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Citation: Kotera, Y.; Ozaki, A.;
Miyatake, H.; Tsunetoshi, C.;
Nishikawa, Y.; Kosaka, M.; Tanimoto,
T. Qualitative Investigation into the
Mental Health of Healthcare Workers
in Japan during the COVID-19
Pandemic. Int. J. Environ. Res. Public
Health 2022,19, 568. https://doi.org/
10.3390/ijerph19010568
Academic Editor: Giuseppe La Torre
Received: 8 November 2021
Accepted: 2 January 2022
Published: 5 January 2022
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4.0/).
International Journal of
Environmental Research
and Public Health
Article
Qualitative Investigation into the Mental Health of Healthcare
Workers in Japan during the COVID-19 Pandemic
Yasuhiro Kotera 1,*, Akihiko Ozaki 2,3 , Hirotomo Miyatake 4, Chie Tsunetoshi 5, Yoshitaka Nishikawa 6,
Makoto Kosaka 4and Tetsuya Tanimoto 3
1School of Health Sciences, University of Nottingham, Nottingham NG7 2HA, UK
2Department of Breast Surgery, Jyoban Hospital of Tokiwa Foundation, Iwaki 972-8322, Japan;
aozaki-tky@umin.ac.jp
3Medical Governance Research Institute, Tokyo 108-0074, Japan; tetanimot@yahoo.co.jp
4Orange Home-Care Clinic, Fukui 910-0018, Japan; hmiyatake@orangeclinic.jp (H.M.);
m.kosaka0811@gmail.com (M.K.)
5Department of Community Health Nursing, University of Fukui, Fukui 910-1104, Japan;
sk21803@g.u-fukui.ac.jp
6Department of Health Informatics, Kyoto University School of Public Health, Kyoto 606-8501, Japan;
yoshitakanishikawa@gmail.com
*Correspondence: yasuhirokotera@gmail.com
Abstract:
The COVID-19 pandemic has negatively impacted the mental health of healthcare workers
in many countries including Japan. While many survey-based findings have reported the serious
state of their wellbeing among healthcare workers, the first-hand experience of the mental health
and coping in this population remains to be evaluated. Accordingly, this study aimed to appraise
them using constructionist thematic analysis on semi-structured interviews attended by a purpo-
sive and snowball sample of 24 healthcare workers in Japan conducted in December 2020–January
2021. Four themes were identified: (1) increased stress and loneliness, (2) reduced coping strategies,
(3) communication
and acknowledgement as a mental health resource, and (4) understanding of
self-care. Participants noted that the characteristics of Japanese work culture such as long hours,
collectivism and hatarakigai (i.e., meaning in work) to explain these themes. These findings suggest
that robust support at an organizational and individual level, capturing intrinsic values, are particu-
larly important for this key workforce to cope with increased stress and loneliness, leading to better
patient care.
Keywords:
healthcare workers; Japan; mental health; COVID-19; coping; intrinsic rewards; self-care
1. Introduction
The mental health of healthcare workers has been negatively impacted by the COVID-
19 pandemic [
1
]. For example, in the United Kingdom, the rates of depression, anxiety and
stress among healthcare workers have quadrupled from pre-COVID-19 to after the first
wave, April–May 2020: the pre-COVID prevalence of severe depression (5%), anxiety (8%)
and stress (11%) raised to 21%, 36% and 46%, respectively, among healthcare workers [
2
].
In the United States, nearly half of healthcare workers experienced serious mental health
symptoms including suicidal ideation [
3
]. Likewise, in Japan, about one-third of healthcare
workers experienced burnout [
4
]. Commonly, fear of infection, close contact with COVID-
19 patients, lack of personal protective equipment and lack of information/guidance were
noted as the primary risk factors for their mental health [
5
,
6
]. Indeed, healthcare workers
are regarded as essential workers, treating COVID patients, risking their own lives: they
are seven times more likely to be infected than other occupational groups [
7
]. Especially,
during the initial phase of the COVID-19 pandemic, healthcare workers were forced to
work in different contexts and roles without sufficient information and guidelines. They
Int. J. Environ. Res. Public Health 2022,19, 568. https://doi.org/10.3390/ijerph19010568 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2022,19, 568 2 of 14
must make practical, sometimes seemingly ‘inhumane’ decisions to prioritize care with
limited medical resources. As illustrated in the Job Demand-Control-Support model—one
established workplace wellbeing model describing how job demands can cause stress whilst
job control and support can help cope with the stress [
8
]—, these increases in job demands
and decreases in job control and support can add extra burden to their wellbeing [
9
].
