them were women (74%) and with tertiary education (90%). Most migrant care workers (81%) had a monthly income between JPY 101,000 and 200,000 (USD 950–1900). Two-thirds of the care workers were holding a Designated Activity visa, which permits them to work within the limitations of their chosen occupation in Japan. On the other hand, one-third had a permanent resident visa, which grants them unlimited permission to work in different occupations. As for the Japanese language proficiency, the majority of the care workers had an intermediate level while some of the permanent resident care workers were fluent. Two of the Indonesian and Vietnamese care workers were also fluent in the Japanese language. The majority of them (97%) had health insurance issued by their workplace. One-third of the care workers reported having bad/very bad self-rated health while the rest had either fair or good health. Despite the positive self-rated health, most of them (74%) had chronic diseases. The majority of the migrant care workers were never-smokers (74%) and occasional/daily drinkers (68%).

Table 1

Socio-demographic characteristics of migrant care workers.

Characteristics	Total (N = 31)
	n	%
Age, mean (SD) 33.3 (8.6)
Sex
Male	8	26
Female	23	74
Nationality
Filipino	21	68
Indonesian	6	19
Vietnamese	4	13
Education
Secondary	4	13
Tertiary	28	90
Marital status
Married	8	26
Never married	20	64
Divorced	3	10
Monthly income (in JPY)
≤ 100,000	2	6
101,000 – 200,000	25	81
201,000 – 300,000	4	13
Visa status
Designated activities*	20	65
Permanent resident	11	35
Length of stay in Japan (years)
< 5	21	68
11 - 20	6	19
> 20	4	13
Japanese reading proficiency
Intermediate	30	97
Native level	1	3
Japanese speaking proficiency
Beginner	1	3
Intermediate	20	65
Native level	10	32
Health insurance status
Issued at the city office	1	3
Issued at workplace	30	97
Self-rated health
Good/Very good	11	36
Fair	10	32
Bad/Very bad	10	32
Chronic diseases
Have	8	26
Don't have	23	74
Smoking
Never-smoker	28	74
Ex-/ Current-smoker	3	26
Drinking alcohol
Non-drinker	10	32
Occasional/ Daily drinker	21	68

SD Standard deviation; JPY Japanese Yen.

Under EPA Program.

Stressors

Table 2 shows the stressors commonly experienced by migrant care workers. There are six themes under stressors – coworker relationship, language barrier, work-life balance, physical environment, and patient relationship. The first theme on coworker relationship explored social issues and Japanese social concepts such as workplace discrimination, workplace bullying, cultural differences, honne-tatemae (private-public life), and senpai-kouhai (senior-junior relationship). The second theme on the language barrier was divided into Kanji (Chinese characters)and verbal communication. The third theme of work-life balance focused on a heavy workload and low salary. The fourth theme of health concerns was further divided into physical and mental health. The fifth theme highlights the physical workplace, and under its category is a hostile work environment. Finally, the sixth theme on patient relationship focused on the patient's attitude and sexual harassment.

Table 2

Stressors commonly experienced by migrant care workers.

Key themes	Categories	Description
Coworker relationship	Workplace discrimination	Migrant care workers were given a large amount of workload and fewer leadership opportunities compared to their Japanese coworkers.
	Workplace bullying	Migrant care workers experienced being bullied by becoming a topic of false humor being spread in the care facility.
	Cultural differences	The passive form of communication in the workplace is one of the social practices that confused migrant care workers.
	Honne-Tatemae (Private-Public life)	Japanese coworkers were not open nor transparent.
	Senpai-Kouhai (Senior-Junior relationship)	It shows the order of the care hierarchy along the lines of age, experience, and citizenship.
Language barrier	Kanji (Chinese characters)	Kanji reading and writing in patient reports were one of the hardest barriers for migrant care workers from non-kanji backgrounds.
	Verbal communication	Migrant care workers feel stressed about communicating with their Japanese coworkers and relatives of the patients.
Work-life balance	Heavy workload	Migrant care workers were burdened with high disparity of the number of care worker and patient ratio.
	Low salary	Migrant care workers reported the low salary compared to the high cost of living in Japan.
Health concerns	Physical health	Migrant care workers experienced chronic back pain from lifting heavy patients.
	Mental health	Death of the migrant care workers’ favorite elderly patients may cause them to have depression.
Physical Environment	Hostile work environment	Elderlies are physically abused sometimes in a care facility because they are not handled with care.
Patient relationship	Patients’ attitude	A few of the patients demand undivided attention or hide items that are not their own.
	Sexual harassment	A rare occurrence but sometimes experienced by the migrant care workers while giving a bath to the elderlies.

