Securing human resources for Japan’s aging population: a mixed methods study of job satisfaction and well-being among Southeast Asian long-term care workers in Japan

Abstract

Background

Japan is one of the countries experiencing a “super-aged society.” The government has looked to Southeast Asia for recruiting workers to fill the demand for long-term care (LTC) workers. However, migrant LTC workers have faced many job-related stressors. This study aimed to examine the factors associated with job satisfaction and subjective well-being among Filipino, Indonesian, and Vietnamese LTC workers in Japan and explore the specific factors behind what makes them satisfied in their jobs.

Methods

A convergent mixed methods study was conducted. The workers were recruited through snowball and convenience sampling and completed a self-administered questionnaire for the quantitative part. The association of the work environment with the workers’ job satisfaction and subjective well-being were analyzed using multiple linear regression analysis. An interpretive phenomenological approach was used to conduct in-depth interviews of the workers, which were analyzed using a deductive and inductive approach for the qualitative part. Quantitative and qualitative results were integrated and interpreted to expand on the findings with new insights.

Results

In the final analysis, 122 workers were included (20 Filipino, 43 Indonesian, and 59 Vietnamese). In the quantitative part, having the necessary tools/equipment (Unstandardized Coefficient [B] = 16.1, 95% Confidence Interval [CI] = 6.8, 25.3) and support from work (B = 18.1, 95% CI = 8.6, 27.6) were associated with a higher level of job satisfaction. Having experienced harassment on the job was associated with a lower level of job satisfaction (B = -18.2, p = 0.007, 95% CI = -28.5, -7.8). There is no strong evidence for the association with subjective well-being. In the qualitative part, prominent themes emerged related to cultural sensitivity and an inadequate knowledge of caring for older adults living with dementia. The integrated findings suggested inadequate and unequal Japanese language training across the facilities. Moreover, the importance of human relations in the workplace emerged, with some workers desiring a deeper connection with their Japanese coworkers.

Conclusions

A supportive and culturally sensitive work environment may bring about more motivated employees and increase employee retention from migrant LTC workers. Government and facilities should consider policies supporting a culturally sensitive work environment and more equitable Japanese language training across all facilities.

Introduction

Today, people are living longer, and the population aged 60 and over is growing faster than all other age groups. By 2030, 1 in 6 people worldwide will be 60 or older [1]. Japan is experiencing what is known as a “super-aged society,” with 30% of its population already aged 60 and above, making it the country with the largest proportion of this age group in the world [2].

The shift in the aging demographics and changes in the structure of family households in Japan has created many challenges in securing the human resources to care for older adults [3]. Due to geographical constraints, work demands, or raising children, many families can no longer care for an aging family member, thus resulting in a substantial growth in the need for long-term care and an increased demand for long-term care (LTC) workers [4, 5]. Like many other high-income countries, Japan has a labor shortage of LTC workers. As the population grows older in Japan, the Ministry of Health, Labour and Welfare (MHLW) estimates that by 2040, there will be a need for 2.8 million LTC workers, leaving an additional 690,000 LTC workers needed to fill the labor gap [6].

To mitigate the labor shortage of LTC workers, the Japanese government has implemented several policies for accepting migrant LTC workers. Since 2008, Japan has received nursing and LTC work candidates through the Economic Partnership Agreement (EPA) from Indonesia, the Philippines, and Vietnam [7]. The EPA permits candidates for LTC work to enter and stay in Japan for up to four years for training to obtain the national care worker certification. Upon receiving the qualification, candidates can live and work in Japan indefinitely. In contrast, candidates who are unsuccessful in passing the exam will be required to return to their home country [8].

However, there have been some challenges for the workers, such as passing the exam, which is in Japanese. The government has since made several modifications to the exam to make passing it more achievable for migrant workers. Several reforms have also been implemented to expand the systems through which migrant workers can come to Japan to work in LTC [9, 10]. There are four systems for employing migrant LTC workers: through the EPA, graduating from a certified care worker training school and obtaining care worker qualification in Japan, through the Technical Intern Training program, and Specified Skilled Worker status of residence [11].