Moreover, inequality of care access has become more salient in the pandemic, adding extra
stress to healthcare workers [
10
]. However, research thus far primarily has focused on
the quantitative findings, missing the first-hand experience of healthcare workers serving
the public during the COVID-19 pandemic. Hence there is a need to appraise the lived
mental health experiences of this worker group. Coping strategies, communication and
self-care were focused on in this study due to their relevance to workplace mental health.
Coping was identified as a key factor to maintain a high level of mental wellbeing among
healthcare workers during the pandemic [
11
,
12
]. Likewise, workplace communication can
also play a crucial role in employee mental health [
13
,
14
]. Lastly, the importance of self-care
has been increasingly highlighted especially in healthcare workers [15–17].
1.1. Coping Strategies
To maintain a high level of mental wellbeing, establishing effective coping strategies
is essential. Previous workplace studies reported that knowledge in the variety of cop-
ing strategies would help maintain their mental health [
18
]. In general, positive coping
strategies—such as help-seeking, meditation, counseling and humor—are conducive to
wellbeing and quality of working life, whereas negative ones—such as avoidance, substance
abuse, self-harm—are risk factors for poorer wellbeing and quality of working life [11,19].
During the COVID-19 pandemic, several effective coping strategies were reported among
nurses in China such as team communication and pro-social behaviors [
20
]. While these
findings offer helpful insights about coping among healthcare workers, how COVID-19
impacted healthcare workers’ existing coping strategies remains to be appraised.
1.2. Communication in Workplace
In the restricted working settings, how colleagues communicate with each other has
changed. Safe and clear workplace communication was noted as an effective coping
strategy [20]
. This was highlighted during the pandemic, where healthcare workers faced
many uncertain situations. For example, among Japanese nurses, an establishment of
standard protocol was a key mental health resource that made them feel safe, enabling
more compassionate care for patients [
21
]. Indeed, communication has been noted as a key
factor for good workplace mental health. In an organization where employees feel that
they communicate with each other well, the level of mental wellbeing tends to be high [
22
].
Communication among colleagues had a great positive impact on employees’ mental well-
being [
23
]. Workplace communication can facilitate authentic dialogues among colleagues,
which are associated with higher wellbeing [
24
]. In the current ‘second pandemic’, that is a
mental health crisis after the COVID-19 pandemic, the importance of workplace communi-
cation has been highlighted ever before [
25
], therefore this study evaluated how that relates
to healthcare workers’ mental health.
1.3. Emerging Importance of Self-Care
Self-care has been increasingly attracting attention in recent mental health studies,
especially among healthcare workers. This emphasis has been further accentuated during
the pandemic, ensuring healthcare workers to maintain a high level of mental health [
26
].
Indeed, many healthcare workers, who have been trained to care for others, feel guilty
caring for themselves, underestimating the importance of self-care [
15
]. However, self-care
is crucial for healthcare workers to cope with the increasing workload and uncertainty, and
to balance their work life and the other areas of life based on their own cultural backgrounds.
Unsurprisingly more healthcare professionals today acknowledge the importance of self-
care: 100% of Australian healthcare workers who practice self-care reported it is effective,
Int. J. Environ. Res. Public Health 2022,19, 568 3 of 14
and 70% of those who do not practice wished to do so [
27
]. Reviews on the wellbeing
of healthcare workers during the COVID-19 pandemic in western countries identified
self-care as a professional imperative [
28
,
29
], and evidence-based strategies were suggested
including spiritual practices, relaxation, focusing on important relationships (e.g., family),
healthy sleeping and diet, and meditation [
30
]. However, how Japanese healthcare workers
view and practice self-care during the COVID-19 pandemic remains to be examined.
1.4. Study Aims
This study aimed to appraise the first-hand experience of mental health among health-
care workers in Japan. Using semi-structured interviews, we explored specific challenges
they have encountered during the pandemic, what they have found helpful to cope with
the mental health difficulties, and what may be effective to support the mental health of
this population group in the future. Three research questions were established, exploring
the impact of COVID-19 on the mental health of healthcare workers in Japan (RQ1), their
coping (RQ2), and their thoughts on the improvement of mental health (RQ3).
