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The course of broken dreams: The expectations and realities of the life of Indonesian nurses as care workers in Japan

      ABSTRACT

      Background

      Despite the contribution of international nurses to the health care services at a destination country, migrant nurses are not always employed based on their competency. Sending nurses to work as care workers in Japan might contradict the international migration of Indonesian health workforce policy which promotes the brain cirulation. Examining the life and work experiences of Indonesian nurses in Japan provides insight into stages of the migratory journey on a receiving country.

      Purpose

      The aim of this study was to describe the narratives and experiences of Indonesian nurse migrants who worked as care workers in Japanese long-term care facilities.

      Methods

      A qualitative descriptive method was employed and a purposive sample of 18 Indonesian nurses participated in this study. Semi-structured interviews were conducted among those participants who worked in long-term care facilities across four prefectures in Japan. Data were analysed using content analysis, supported by QSR NVIVO 10 software.

      Results

      Three key themes emerged from the data analysis: (i) broken dreams; (ii) surviving the struggle; and (iii) supportive environment. These three themes include the unmet expectations of the participants, their experiences as foreign care workers, and the support they received from their work environment.

      Conclusion

      Indonesian nurses in this study who migrated and worked in Japan's long-term care facilities as care workers were left disillusioned due to unmet expectations but able to cope with the challenges with supports from the institution and people at their workplace. International care workers with nursing educational backgrounds should be provided with opportunities to develop their professional careers.

      Keywords

      Summary of relevance
      Problem or issue
      Indonesian nurses who work as care workers in Japan experienced the loss of nursing skills, such as suctioning, administering infusions and had unmet expectations.
      What is already known
      Career moves during the migration stage are essential to the professional development of migrant nurses.
      What this paper adds
      Changes in nurses’ employment during the migration stage should be considered by sending and receiving countries to provide and facilitate professional development. Stakeholders involved should acknowledge the adverse effect of international migration on nurses’ careers.

      1. Introduction

      The transnational movement of nurses has received attention following the increased demand for health care globally especially during the Coronavirus Disease 2019 (COVID-19) pandemic (

      World Health Organization. (2020). Addressing the international migration of health workers.

      ). Since the start of the COVID-19 pandemic, ICN has sent a strong message that the world needs more nurses, and estimates the shortage of global nurses to be 13 million (

      ICN. (2021). Policy brief: the global nursing shortage and nurse retention.

      ). The World Health Organization (WHO) recognises the international migration of health workers as being complex in terms of volume and growth (

      World Health Organization. (2021b). Year of health and care workers 2021.

      ). The international mobility of health workers remains challenging, although the world has agreed to adopt a Global Code of Practice on the International Recruitment of Health Personnel in 2010. The Code was intended to promote ethical practice in managing health workforce cross-country mobility, while also acknowledging the individual right to freedom of movement (

      World Health Organization. (2021a). WHO global code of practice on the international recruitment of health personnel: report of the who expert advisory group on the relevance and effectiveness of the who global code of practice on the international recruitment of health personnel. World Health Organisation.

      ). The International Council of Nurses (ICN) acknowledged that the international mobility of nurses could benefit brain cirulation, however, it also has potential issues including the lower professional status (
      International Council of Nurses
      Guidelines career moves and migration: critical questions.
      ). ICN further called for governments and employers to implement ethical recruitment practices when they employ nurses from overseas (

      ICN. (2019). International council of nurses calls for ethical recruitment process to address critical shortage of nurses | ICN - International council of nurses.

      ).
      The importance of managing international nurse migration has been signified in the WHO Global Strategic Directions for Nursing and Midwifery 2021–2025 (

      WHO. (2021). Global strategic directions for nursing and midwifery. world health organization.

      ). Migrant nurses are motivated by push factors (unclear career path, work environment etc.) in their countries of origin and pull factors (better career path, better salary etc.) in their destination countries (
      • Bludau H.
      Global healthcare worker migration.
      ). Professional development and economic motives are among major reasons that drive nurses migrating and working overseas. Nurses are among the highest number of health professionals that migrate from Indonesia with most going to Asian and Middle Eastern countries as their destination every year (
      • Efendi F.
      • Oda H.
      • Kurniati A.
      • Hadjo S.S.
      • Nadatien I.
      • Ritonga I.L.
      Determinants of nursing students’ intention to migrate overseas to work and implications for sustainability: the case of Indonesian students.
      ). Despite having qualification as nurses, some Indonesian migrant nurses do not take nursing jobs. They work as care workers such as in Taiwan and Japan (
      • Efendi F.
      • Mackey T.T.K.K.
      • Huang M.-C.M.
      • Chen C.-M.C.
      IJEPA: gray area for health policy and international nurse migration.
      ;
      • Nursalam N.
      • Chen C.-M.C.-M.
      • Efendi F.
      • Has E.M.M.
      • Hidayati L.
      • Hadisuyatmana S.
      • Ferry C.C.
      • Eka E.
      • Mar M.
      The lived experiences of Indonesian nurses who worked as care workers in Taiwan.
      ).
      In accordance with the Economic Partnership Agreement (EPA) entered into between Japan and Indonesia, Indonesia has been sending nurses and care workers to Japan since 2008 (
      • Ogawa R.
      Globalization of care and the context of reception of southeast Asian care workers in Japan (international migration of southeast Asian nurses and care workers to Japan under economic partnership agreements).
      ). In this bilateral labour agreement, two job positions, those of nurse (kangoshi) and care worker (kaigofukushishi) are offered to Indonesian nurses. The two job positions are clearly distinct in Japan: one is for medical care and the other for long-term care. However, in Indonesia, the difference between these two jobs remains unclear as the care worker position has only recently been defined in Indonesia (
      Kemnaker
      Keputusan menteri ketenagakerjaan ri no 28 tahun 2021 tentang penetapan standar kompetensi kerja nasional indonesia kategori aktivitas kesehatan manusia dan aktivitas sosial golongan pokok aktivitas kesehatan manusia bidang caregiver lanjut usia.
      ). Employment of nurses as care workers, or kaigofukushishi, is quite problematic as this position is not a nursing position and has been viewed as a demotion or degradation of their nursing skills by some nurses who have returned to their countries of origin after working in another country (nurse returnees) (
      • Kurniati A.
      • Chen C.-M.
      • Efendi F.
      • Ogawa R.
      A deskilling and challenging journey: the lived experience of Indonesian nurse returnees.
      ). Being kangoshi or kaigofukushishi solely depends on the individual's job choice of freedom of movement. The nurses are given the job choices during the recruitment process based on the job requirement. The job requirement includes being a maximum of 35 years old, holding diploma three or bachelor degree in nursing, Japanese Language Proficiency Test N5 level and others (