While passing the national care worker certification exam is one challenge, many workers have also reported negative experiences on the job. One study that surveyed 146 EPA nurse and LTC worker candidates from Indonesia, the Philippines, and Vietnam showed that dissatisfaction with their job was significantly associated with returning to their home country [12]. In other studies, migrant workers cited dissatisfaction with working conditions such as the long hours, physical health concerns, and coworker relationships, as well as stressors such as language barriers, workplace discrimination, and cultural differences [13,14,15].

The Range of Affect Theory (1976) is a job satisfaction model developed by Edwin A Locke. This theory proposes that an individual’s job satisfaction depends on the workers’ expectations from the job and if the expectations are met. Further, the theory states that how much the worker values any given part of the job (autonomy, coworker relationships, organizational culture, management practices, etc.) determines their satisfaction or dissatisfaction when expectations are met or not met [16].

With the growing demand for qualified migrant LTC workers in Japan, the government must study all aspects of the human resources shortage and turnover among migrant LTC workers. Previous literature on migrant LTC workers in Japan primarily focused on the stressors and dissatisfaction of the workers who were mainly part of the EPA system and working as nurses. Little research to date has investigated the factors associated with satisfied migrant LTC workers and the association between their work environment with their job satisfaction and well-being. By understanding what makes migrant LTC workers satisfied and happy in their jobs, new methods and strategies can be employed to modify the work environment, reduce employee turnover, and optimize retention among this group of workers. Figure 1 illustrates the conceptual framework used in this study.

Fig. 1

Conceptual framework

This study had two objectives: to examine the factors associated with job satisfaction and subjective well-being among migrant LTC workers in Japan and to explore the factors behind what makes the workers satisfied with their jobs.

Methods

A convergent mixed methods study was conducted across all 47 prefectures (administrative regions) in Japan. The convergent mixed methods design was employed to meet the needs of the objectives and to be able to examine the situation of the workers from different angles and within the study’s timeline. The convergent design allowed quantitative and qualitative data to be collected in parallel but analyzed independently [17].

Quantitative study design and participants

Participants of this study included Filipino, Indonesian, and Vietnamese LTC workers who were either certified or trainees working in an LTC facility, excluding daycare centers and in-home care services. The workers were at least 20 years of age. This population was selected as it represents the three main countries from which the majority of migrant LTC workers are recruited and where Japan holds EPA Agreements.

A minimum sample size of 350 was calculated using OpenEpi software, taking the mean difference in job satisfaction from the bivariate analysis of a study on job satisfaction and associated factors among healthcare professionals in Ethiopia [18]. The significance level was 5%, with a statistical power of 80%.

The workers for this study were recruited by employing both a convenience sampling and snowball sampling method through social media groups and with the cooperation from non-governmental organizations (NGOs), LTC facilities, and supervising organizations that support migrant workers in Japan.

Variables and assessment

Exposure variables

Work environment

The work environment was assessed by asking the following “Yes” or “No” questions, “My workplace provides me with the necessary tools/equipment to perform my job,” “I have experienced harassment or discrimination in my workplace,” and “There are enough staff in my workplace to provide the necessary care for the users.” Social support at work was assessed by asking, “Is there someone at work to talk to about understanding a situation or any problems.”

Outcome variables

Job satisfaction

The workers’ job satisfaction was measured using the Job Satisfaction Survey (JSS) developed by Paul Spector. Spector’s JSS was based on Locke’s (1976) job satisfaction theory [19]. The workers responded based on a 6-point Likert scale ranging from 1 “disagree very much” to 6 “agree very much” with scores ranging from 36 to 108 interpreted as “dissatisfied,” whereas scores of 144 to 216 interpreted as “satisfied” [20]. The questionnaire also consists of nine subscale domains (pay, promotion, supervision, fringe benefits, contingent rewards, operating conditions, coworkers, nature of work, and communication). The JSS has adequate reliability with Cronbach’s alpha score that averages 0.7 for all nine subscales, making it a reliable tool for evaluating job satisfaction [21]. The JSS has been translated into 27 languages and has been used in studies worldwide, demonstrating the instrument’s acceptability across cultures [22].

Subjective well-being

The WHO-5 Well-being Index (WHO-5) was used to measure the workers’ subjective well-being. Responses to this questionnaire are based on a 6-point Likert scale ranging from 0 “none of the time” to 5 “all of the time,” with a total score of 25 representing the “best imaginable well-being” while scores below 13 indicate “poor well-being”. The WHO-5 has been translated into over 30 languages and due to the diversity of its application, the WHO-5 instrument has shown to be successful across different regions of the world [23].