2. Materials and Methods
2.1. Research Design
Thematic analysis of in-depth semi-structured interviews attended by 24 healthcare
workers in Japan (14 males and 10 females; Age M = 34.29, SD = 6.45, Range 27–49 years
old; 14 doctors, 2 nurses, 6 physiotherapists, and 2 administrators; Table 1) was performed
within a social constructionist framework, evaluating how their experiences are created
based on the data [
31
]. The eligibility criteria for participation were 18 years or older, and a
healthcare worker who was working or had worked during the time of restrictions due
to COVID-19. This study adhered to the consolidated criteria for reporting qualitative
research [32].
2.2. Procedure and Analysis
The university research ethics committee approved this study (No. ETH2021-0101).
Participants were recruited through purposive and snowball sampling methods: an initial
announcement about the study was disseminated through authors’ professional networks.
The healthcare workers who responded to the announcement were invited to the interview
with the study information and consent form.
We used the semi-structured interview method to collect detailed information and
allow participants to express their experiences, feelings and thoughts [
33
]. This interview
method is particularly advantageous for appraising complex issues, because it allows
researchers to add follow-up questions to cover information that could be missed in a
standardized data collection method such as close-ended surveys [
34
]. As the mental health
of healthcare workers in Japan during COVID-19 pandemic has not been evaluated in
depth, we employed this method to counter the possibility of missing information.
Prior to the interview, all participants received the pre-designed interview questions,
which focused on mental health and coping (Appendix A). Due to the physical distance
restrictions, all interviews were conducted online. The interviews, conducted in December
2020 and January 2021, were recorded and transcribed verbatim, which were confirmed for
accuracy by the participants after the interview. The study time fell between the second and
third waves of infections in Japan, which was before the rollout of vaccination in February
and overlapped with the Second State of Emergency, 8 January to 21 March 2021.
Thematic analysis was used to analyse the interview data. This analysis method
helps to organize and identify patterns of meaning (i.e., themes) throughout a dataset in a
systematic manner [
35
]. Thematic analysis is particularly helpful to identify meanings and
understand idiosyncratic experiences. Moreover, it is noteworthy that the main function of
thematic analysis is not related to commonality in data, rather it evaluates the importance
and relevance to the research questions to identify themes. The six steps suggested by
Braun and Clarke [36] were followed.
Int. J. Environ. Res. Public Health 2022,19, 568 4 of 14
Table 1. List of participants (n= 24).
No * Age Sex Role Work Setting
Work
Experience
(Yr)
Weekly
Working
Hrs
Treat
COVID
Patients
Regional Level of
Infection **
P1 31 M Doctor Clinic 7 32.5 Y Low
P2 29 F Doctor Clinic 6 45 Y Low
P3 35 F Doctor Hospital 6 58 Y Low
P4 34 F Doctor Hospital 8 45 Y Low
P5 32 F Doctor Hospital 9 50 N High
P6 32 M Doctor Hospital 9 50 N High
P7 36 F Doctor Hospital 10 55 N Low
P8 35 M Doctor Hospital 12 60 Y High
P9 49 M Doctor Other 16 60 N High
P10 31 F Doctor Hospital 7 80 Y Low
P11 30 F Doctor Clinic 7 55 N Low
P12 36 F Doctor Hospital 8 25 N Low
P13 34 M Doctor Hospital 10 70 Y High
P14 48 M Doctor Clinic 23 60 N Low
P15 48 F Nurse Hospital 28 48 Y High
P16 43 F Nurse Hospital 22 50 Y High
P17 34 M Physiotherapist Hospital 10 40 N Low
P18 29 M Physiotherapist Hospital 6 40 N Low
P19 27 M Physiotherapist Home care station 5 45 N Low
P20 31 M Physiotherapist Home care station 9 40 N Low
P21 28 N Physiotherapist Home care station 6 42 N Low
P22 27 M Physiotherapist Hospital 5 40 N Low
P23 34 M Administrator Clinic 3 40 N Low
P24 30 M Administrator Hospital 5 65 N Low
* ‘P’ = ‘Participant’. ** Prefectures included in the Second State of Emergency (8 January to 21 March 2021) at the
time of the interview were rated as high.