Coworker relationship

Coworker relationship is the first stressor among migrant care workers.

Workplace discrimination: the migrant care workers reported being given a large workload and fewer leadership opportunities than their Japanese coworkers. Some of them shared that they experienced varying degrees of discrimination in their workplace. A few of them said that they are not given work promotions because of their status as a foreigner.

"It is tough because I am the only one who is doing the hard work. My other coworkers keep walking and walking. I sometimes ask myself if I am the only worker here? I cannot complain about it because people might not believe me. They say they are working, but I do not believe them.” (Kuper, 29 years old)

"The issue is what if foreigners have the same night schedule? What if we all work on the same night shift and only one Japanese work that night? How about the food which is the leader's responsibility, especially if that Japanese is a new one and we are like working longer than that one Japanese? They do not think we can handle the responsibility of being a leader because they think we are a foreigner." (Pearla, 31 years old)

Workplace bullying: the majority of migrant care workers shared being bossed around or have experienced being bullied by becoming a topic of false humor being spread in the care facility. There are different variations of bullying that migrant care workers have experienced. Some of them reported the bossiness of local coworkers on the same level as them. A few have experienced intimidation and even humiliation, and have been backstabbed through gossip.

"She is a 'maldita' or a person with a bad attitude. She is friendly when we are in front of the manager. She keeps ordering me around even though it is not my responsibility. I told her that it is her responsibility; that is why I do not do it. Why should I do her job? If she acts nasty, then I will also act nasty. However, if I am wrong, then I say sorry. She is treating me like a slave. The manager told me to try to stay away from her because that is her attitude ever since. She already bullied many caregivers even before me." (Donna, 30 years old)

Cultural differences: the passive form of communication in the workplace is one of the social practices that confuse migrant care workers. Some of the migrant care workers highlighted that cultural differences are among the points of friction among them and their local coworkers.

"My Japanese coworkers are not direct, unlike Filipinos. Filipinos are direct when saying you are like this, or you are like that. My coworkers would deliberately talk about you to others when you are in the same room. They would not tell me directly what I did wrong. For example, I forgot to place back the dentures of the elderly patient. Then the assistant leader fed the same elderly. I was standing in the assistant leader's side when he exclaimed to another coworker that the elderly's dentures were not placed back. He knows that I was the one who gave a bath to the elderly. I was thinking that he should have just told me directly instead of saying to another Japanese coworker. I confronted the issue to him, and he just laughed. The laugh sounded sarcastic." (Maan, 31 years old)

Honne-Tatemae (private-public life): the migrant care workers expressed their dissatisfaction with their Japanese coworkers’ lack of openness and transparency. Some of them shared their coworkers acting cold and distant toward them. A few of the Filipino migrant care workers described their local coworkers as 'plastic' or not showing their real personality.

"You are fortunate if you have a Japanese coworker whom you become close friends with. It is because their work persona is different from their real persona. There are times when my coworkers will ask me to eat outside together. After asking me to eat out, then she will disappear. I do not know why. I guess work is work." (Ellen, 28 years old)

Senpai- Kouhai (senior-junior relationship): the migrant care workers shared their dissatisfaction with being on the lowest order of the care hierarchy along the lines of age, experience, and citizenship. Some of them expressed dissatisfaction with how they are being unequally treated at their care facility. They are expected to follow their seniors' orders regardless of other possible alternatives to finishing the task.

"The culture here is all about ranking. Look at the simple gesture of bowing down. It is all about hierarchy. One of my Japanese friends told me that you Filipinos could say what you want to say. Yes or no. For the Japanese people, they find it hard to do that. All you have to do is keep telling yes. For me, that is not possible." (Karina, 50 years old)

Language barrier

The language barrier is the second stressor for migrant care workers. The majority of the Filipino and Indonesian migrant care workers under the EPA program expressed their frustration in learning the Japanese language. On the other hand, some migrant long-term resident care workers stated that they have become fluent after several years of using the language to communicate with their Japanese spouse and children.

Kanji (Chinese characters): Kanji reading and writing in patient reports are among the hardest barriers for migrant care workers from non-kanji backgrounds. The majority of them said that learning Kanji is one of the biggest challenges in their work line. Some of them said it was hard to remember the complicated Kanji medical terms and patient names.