Translated and validated versions of previous studies’ JSS and WHO-5 questionnaires were used for Filipino and Vietnamese workers. There were no translated versions of the JSS or WHO-5 for Indonesian workers, so for this study, a forward–backward translation from English to Indonesian was performed by a researcher fluent in both languages and with a background in health science. The primary researcher conducted face and content validity and pre-testing on a sample of six Indonesian LTC workers to assess the understanding of each questionnaire for linguistic and cultural validation. Pre-tests were also conducted on a small sample of two Filipino and five Vietnamese workers before the start of the study. Cronbach’s alpha was calculated to check internal consistency, which came out to α = 0.93 for the JSS and α = 0.90 for the WHO-5.

Confounders

Potential confounders of this study are length of time living in Japan, Japanese language proficiency, being a certified care worker, number of years of LTC work, living situation, and work location.

Covariates

Covariates of this study are background-related factors of the workers, which included age, sex, nationality, weekly working hours, and monthly income.

Data collection

A 58-item web-based, anonymous, self-administered questionnaire was created in the native language of the workers, Tagalog, Indonesian, and Vietnamese, and distributed online using the Google Forms platform. A paper-based questionnaire was also made available if needed. Quantitative data were collected from mid-May to mid-October 2021.

Data analysis

Descriptive statistics were used to summarize the characteristics of the workers. The mean scores of the JSS nine subscales were calculated to examine the specific job domains in which workers are satisfied or dissatisfied. One-way Analysis of Variance (ANOVA) was conducted to test the differences in the JSS subscale mean scores among the nationalities.

Multiple imputation was performed for variables with missing data. Multiple linear regression analyses were performed to identify the association of the work environment with job satisfaction and subjective well-being. The variance inflation factor (VIF) was calculated to check the multicollinearity, and values below 5, suggesting a moderate correlation, but not severe enough to warrant corrective measures, remained in the model [24]. The level of statistical significance was set at p < 0.05. All analyses were performed using Stata/SE 16 (StataCorp, College Station, TX, USA).

Qualitative study design and participants

For the qualitative part of the study, an interpretive phenomenological approach was employed to explore further and interpret the workers’ perceived experiences at work and in life and identify the factors behind what makes them satisfied in their jobs. Eligible workers who completed the questionnaire were recruited from the quantitative part of the study. An estimated sample size of 20 eligible workers (10 "satisfied” and 10 “dissatisfied”) were purposively selected and screened before sending a formal invitation to collect and compare workers at both ends of the satisfaction spectrum. The nationality of the workers was also considered to include a balanced number of workers from all three nationalities included in the study.

Data collection

In-depth interviews were conducted using a semi-structured approach with guided questions developed for this study. The primary researcher and an interpreter (research assistant speaking the local language of the worker) interviewed the workers on the Zoom online platform, where workers chose a convenient private location. Informed consent was taken verbally on the day of the interview before starting. The workers were given ID codes in place of their names during the Zoom interview to confirm their identity and stay anonymous. Questions asked in the interview were framed around their (1) background, (2) work environment, (3) social support, and (4) unique behaviors (Appendix A). Qualitative data were collected from August to mid-October 2021. Data saturation was checked and discussed after each interview.

Data analysis

All transcripts not in English or Japanese were translated by the interpreter and analyzed by the primary researcher using a deductive and inductive thematic approach in parallel with another researcher trained in qualitative interviewing. Each researcher independently coded the transcripts and met to discuss their codes, which were then grouped into more conceptual categories and themes. Lastly, to minimize researcher bias, themes included in the final analysis were mutually agreed upon through peer debriefing with a third external researcher. The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was completed for this study. MAXQDA 2020 (VERBI Software, 2019) qualitative data analysis software was used to manage and code the data.

Integration

The data from the quantitative and qualitative parts were collected in parallel and analyzed independently. The results were then merged and interpreted. Significant findings that confirm the results in both parts or expand on the results by providing new insights were organized and presented as joint displays showing both quantitative and qualitative findings side-by-side. Meta-inferences were drawn to describe new findings obtained from the integration.