The lead author Y.K., an accredited psychotherapist and mental health researcher,
interviewed all participants and transcribed the interview data. Y.K. then analysed the data
using thematic analysis. The other co-authors helped with recruitment and reviewed the
analysis. In order to retain coherence and transparency of analysis, an investigator triangle
was formed with a psychology researcher and health researcher [
37
]. All themes have been
checked and agreed upon by all co-authors and researchers, and later by all participants.
2.2.1. Familiarization
Interview data was read repeatedly to understand the entire data and gain initial
interpretations and patterns, informing possible themes [35,36,38].
2.2.2. Generating Initial Codes
To start the systematic analysis of data, coding was conducted offering labels to
data [
35
]. The theory-driven approach [
36
] for coding was utilized, relating to our research
questions.
RQ1: What was the mental health impact of COVID-19 among healthcare workers
in Japan?
RQ2: How did they cope with the impact?
RQ3: How can their mental health be improved?
One hundred and five codes were identified (Appendix B) including stress, loneliness,
COVID stigma, affable atmosphere, self-care, social gathering, and acknowledgement. A
data corpus and mind-mapping were used for transparency and coherence [39].
2.2.3. Searching for Themes
The codes were organized into potential themes. We used the mind-map method to see
all the codes at the same time, and move and connect them freely [
36
]. The 105 codes were
Int. J. Environ. Res. Public Health 2022,19, 568 5 of 14
grouped together into four themes: increased stress and loneliness (T1), reduced strategies
for coping (T2), communication and acknowledgement as a mental health resource (T3),
and understanding of self-care (T4).
2.2.4. Reviewing Themes
Next, those four themes were reviewed to see whether the themes accurately capture
the relevant dataset [
35
]. Codes were compared with the relevant data extracts (see the
Results section) to ensure the coherence between each theme and each set of extracts [
36
]
more specifically (a) themes capture the most important elements of the data and (b) themes
are relevant to the research questions [35].
The data were organized to address our research questions. The increased levels of
stress and loneliness that healthcare workers experienced during the pandemic (T1) corre-
sponded to RQ1; reduced coping strategies for mental health difficulties (T2) corresponded
to RQ1; supportive communication in the workplace, and acknowledgement of their work
helped to protect their mental health (T3), which answered RQ2; and more understanding
and positive regard to self-care as an effective mental health approach (T4) addressed RQ3.
2.2.5. Defining and Naming Themes
The essence and range of the collated data were reviewed to establish that each theme
is presented to accurately demonstrate the accompanying narrative [35].
3. Results
The datasets from T1 ‘increased stress and loneliness’ considers that healthcare work-
ers experienced more stress and loneliness during the pandemic than before. There were
no established guidelines and experts to consult; healthcare workers were faced with un-
certainty, while treating ever-increasing COVID-19 patients. Moreover, social expectation
that healthcare workers cannot be infected with COVID-19, forced them to more limited
daily life activities and more alert precautions, leading to a sense of loneliness. Loneliness
was also experienced in the workplace, with segmented rooms and limited interactions.
These lead to T2 ‘reduced strategies for coping’ that entails no informal gatherings among
colleagues, which have been an effective way to connect with colleagues and create a
supportive workplace culture. Additionally, other personal activities such as visiting family
members and going shopping were restricted, making it harder to support their own mental
health. However, while recognizing these barriers, healthcare workers identified T3 ‘com-
munication and acknowledgement as a mental health resource’ reporting that these were
particularly helpful to maintain their mental health. Lastly, healthcare workers suggested
T4 ‘understanding of self-care’ in their work culture can contribute to improvement of
mental health in this sector. Findings are summarized in Table 2.
3.1. Theme 1: Increased Stress and Loneliness
All participants reported that since the outbreak, their stress level and sense of loneli-
ness have increased, associated with various factors including uncertainty, increased work
demands, fear of being infected, and social pressure for healthcare workers.
P1 (Participant 1): There were no established guidelines nor legal support and protection
for us. I had to look up many things and interpret various pieces of information.
. . .
I
also had to report our cases to the management. These have significantly increased my
workload.
P16: As a healthcare worker, I must not be infected, as that will impact the hospital’s
reputation. This means that my family also had to restrict their daily behaviours, which
was especially stressful for my children.
Int. J. Environ. Res. Public Health 2022,19, 568 6 of 14
Table 2. Summary of findings.