“I find it surprising that we need to write the incident report alone when the patient gets an injury. Sometimes our Japanese coworkers would help us when we were not very good in Japanese. It was very hard before, and it is still very hard up until now. It is such a struggle to type in Japanese, especially the Kanji medical terms." (Noel, 30 years old)

Verbal communication: Japanese communication with coworkers and relatives of the patients is stressful for EPA care workers. Some of them said that verbal communication with coworkers was hard for them. They highlighted that speaking in Keigo or formal Japanese was like learning a new language. A few of them said that their listening comprehension might be high. However, their ability to verbally articulate what they heard in Japanese was low. This shortcoming sometimes resulted in cultural friction in the workplace.

"I find it hard to converse with the patients' relatives because you need to speak in Japanese fluently. There are different levels of politeness when speaking the local language. I find it hard to use the polite language pattern." (Pearla, 31 years old)

“Sometimes, they will tell you that you did not understand what they said. I know deep within myself that I understand, but it is just that I cannot explain properly because I cannot speak in Japanese properly." (Queenie, 31 years old)

Work-life balance

The work-life balance is the third stressor among migrant care workers. Some of the migrant care workers shared the lack of time and energy to do hobbies outside their working hours.

Heavy workload: the migrant care workers are burdened with high disparity of the number of care workers and patient ratio. The majority of them reported that there are not enough care workers in their care facility to efficiently finish all the tasks. There are some night shifts when only three care workers had to take care of all the elderly patients in the care facility.

“It was tough during my first night shift. It was because there were only three of us when one of the elderlies passed away. One of us called the ambulance. The police were interviewing the other one. What was painful about that was I was the one who needed to look out over all the other patients. There were approximately 100 patients. I felt so tired after that day. It was because I took care of many elderlies.” (Camille, 51 years old)

Low salary: some of the migrant care workers reported being unsatisfied with their low salary compared to the high cost of living in Japan. Some of them shared that they were disheartened when they realized that almost one half of their salary goes to paying the rent. The majority of them also shared that they were not properly being compensated for the amount of work they do.

“My God, my salary was not able to reach 200,000 yen when I first started working as a care worker. How will you survive with that here if you live in Shinjuku? The rent for my apartment is 100,000 yen, and then you have to add food and transportation, electricity, water, and phone. That was one of the lowest points of my life.” (Camille, 51 years old).

"Our low salary is not compensating for our huge workload. I am considering quitting because we have so many tasks to finish, but so little salary.” (Olive, 25 years old)

Health concerns

Health concerns are the fourth stressor for migrant care workers. A few migrant care workers expressed health concern as the primary reason they think they cannot continue being a care worker in Japan.

Physical health: a few of the women migrant care workers reported having chronic back pain from lifting heavy patients. They reported the physical demands of their job and the strain it is causing to their physical health. This problem arises from the gender and age disparity of care workers in care facilities.

“Lifting the elderlies is so tiring. We have a new patient who is heavy. That is the time when my back pain started. It is because there should be two people who are assisting him. It is because we lack enough care workers, that is why I have no choice but to lift him by myself. We do not have the lifting equipment. You need to use all your strength to lift him. Instead of being a care worker, it is like I became a construction worker.” (Queenie, 31 years old)

"I am exhausted after two years of being a care worker. It is like being tired has become normal for me because I have been doing this for so long. Our responsibility is always growing towards the elderly. Like in my workplace, my coworkers are also old; that is why I am the one who often carries the patients. They rarely show initiative to help me. Also, we lack male care workers." (Alia, 25 years old)

Mental health: the death of migrant care workers' favorite elderly patients may cause them to have anxiety and depression. Some of them shared how the death of their favorite elderly patients has caused them to experience grief and sadness. They treated some of the elderly like their own family member; thus, they get affected when they pass away.

“It is because, in our field of work, you cannot prevent anxiety and depression. It is because you get affected by their life stories. You can feel it after taking care of them every day. This is especially true after they die of old age. You cannot help but get affected.” (Tina, 37 years old)

Physical environment

The physical work environment is the fifth stressor among migrant care workers.

Hostile work environment: a few of the migrant care workers shared that sometimes elderlies are physically abused in a care facility because they are not handled with care. A few of them shared that elderly abuse adds to their stress. Some of the long-term resident care workers were confident in sharing about the abuse. In contrast, a few of the EPA care workers were hesitant in sharing the information. They were afraid that sharing the information could cause them to lose their livelihood, or for the information to be turned around and be used against them.