Results

Quantitative part

In total, 124 workers completed the survey. After data cleaning, it was found that two entries were missing substantial data and were excluded from further analysis. The final analysis included 122 workers from 31 prefectures (Appendix B). The calculated estimated sample size in this study was not met due to challenges in recruiting participants during the COVID-19 pandemic, and given the time limitation, it was decided for the data collection to stop at 124 workers. However, the statistical power for each significant outcome variable in the regression analysis of this study was sufficient.

Sociodemographic characteristics of the workers

Table 1 shows the sociodemographic characteristics of the workers, 20 Filipino, 43 Indonesian, and 59 Vietnamese. Their mean age was 27.9 years (SD 6.1), and most were women (79.5% vs. 20.5%). Most workers (79.8%) had a monthly income of JPY 200,000 (USD 1,900) or less. 34.4% were employed through EPA, followed by Specified Skilled Worker (23.8%) and Technical Intern Trainee (21.3%). Concerning their Japanese language proficiency, 70.5% of the workers self-rated their Japanese speaking proficiency as working-level or greater.

Table 1 Sociodemographic characteristics of the workers

Overview of the Job Satisfaction (JSS) and the WHO-5 subjective well-being (WHO-5) scores

Table 2 shows the JSS subscale mean scores for each of the nine subscale domains. The mean scores of the subscale domains: “nature of their work” (17.6), “communication” (17.1), “supervision” (17.0), and “coworkers” (16.7) all suggest a higher level of satisfaction. The results from ANOVA showed no significant differences among the nationalities (Appendix C). The WHO-5 mean scores were calculated at 12.9 points, indicating poor well-being. The Cronbach’s alpha of the JSS scale used for this study was α = 0.92 for Tagalog, α = 0.93 for Indonesian, and α = 0.91 for Vietnamese. The Cronbach’s alpha of the WHO-5 scale used for this study was α = 0.91 for Tagalog, α = 0.90 for Indonesian, and α = 0.93 for Vietnamese.

Table 2 Job Satisfaction Survey (JSS) subscale mean scores

The association of the work environment with job satisfaction and subjective well-being

Table 3 shows the results of the multiple linear regression analysis for the association of the work environment with job satisfaction. Workers that reported having the necessary tools/equipment (Unstandardized Coefficient [B] = 16.1, p = 0.007, 95% CI = 6.8, 25.3) and support from work (B = 18.1, p = 0.006, 95% CI = 8.6, 27.6) were significantly associated with having a higher level of job satisfaction compared with workers who did not. Workers who have experienced harassment or discrimination at work (B = -18.2, p = 0.007, 95% CI = -28.5, -7.8) were significantly associated with a lower level of job satisfaction compared with workers who have not.

Table 3 Results of the multiple linear regression analysis: association of the work environment with job satisfaction (JSS) (n = 122)

Table 4 shows the results of the multiple linear regression analysis for the association of the work environment with subjective well-being. Although the WHO-5 mean scores were calculated at 12.9 points, indicating poor well-being, strong enough evidence for the association between work environment with subjective well-being was not found. However, based on the value of the coefficients and the confidence interval, the following variables could be potential factors contributing to subjective well-being. Being a certified care worker (B = 3.1, p = 0.097, 95% CI = -0.8, 7.0), Filipino worker (B = 2.4, p = 0.130, 95% CI = -1.1, 5.9), working 30 hours or less in a week (B = 2.3, p = 0.089, 95% CI = -0.5, 5.1), and having support from family and friends (B = 2.1, p = 0.101, 95% CI = -0.6,4.8) might be important factors that contribute to a higher level of subjective well-being.

Table 4 Results of the multiple linear regression analysis: association of the work environment with subjective well-being (WHO-5) (n = 122)

Qualitative part

Out of the 76 contacted workers, 16 interviews were successfully arranged. Table 5 shows the sociodemographic characteristics of the workers who participated in the interviews: 2 Filipino, 8 Indonesian, and 6 Vietnamese, with a mean age of 28.3 years (SD 4.6).

Table 5 Sociodemographic characteristics of the workers interviewed

Two main themes emerged from the qualitative findings: unique behaviors of the workers and positive factors of their work environment. Table 6 summarizes the themes, sub-themes, and descriptions from the findings.