No Theme (Corresponding RQ) Example Participant Excerpt
1
Increased Stress and Loneliness (RQ1)
There were no established guidelines nor legal support and protection for
us. I had to look up many things and interpret various pieces of
information. . . . I also had to report our cases to the management. These
have significantly increased my workload (P1).
2
Reduced Strategies for Coping (RQ1)
We used to have a lot of chitchats, for example, at the end of our shifts.
While writing a daily report, we also talk about how our families are or
what we did on a weekend. . . . During a shift, sometimes we must have
direct, negative or intense conversations, but chitchats will help retain our
relationship: you know that the person doesn’t dislike you (P22).
3
Communication and Acknowledgement as a
Mental Health Resource (RQ2)
It is very helpful to connect with healthcare workers who are in a similar
circumstance to me. Now we use video calls to connect with such
colleagues, sharing what is happening or giving advice to each other. . . .
This kind of conversation happens organically in the face-to-face context,
but now we need a video call to do that (P3).
4
Understanding of Self-Care (RQ3)
My line manager believes that if we don’t take good care of ourselves, we
cannot take care of others. He supports self-care, which positively impacts
our workplace culture. I am very thankful to him for that (P4).
RQ1: COVID impact on mental health. RQ2: Coping. RQ3: Improve mental health. ‘RQ’ = Research Question.
‘P’ = ‘Participant’.
Additionally, some commented on the stigma related to COVID-19, along with a
discrimination and harsh criticism for those who are infected.
P10: There is a discrimination against people who are infected. They are unreasonably
criticized [for being infected]. Anyone could be infected. Sometimes it’s not within their
control. Staff at a care home, where a cluster was found, was and still is criticized.
P21: If people know that there is a positive case among staff at the hospital, it will be a big
deal. Everyone at the hospital thinks ‘I don’t want to be the first one’. Stigma for COVID
is strong. We had a patient who was infected, but she moved to another town because
people in the community were harsh to her.
These comments suggest that negative views placed onto people who are infected,
especially healthcare workers, added another layer of stress and loneliness.
3.2. Theme 2: Reduced Strategies for Coping
Participants reported that their limited workplace and daily life activities exacerbated
their mental health. Some of the healthful activities, which they used to engage with
pre-COVID, were prohibited during the pandemic, compromising their ability to cope with
mental distress.
P22: We used to have a lot of chitchats, for example, at the end of our shifts. While writing
a daily report, we also talk about how our families are or what we did on a weekend.
. . .
During a shift, sometimes we must have direct, negative or intense conversations, but
chitchats will help retain our relationship: you know that the person doesn’t dislike you.
P19: As a physiotherapist, what I can do for my patients is now limited as my work
usually involves direct touch on the patient’s body. I feel less of the meaning of work,
hatarakigai, as now I don’t feel like I am a physiotherapist sometimes.
In addition to their workplace activities, their activities outside the workplace, which
could help their mental health, are also limited.
P13: We cannot travel, meet with friends, and engage with hobbies, so there is no way to
destress ourselves. Moreover, we cannot have social gatherings with colleagues, which
now I realize, are very important for our wellbeing, knowing each other better.
Int. J. Environ. Res. Public Health 2022,19, 568 7 of 14
Restrictions associated with the pandemic reduced the range of healthful activities inside
and outside the workplaces, making it hard for healthcare workers to cope with increased
distress.
3.3. Theme 3: Communication and Acknowledgement as a Mental Health Resource
Despite the limited strategies for coping, healthcare workers identified some mental
health resources that help them counter mental distress, including supportive workplace
communication, where they feel safe to discuss difficult issues [
40
], and acknowledgement
of their hard work from their colleagues or patients.
P3: It is very helpful to connect with healthcare workers who are in a similar circumstance
to me.
. . .
This kind of conversation happens organically in the face-to-face context, but
now we need a video call to do that.
P10: I feel comfortable talking about my mental distress with my colleagues.
. . .
Everyone
is available and willing to help if I need to talk.
These comments indicate the importance of communication to their mental wellbe-
ing. Participants recognized the importance of communication even more during the
pandemic. Moreover, acknowledgement of their work was also noted as a protective factor
for mental health.
P5: Positive feedback from my line manager or the head of the hospital helps me cope with
stress. Also, some patients brought me some gifts, appreciating my treatment. That kind
of moment is helpful for my mental health.