"It is because they are being bullied and physically abused by their race. Sometimes when I try to talk to the people in high ranking positions, they block me. I am not afraid of them; I talk with them straight. The elderly are like babies. So the approach has to be different. You can feed them without hurting them. That is why being inside the office is like war. However, I learned my lesson that no matter how you do, what you say, it is their country. It is their law. I feel guilty about the situation of the elderly, and they are paying much money. I understand that caregiving institutes are big business here." (Karina, 50 years old)

"It is up to you on how you will take care of the elderlies, but we have some Japanese coworkers who will hit the heads of the elderlies. We cannot say anything because they will turn the story around and say it is our fault. If we tell our higher-ups, they might think that we are not doing our job and believe their own. This might affect our visa status. That is why we ignore the maltreatment against the elderly. I guess some higher-ups will believe you, but it depends on their attitude." (Kuper, 29 years old)

Patient relationship

The patient relationship is the sixth stressor for migrant care workers. The majority of the care workers stated that a patient relationship is the most important in their job. Their primary responsibility is to provide the elderly's needs during the last remaining years of their life.

Patients’ attitude: some migrant care workers reported experiencing difficulty on patients’ attitude. A few patients caused them stress by demanding their undivided attention or by hiding items that are not their own. Most of the migrant care workers stated that elderly people are a source of happiness for them, but a few of them said they could also be a source of stress.

“I was only stressed with one elderly who keeps calling me. He keeps calling me so that he has someone to talk to. Of course, I cannot always stay with him because I have work to do. I have much work to do. He keeps calling me. I got annoyed. It is because he holds me. He does not want others to bathe him and wants only me. I was stressed. I do not like him. He even has a loud voice when he calls. He calls me whenever he hears my voice. My ears started to ache.” (Belinda, 53 years old)

Sexual harassment: sexual harassment is rare but is sometimes experienced by the migrant care workers while giving a bath to the elderly. A few of the migrant care workers reported about sexual harassment.

“I told him that it is not allowed, but I was not angry. I told the incident to our manager. I told the manager that I do not like him because he touched my breast. The manager reprimanded him, but the offensive elderly still repeated it. I stopped helping him take a bath. That is why a man caregiver started to bathe him.” (Belinda, 53 years old)

Discussion

Six key themes emerged that were related to stressors on caregiving, and these include (1) coworker relationship, (2) language barrier, (3) work-life balance, (4) health concerns, (5) physical environment, and (6) patient relationship.

In this study, migrant care workers experienced workplace discrimination. Most of them are expected to do more work than their local coworkers. A few of the permanent resident care workers, who have been working for a long time in the industry, said that they are qualified to be caring leaders but are not trusted because of their status as a foreigner. They shared great fulfillment in their jobs but low satisfaction with their monthly salary. On the other hand, the EPA care workers are more vulnerable to discrimination because of their status as a candidate or temporary worker. Care workers who just arrived are still considered to be ‘candidates' because they are required to undergo training at Japanese hospitals, nursing homes, and care facilities. They are expected to fully comprehend how to obey local regulations along with Japanese nurses and care workers and pass the Japanese language-based examination before becoming a regular employee (Kaneko, 2016). Hence, their temporary visa status becomes a starting point for EPA care workers to experience workplace discrimination. One cross-sectional study highlighted the rise of workplace bullying in health care setting in Japan (Yokoyama et al., 2016). They reported the three most negative acts, such as withholding information, unmanageable workload, and being shouted at or targeted of spontaneous anger (Yokoyama et al., 2016). However, they did not include migrant care workers in their study.

As shown in the results, language barrier was a significant stressor for migrant care workers in Japan. Language, dialects, choice of words, and accents become how people are classified and treated (Salzmann et al., 2014). A few of the permanent resident care workers experienced language discrimination because their care managers do not trust them with leadership positions. Their lack of Japanese writing skills blocks them from advancing in their profession. Paxton and Svetanant (2013) have emphasized how the Japanese language is considered one of the hardest words to learn for non-kanji background learners. Our findings reported that learning Kanji is one of the most challenging hurdles to be a care worker in Japan, consistent with previous studies (Paxton and Svetanant, 2013; Ohno, 2012).

Deteriorating health is one of the primary reasons why most of the migrant care workers in this study desire to quit their job. One-third of the care workers reported that they are not in good health. Some of the migrant care workers have experienced chronic low back pain from lifting heavy elderly. The young women EPA care workers shared that their coworkers rely on them to support the weightier elderly because of their young age. Some of them shared the lack of men migrant coworkers and the unwillingness of local coworkers to help them. They also shared the lack of equipment and robots in supporting them to lift the elderly. The care workers who shared the lack of equipment were assigned at prefectures outside Tokyo, such as Ibaraki and Osaka. EPA female care workers have developed chronic back pain and fatigue after two years of caregiving practice. Musculoskeletal symptoms such as lower back pain in female care workers are related to other aspects such as feelings of the burden of care, decline in mental health due to depressive symptoms, and type of care activity (Smith et al., 2003). Previous studies have explored the development of lower back pain among family caregivers but did not include care workers in long term care facilities (Suzuki et al., 2016).