Table 6 Results of the qualitative analysis: Themes - unique behaviors of the workers and positive factors of the work environment

Unique behaviors of the workers

Religious beliefs and practices

Religion was mentioned by many of the workers from Indonesia and the Philippines. The workers talked about their religious practices, with several stating religion as a strong factor in their motivation for continuing their work and dealing with stressors related to work or daily life.

“Just staying motivated in that work because I’m a Christian, that is my motivation to do a job. And then even if the situation is very hard, so you need to be focused and you need to stay motivated in that job, because of our God.” (Filipino, female, 30 s, works in Aichi)

Community participation

Some of the workers discussed their involvement in community activities. Community participation or volunteering has been associated with migrant workers feeling more connected to Japan [25].

“There are some Japanese people more like a mother figure that are around me who I know from the cultural center. There’s a space to meet and study Japanese and exchange culture and there are many older Japanese ladies that also visit and or work there and I often talk with them.” (Indonesian, female, 20 s, works in Aichi)

Cultural adaptability

While many workers highlighted cultural differences as challenges within the workplace, some talked about having more of an ability to quickly adapt and integrate due to previous education or interest in Japanese culture and language.

“There are some points that I am accustomed to, and others are still shocking to me. Before coming to Japan, I was able to learn about Japanese culture and manner, so it was easy to get use to the differences.” (Indonesian, female, 20 s, works in Aichi)

Knowledge of care for older adults (users) living with dementia

Workers who have been working in LTC for some years or who are certified in Japan mentioned being more familiar with the varying behaviors of dementia among older adults. In comparison, recently employed workers talked about their shock and challenges with how to care for the users in their facility who are living with dementia.

“There are some users that are suffering from dementia and there are many different stages so there can be users who can go on a rampage wanting to return back to their home… I was surprised, during my training there was no mention of this…I never thought [of it] until experiencing this at the facility.” (Indonesia, female, 20 s, works in Aichi)

Positive factors of the work environment

Leadership and development opportunities

Some workers spoke enthusiastically about leadership opportunities. Providing opportunities for the workers to be more involved in taking ownership of responsibilities other than their daily tasks can empower them to be more motivated. It may also create a more inclusive working environment for the migrant workers to feel equal to Japanese workers.

“There is a [training] program here, every month we discuss about an issue for example diseases infection prevention, how to improve quality of the patient’s condition…The training can develop into a career. I have worked already as a floor leader position and team leader.” (Indonesian, male, 30 s, works in Tokyo)

Japanese language training

Although all the workers are required to meet a minimum intermediate level of Japanese language requirement [JLPT N3] for working as an LTC worker, the majority stated having insufficient language ability to perform their duties confidently and spoke about Japanese language being one of the significant challenges at work. Furthermore, many workers talked about the need for self-study or paying for lessons independently. In contrast, others mentioned that Japanese language support or even allowance for study time was provided within their facilities.

“My facility also facilitated me to learn Japanese, the sensei [language instructor] comes to my facility… Two hours, every week.” (Indonesian, female, 20 s, works in Gifu)

“Before the exam [National care worker certification exam] they will give us 40 days, we can study at any day. We will still have to go to the facility, but it won’t be to work, but just to study, during that time.” (Vietnamese, female, 20 s, works in Tokyo)

Cultural sensitivity

When bringing other nationalities and cultures into the workplace, it is essential to have an awareness and understanding of the different cultures of the workers [26]. Those workers in facilities where the management understood the importance of accepting the workers’ cultural and religious practices shared how lucky they felt to work in such a facility.

“I discussed this [my religion] with the facility management prior to joining in the interview. I explained that it was necessary for me to pray five times a day and they were understanding about it…and are flexible with giving me time off for religious obligations as well. I am very appreciative of this.” (Indonesian, male, 20 s, works in Gunma)

Social support

Coworker support has been associated with a more positive work environment, higher job satisfaction, and lower turnover intentions [27]. Additionally, it helps to build human relationships and skill sharing. For migrant workers, many are here in Japan alone, and some may have no other support system apart from support from their facility.