P20: Today many healthcare workers who work with COVID patients are featured in
a TV programme or a section in news shows. Because of that, people’s understanding
towards those workers has been increasing. But those who don’t directly work with
COVID patients are also impacted. They want to be acknowledged too. In many cases,
just a ‘thank you’ would be enough.
Healthcare workers reported that acknowledgement of their work from their col-
leagues and patients helped or would help to cope with occupational stress and protect
their mental health.
3.4. Theme 4: Understanding of Self-Care
To improve the mental health of healthcare workers, participants suggested that it
is essential to have an increasing understanding of self-care. They believe that a good
workplace understanding of self-care may be helpful for Japanese healthcare workers to
achieve a high level of mental health.
P4: My line manager believes that if we don’t take good care of ourselves, we cannot take
care of others. He supports self-care, which positively impacts our workplace culture. I
am very thankful to him for that.
P7: My team endorses self-care; it may be because we are in palliative care. If I think
about the culture among doctors in Japan, I don’t think that’s the case.
At the same time, under-emphasis and difficulty of self-care in the current practice
was also noted. Often this was discussed in relation to Japanese work culture.
P16: I think it’s in Japanese culture. We cannot say we are suffering, or we are in
pain, because other people may be also
. . .
Japanese people are not good at taking care of
themselves. That is a taboo, you cannot say that in this culture.
P8: As a doctor, I find it hard to self-care.
. . .
The root of this is a value of Japanese
people during WWII, ‘We don’t ask for anything until we win’. We believe that asking
for something means we are not cooperating, but in reality, we need to care for ourselves,
before care for others. . . . It’s been a challenge for me to take good care of myself.
Int. J. Environ. Res. Public Health 2022,19, 568 8 of 14
Participants highlighted those aspects of Japanese culture, especially among older gen-
erations, which may hinder their attitudes towards taking care of themselves. However,
they are also aware of the importance of self-care, and want it to be more emphasized in
the healthcare sector in Japan (see Supplementary Material File S1 for more comments in
each theme).
4. Discussion
This study aimed to appraise the first-hand experience of healthcare workers in Japan
during the COVID-19 pandemic regarding mental health. Our participants reported that
they have experienced increased levels of stress and loneliness, which were managed by
their limited coping strategies. They also noted that supportive workplace communication
and acknowledgement were helpful to their mental health, and an understanding of self-
care as an essential factor for the mental health of healthcare workers in Japan. Findings
are discussed in turn.
In line with other countries, healthcare workers in Japan also suffered from heightened
stress and loneliness (T1). Uncertainty, increased workload, fear of being infected, and
social pressure were noted as key factors causing their mental distress. Indeed, the ability
to tolerate uncertainty was highlighted as a preventative construct against burnout, among
healthcare workers in COVID [
41
]. An established and informed protocol was noted as
a positive wellbeing factor among Japanese nurses, reducing uncertainty [
21
]. The Job
Demand-Control-Support model that posits the job characteristics influence employee
wellbeing may help explain our findings [
8
]. During COVID, healthcare workers have
faced an increased workload (while recognizing some healthcare workers, especially those
not treating COVID patients, had reduced workload), restricted work environment, fear of
being infected (as the study was before the implementation of vaccine), social pressure (e.g.,
stigma), and uncertainty (Demand). However, those who gained information and clarity
about how they should operate (Control) and receive support from the organization (e.g.,
frequent update) (Support) maintained a relatively high level of wellbeing. What is novel
in our study, though, may be that in the COVID-19 pandemic, what healthcare workers can
control was limited. This may help explain why communication and acknowledgement
(T3) and self-care (T4) were noted as a positive mental health resource by the participants,
compensating for the lack of the control factor. During the early phase of the pandemic
(between the second and third waves), healthcare workers experienced stress and loneliness,
and the interventions to enhance a sense of control and support may be particularly helpful
to reduce those negative mental health outcomes.