Some of the migrant care workers experienced a hostile work environment in their care facility. Some of the permanent resident migrant care workers opened up about their local coworkers' physical abuse against the elderly. They stated that the patients could not stand up for themselves; thus, they were going to protect them. A few of the EPA care workers mentioned about the physical abuse the elderlies are experiencing but were hesitant as they are still holding candidate or temporary visas. The EPA care workers ignored the physical violence against the elderly, as they were fearful they could lose their chance to stay in Japan. At present, there is no formal notification system for elder abuse in Japan. Elder abuse is becoming increasingly recognized as a severe social problem in Japan, given the high rate of elderly people with chronic mental and physical disabilities and the stress and burden that caregiving poses on family members (Shibusawa et al., 2005). Soeda and Araki (1999) previously tackled elder abuse by a daughter-in-law. However, elder abuse in care facilities is yet to be explored.

Finally, this study underscored work-life balance and cultural conflict between the migrant care workers and local care workers as additional stressors at work. Lan (2016) has described the care facility as a ‘zone of cultural friction’ where cultural dissimilarities become complicated workplace interaction. While migrant care workers are expected to assimilate culturally, the Japanese workplace offers them little cultural intimacy but an eroded sense of value and skills (Lan, 2016). On the other hand, the work-life balance poses a significant risk of burnout of care workers within the health industry. Our findings are in agreement with previous studies conducted by Kaneko (2016) and Narumoto et al. (2008). They have emphasized the provision of shorter hours and higher salaries to be more attractive for migrant care workers to come to Japan (Kaneko, 2016; Narumoto et al., 2008).

Strengths and limitations

This study provided several significant findings and insights. However, several limitations should be noted. First, we cannot generalize our results to all migrant care workers in Japan. Second, we recruited a small convenience sample of Indonesians and Vietnamese care workers. Even with the use of an interpreter, they might have felt inhibited to candidly share their experiences on caregiving; in contrast, Filipino care workers were interviewed in their local language. Third, interviews were conducted either online at home or through face-to-face in a café or a restaurant. Problems with researcher-participant relationships (e.g., building trust) and privacy might arise. To overcome these problems, we asked probing questions to encourage them to talk and share their experiences freely. We also made efforts to establish rapport with them and emphasized the confidentiality of the information shared with us. Despite these limitations, this study is the first to explore the stressors on caregiving among migrant care workers from the Philippines, Indonesia, and Vietnam.

Implications

Findings from this study carry important implications for care facilities, the Japanese government, and the migrant care workers’ government. Care facilities are suggested to facilitate open communication among the care managers, local workers, and migrant care workers. They could conduct a 10–15-min daily meeting before the beginning of the shift in which care workers can freely share their work concerns and grievances. Moreover, effective care manager leadership and support as well as appropriate staff management may improve harmony in the workplace. On the other hand, the Japanese government is suggested to provide additional financial support to care facilities accepting migrant care workers. The additional financial aid will help motivate care facilities to accept more migrant care workers leading to a better work-life balance. The Japanese government is also suggested to amend their care work policy and provide psychosocial support tailored explicitly for migrant care workers. Psychosocial support programs and interventions should be culturally sensitive and aim to reinforce the migrant care workers’ rights and protection. Finally, the Philippine, Indonesian, and Vietnamese governments are suggested to monitor the well-being of migrant care workers and conduct biannual meetings at their respective embassies so they can help address their concerns. Both the host country and the Japanese government should continue to revisit and amend existing immigration policies and develop a sustainable long-term partnership.

Conclusions

This study is the first step in highlighting the current issues being faced by migrant care workers in Japan. The identified stressors revolve around coworker relationship, language barrier, work-life balance, health concerns, physical environment, and patient relationship. These stressors were the identified psychosocial issues of migrant care workers in Japan. Countries that are experiencing a rapid rate of aging, such as South Korea, China, and Taiwan, who need of migrant care workers can benefit from the results of the study. They could create a bilateral economic partnership agreement with other Southeast Asian countries while taking into account the lessons and experiences of Japan.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors statement

EA and RRC participated in the design of the study. EA conducted the data collection. EA and RRC conducted the thematic analysis and interpreted the results. EA drafted the manuscript. RRC supervised the study and the revisions of the manuscript. All authors contributed to the writing of the manuscript and approved the final draft.

Declaration of Competing Interest

The authors declared that they have no competing interests.