“The positive point for me, the director is easy-going; they support learning, study time, teachers, books, a lot. Plus, we’ve had a raise recently.” (Vietnamese, female, 20 s, works in Tokyo)

Integration

Two new findings were brought to light after integrating the quantitative and qualitative data results. The first integrated finding in Table 7 shows that while Japanese language proficiency was not significantly associated with job satisfaction in the quantitative part, in the qualitative part, almost all the workers mentioned that speaking and or writing in Japanese remained a significant challenge for them.

Table 7 Joint display of Japanese language training and job satisfaction

The second integrated finding that emerged relates to workplace human relations. Based on the JSS total subscale mean scores in the quantitative findings, the workers were satisfied with the domains: “nature of their work” (17.6), “communication” (17.1), “supervision” (17.0), and “coworkers” (16.7). The results in Table 8 show comparable responses from the qualitative findings, where workers shared about their “friendly environment” and “helpful coworkers.” While most of the workers noted a high level of social support in the workplace, some also mentioned wanting a deeper connection with Japanese coworkers.

Table 8 Joint display of human relations in the facility and job satisfaction

Discussion

This study aimed to examine the factors associated with the job satisfaction and the well-being among migrant LTC workers in Japan and to explore the unique behaviors of those workers who are satisfied in their jobs. Four main findings emerged from this study. First, it highlights the importance of cultural sensitivity among management and staff in the facilities as an important factor for many workers, particularly when it involves understanding religious practices. Second, having the necessary tools, equipment, and social support in the facility was positively associated with the level of job satisfaction; conversely, facing discrimination and harassment in the facility was negatively associated with the level of job satisfaction. Third, some of the workers felt that their knowledge and level of training in caring for older adults living with dementia was inadequate. Fourth, in the integrated findings, a divergent finding emerged that although the association of Japanese language level was not found statistically significant with the workers’ job satisfaction or well-being, Japanese language is an ongoing challenge for many of the workers, and that there are disproportionate levels of training across facilities. Furthermore, the importance of social support and human relations at work was confirmed in the integrated findings.

The importance of cultural sensitivity and acceptance of cultural practices in the workplace

In this study, religion was found to be an important factor for many of the workers. Many of the Muslim workers talked about the cultural barriers they have faced when it comes to their religious obligations of daily prayers. On the other hand, some of the Muslim workers expressed how “lucky” they felt to work for a facility that respected their culture and religious practices. Muslims are required by their faith to observe five daily prayers at set times, usually at dawn, mid-day, mid-afternoon, sunset, and nighttime. One study in Malaysia highlighted the impact that daily prayers had on Muslim workers’ motivation to work hard in their organizations [28]. Christian workers also spoke about religion as a motivating factor for dealing with daily stressors and for their resilience to continue even when work gets demanding.

Furthermore, the increase in migrant LTC workers from Southeast Asia brings a new cultural diversity to many of the facilities, with workers who hold different beliefs, values, and behaviors from the Japanese workers. Facility management should consider implementing cultural sensitivity practices in their facilities, as it has been found to be a strong predictor of job satisfaction and employee retention [29, 30].

The association of the work environment with job satisfaction

Workers at facilities with the necessary tools/equipment and support from work were associated with a higher level of job satisfaction compared with workers who do not. Many of the workers interviewed in this study who expressed their satisfaction with their job also mentioned that they received support from their coworkers or supervisors in dealing with issues in their daily lives. It is beneficial for management and staff to have healthy interactions, such as sharing resources and information. Past studies have found a link between support from supervisors or coworkers and job satisfaction [31,32,33]. In the case of migrant LTC workers, most of the workers come to work in Japan alone, so they do not necessarily have the same level of support outside of work as their Japanese coworkers. This places even more importance on the level of support provided by the facility to the workers. The integrated findings in this study also highlighted how significant social support and human relations at work are for the workers, with many workers also expressing wanting to have a deeper connection with the Japanese workers in their facility.

Workers who have experienced harassment or discrimination at work were associated with a lower level of job satisfaction compared with workers who have not. Previous studies highlight the impact experiences of harassment and discrimination, such as being undervalued, ignored for promotion, and excessive discipline by supervisors, have on job satisfaction and well-being [34,35,36]. For example, one qualitative study on migrant care workers in Japan, which was used as the basis of this study, found discrimination as one of the stressors LTC workers face in Japan [15]. Migrant and minority workers are most at risk of harassment or discrimination on the job and suffer more adverse health outcomes in comparison to the majority demographic group of the country in which they are living [37]. The quantitative findings in this study support how among all the other factors how much facing harassment or discrimination at work negatively impacts the level of job satisfaction.