Healthcare workers were not able to use their usual coping strategies during the
pandemic (T2), which exacerbated their mental health. Workplace chitchats were reduced
due to the workspace separation. Indeed, although office chitchats could hinder employees’
concentration, these informal conversations were helpful to mental health [
42
]. Social
gatherings including having a drink with colleagues, which many participants reported
as important to build good colleague relationships, were not allowed, damaging the
workplace relationships. High-quality workplace relationships were associated with better
staff wellbeing and lower stress among Vietnamese nurses [
43
]. Likewise, a sense of
teamwork was identified as a protective factor for mental health under enhanced work
pressure [
44
]. Evolutionary Theory claims that these informal conversations or chitchats
play a key role in facilitating cooperation in the group [
45
]. Our participants reported that
those common means to maintain workplace relationships (e.g., office chitchats, social
gatherings) were prohibited during COVID, which sabotaged their meaning in work,
namely hatarakigai, and challenged their coping skills with workplace stress.
In this difficult situation, where stress and loneliness were increased (T1) and the cop-
ing was limited (T2), healthcare workers recognized communication and acknowledgement
as helpful mental health resources (T3). A workplace atmosphere in which employees
feel able to discuss concerns, i.e., psychological safety, is essential for staff wellbeing and
effective patient care [
46
]. Moreover, talking with other healthcare workers who are in
Int. J. Environ. Res. Public Health 2022,19, 568 9 of 14
a similar situation to them relates to common humanity, one of the three components
of self-compassion [
47
], reducing stress. Similarly, participants reported that a sense of
being acknowledged by colleagues, patients and community was conducive to their mental
health. Self-Determination Theory holds that intrinsic motivation is associated with higher
wellbeing, whereas extrinsic motivation is associated with lower wellbeing [
48
]. Consistent
with a previous systematic review [
49
], our sample of healthcare workers in Japan found
recognition and acknowledgement, both categorized as intrinsic rewards, are helpful to
their mental health. As healthcare workers in general have higher intrinsic motivation than
other occupations [
50
], they may find intrinsic rewards even more fulfilling. Relatedly, it
is noteworthy that the Japanese government offered monetary compensation (extrinsic
reward) for all employees in healthcare, which was negatively regarded by healthcare
workers (e.g., underestimating their professionalism) whereas positively regarded by ad-
ministrative staff (e.g., feeling appreciated and recognized) in our sample. These findings
suggest that organizations need to be aware of employees’ intrinsic rewards and offer them
appropriately. As many participants noted that their professional identity and meaning in
work were important, future research should investigate interventions to enhance those
positive constructs.
Lastly, a sector-level understanding of self-care was emphasized as a possible solution
for their challenging mental health (T4). As noted above, the control domain in the Job
Demand-Control-Support model was compromised during the pandemic, leading to re-
liance on support. In addition to the workplace support (T3), self-care to support oneself is
essential for healthcare workers to maintain wellbeing and good patient care [
15
]. However,
participants reported difficulties implementing their self-care strategies in their workplace,
often related to Japanese work culture. This accords to a recent study that identified that
Japanese employees’ long working hours were associated with the organizational factors
such as team norms and leadership [
51
], indicating that an organization’s or manager’s
understanding of self-care needs to be established for each healthcare worker to care for
themselves. While the national policies to stop long working hours have been implemented
(e.g., Karoushi Prevention in 2014, Work Style Reform in 2020), traditional cultural value
still favors long working: long overtime hours were positively associated with work vigor
among Japanese male workers [
52
]. Indeed, working hours alone do not represent self-care;
however, these positive regards on long working can support the participants’ comments
about difficulties implementing self-care. Culture and self-care need to be further evalu-
ated [
53
] to identify a better approach to embed self-care into the Japanese healthcare sector.
Moreover, recognizing guilt and shame associated with self-care in other countries [
15
], our
findings highlighting the importance of a sector-level and organizational understanding of
self-care may not be limited to Japan (e.g., [54,55]). Further investigation is needed.
While this research offers helpful insights, limitations should be noted. First, our sam-
ple relied on doctors and relatively young professionals, therefore the representativeness of
healthcare workers was not high. More diverse samples are needed (e.g., inclusion of other
healthcare workers). Nonetheless, our findings will be of interest to healthcare workers
in general, appraising their mental health status in the COVID-19 pandemic. Second,
the recruitment was done through self-selection: those who were not interested in nor
concerned with mental health might not have participated. Third, the analysis was carried
out by one author, and all co-authors are healthcare workers: bias might have been present.
Fourth, the pandemic is still ongoing, therefore their mental health after the interviews was
not considered in this study.
5. Conclusions
Mental health of healthcare workers was negatively impacted by the COVID-19 pan-
demic. This qualitative study appraised the first-hand experience of healthcare workers in
Japan regarding the mental health and coping strategies. Our participants reported that the
levels of stress and loneliness were increased, while their coping strategies were limited.
Intrinsic rewards such as workplace communication and acknowledgement of their work
Int. J. Environ. Res. Public Health 2022,19, 568 10 of 14
were identified as positive resources for their mental health. Self-care was highlighted
as a possible solution for the challenging mental health in this essential workforce. Our
findings can help healthcare organizations and managers identify effective measures to
protect employee wellbeing in this crisis.
Supplementary Materials:
The following are available online at https://www.mdpi.com/article/10
.3390/ijerph19010568/s1, File S1: Participants’ Comments for Each Theme.
Author Contributions:
Conceptualization, Y.K. and A.O.; methodology, Y.K.; software, Y.K.;
validation, All authors; formal analysis, Y.K.; investigation, Y.K. and T.T.; resources, All authors; data
curation, All authors; writing—original draft preparation, Y.K.; writing—review and editing, All
authors; visualization, Y.K. and T.T.; supervision, Y.K.; project administration, Y.K. and A.O.; funding
acquisition, N/A. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement:
The study was conducted according to the guidelines of
the Declaration of Helsinki, and approved by the University of Derby, Research Ethics Committee
approved this study (No. ETH2021-0101 on 20 October 2020).
Informed Consent Statement:
Informed consent was obtained from all subjects involved in the
study.
Data Availability Statement:
The data presented in this study are available on request from thecor-
responding author. The data are not publicly available due to ethical restrictions.
Acknowledgments: We are grateful to all the healthcare workers who took part in this study.
Conflicts of Interest: The authors declare no conflict of interest.
Appendix A. Interview Schedule
The aim of this interview schedule is to explore your experience of how COVID-19
has impacted on your mental health, and what can be done to protect your mental health.
Below are guide questions to stimulate this exploratory discussion.
1.
Could you tell me how your mental health has been affected by COVID-19? Is there
any uniqueness compared to other mental health difficulties?
2.
How is the leadership in your organization? Has clear communication been achieved
by the leadership?
3.
What countermeasures have been taken in your organization? How is it working?
Any mental health stigma/shame preventing help-seeking?
4.
What kinds of support do you think are needed for the mental health of healthcare
workers in Japan at the individual, team, organization, society and national levels?
5. What do you hope for in the future?
6.
Is there anything else that you feel I should have asked, or that you would like to add?
Appendix B. Codes Generated (n= 105)
acknowledgement
affable
affable atmosphere
against culture
answer unknown
anxiety
awareness of death
change in generation
chitchat
clear communication
communication
communication as solution
Int. J. Environ. Res. Public Health 2022,19, 568 11 of 14
COVID stigma
curious
depression
difference from general public
dissociate
easy-to-talk-to
effective social support
empathy
fatigue
frequent use of video conference
good communication
good team
good understanding of self-care
growth mindset
guilt
guilt on self-care
hard to organize gathering
hard to take a day-off
hatarakigai
healthcare worker as one individual
human resources
importance of acknowledgement
importance of communication
importance of knowledge
importance of off-time
importance of self-care
incentive
increased team cohesion
isolation
lack of acknowledgement
lack of communication
lack of knowledge in mental health
lack of yarigai
less communication
less family contact
less social gathering
loneliness
long hours
meaning
mental fatigue
mental health stigma
mentor/mentee relationship
mindfulness
mission
morning meetings
nature recreation
need for clinical psychologist in workplace
need for top’s involvement
network with similar professionals
no expert/mentor
no guidelines
no socializing
no stress release
online dinner
Int. J. Environ. Res. Public Health 2022,19, 568 12 of 14
positive attitude as manager
positive thinking
powerless
professional identity
promote self-care
reduced hours do not apply to healthcare
reduced interaction with colleagues
relation with colleagues in other sections
resilience
restless
satisfaction with new situation
scared
self-awareness
self-care
self-care is against culture
self-care is hard
social gathering
social media for stress reduction
soft communication
soft skills
stigma and culture
stress
stress due to uncertainty
strict atmosphere
students’ motivation change
teamwork
tense atmosphere
time for self
too busy to care for poor mental health
too much caregiver identity
unable to see last moment of grandma
uncertainty
understanding of mental health
understanding of self-care
venting
venting helps
vertical communication
want to be a hero
work style review
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