Inequalities in the level of training across long-term care facilities

Many workers spoke about the on-the-job training they receive at their facilities, which includes the physical care and support training required for daily work. Having the knowledge and understanding of caring for older adults living with dementia was one part of the job that some of the workers felt inept in handling. Workers who have been working longer in LTC in Japan had a better understanding of dementia. In contrast, workers who have recently started working spoke about the challenges they faced when caring for users in their facility living with dementia. This finding suggests that among migrant LTC workers, there is a need for more awareness, knowledge, and training on caring for older adults living with dementia. Based on 2020 projections, over the next 25 years in Japan, dementia in people older than 65 years is projected to exceed 25% nationwide [38].

It also emerged that some workers want to have a deeper connection with their coworkers. Language could be a potential barrier to forming a deeper connection. While the workers are expected to have a minimum level of Japanese language requirement, many expressed a lack of confidence in speaking and writing in Japanese at work. Some workers mentioned that their facilities provide free Japanese language training for them on-site. In contrast, others talked about having to supplement their Japanese language learning through their own financial means.

The integrated findings of this study suggest that the current amount of Japanese language support provided is insufficient. In the quantitative findings, although there was no significant association between Japanese language proficiency and job satisfaction, in the qualitative part, most of the workers discussed the challenges and barriers that remained with speaking and writing Japanese at work, with one worker stating difficulties with the Japanese language, “sometimes makes me want to quit”. This finding corroborates with past literature where it was found among migrant nurses and care workers that Japanese language, especially understanding kanji and writing incident reports in Japanese, remained difficult [39, 40].

Ensuring equitable access to language training across facilities nationwide can enable workers to form a deeper connection with coworkers and establish a better relationship with the facility’s users. Moreover, given the pass rate of the national care worker certification exam for migrant workers, having the necessary Japanese language training to pass the exam and get certified is important for retaining migrant workers for the future.

Strengths and limitations

The mixed methods approach in this study utilized the strengths of both quantitative and qualitative findings. However, there were three limitations to address. First, only a small sample size was attained, and the estimated sample size for this study was not achieved, limiting the study’s representativeness and generalizability. This study was conducted during the peak of the COVID-19 pandemic, limiting the accessibility of workers at the time, however, having more authority through government agency with support for recruitment methods may have had a better response, in addition to having an incentive for the facility management to encourage the participation of their employees. Second, multiple imputation was used for the data missing at random, which can reduce the study’s statistical power. Therefore, a statistical power calculation was performed for the variables that showed significance and were all sufficient at over 80%. Third, most of the workers who participated in the interviews had a high level of satisfaction based on their JSS mean score, resulting in possible selection bias. There was an effort to reduce this bias in the beginning by purposively selecting workers who were both satisfied and dissatisfied to compare. However, those workers who were less satisfied were not as responsive, and many could not be interviewed.

Despite such limitations, this study benefits from several strengths. This study examines the experiences and positive factors of migrant LTC workers in Japan from all four government employment systems and across 31 out of 47 prefectures working in both urban and rural settings. The mixed methods design of this study further strengthens the findings. For instance, the qualitative interpretive approach allowed the primary researcher to examine the experiences of the workers from their perspective, which brought to light many significant findings that could not be seen in the quantitative part, such as the importance of cultural sensitivity and the need for more knowledge and training in caring for older adults living with dementia. Future research could explore the experiences and challenges of employing migrant LTC workers from the LTC facilities and management perspective.

Conclusions

With Japan’s aging population and labor shortage in long-term care, workers from Southeast Asia are an important pool of future human resources to hold the industry together. Therefore, policies and interventions should be implemented to promote cultural sensitivity training for all employees in LTC facilities while also allowing flexibility and accommodations for workers with specific religious or cultural obligations. Moreover, facilities and supervising organizations should focus on more education and training on caring for older adults living with dementia and Japanese language. Providing a culturally sensitive working environment and sufficient and equitable training and support are some of the ways to create a more encouraging workplace and improve employee retention.