      BP2MI. (2021b). Pengumuman pendaftaran penempatan calon kandidat pekerja migran Indonesia (PMI) nurse (Kangoshi) dan calon kandidat PMI careworker (Kaigofukushishi) program G To G Ke Jepang batch XV penempatan tahun 2022.

      ).
      Only nurses with a minimum of 2 years of clinical work experience are eligible to apply for the nursing job positions. Newly graduated nurses who want to work in Japan under this EPA scheme should apply for the care worker position. Applicants for the care worker position are not required to submit their nursing registration certificate from the Indonesian Health Professional Council. The number of nurses taking up the care worker job position is much higher than that of nurse because the demand is higher, and no work experience is required for the job. Between 2008 and 2020, the number of nurses recruited was 691 for the nurse position, and 2,092 for the care worker position (

      MoH. (2020). Kebijakan Pendayagunaan SDM Kesehatan ke Luar Negeri. Kementerian Kesehatan.

      ). The high number of Indonesian nurses taking up employment as care workers in Japan has concerned the Indonesian Health Minister, who is of the opinion that Indonesian nurses should take up a nursing role based on their educational background (

      Warta Perawat. (2019). Mantap! menkes mengapresiasi perawat menjadi caregiver di jepang & inginkan jadi kangosi.

      ).
      Responding to rapid population ageing in Japan, the Japanese government has quickly opened up several migratory channels for care workers under market-oriented schemes since 2017 (
      • Sasaki A.
      • Ogawa R.
      Social Stratifications of migrant care workers in Japan.
      ). For example, recently the working visa status, namely Specified Skilled Worker, was introduced to open jobs in 14 sectors including care worker for nationals from the Philippines, Vietnam, People's Republic of China, Cambodia, Myanmar, Thailand, and Indonesia. (

      BP2MI. (2021a). Informasi Tentang Specified Skilled Worker (SSW).

      ). The movement of people between Indonesia and Japan is unique, not only because of these two countries’ long economic histories, but also because of their adoption and implementation of the WHO Global Code of Practice on the International Recruitment of Health Personnel. Indonesian migrants working in the health care field in Japan have been studied from a migration perspective, bridging the macro-level policies and micro-level interactions (
      • Ford M.
      • Kawashima K.
      Temporary labour migration and care work: the Japanese experience.
      ;
      • Ogawa R.
      When local meets global: the changing face of old-age care in Japan.
      ); mental health perspective and how it relates to various factors namely gender, job satisfaction, fatigue, and other variables (
      • Nugraha S.
      • Ohara-Hirano Y.
      The mental health predictors of Indonesian EPA nurses and certified care worker candidates in Japan.
      ), anthropological study perspective using the concept of intimacy (
      • Świtek B.
      Reluctant intimacies: Japanese eldercare in Indonesian hands.
      ), and from a viewpoint of feminism and human waste studies (

      Saraswati, L. A. (2017). The gender politics of human waste and human-as-waste: Indonesian migrant workers and elderly care in Japan. 24(6), doi:10.1111/gwao.12183.

      ). However, to the best of our knowledge, there is a lack of evidence regarding the experience of Indonesian nurses working and living in Japan's long-term care industry as migrant care workers. Understanding Indonesian migrant care workers’ experiences is essential to inform policymakers in designing recruitment programs for care workers. The current study thus aimed to describe the narrative views and experiences of Indonesian nurses working as care workers in Japan.

      2. Methods

      2.1 Study design

      This study employed a qualitative descriptive approach that allows researchers to investigate and understand nurses’ social behaviour by examining reality from individual experience (
      • Graneheim U.
      • Lundman B.
      Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness.
      ). Data were collected using semi-structured individual interviews. Considering the phenomenon of international nurse migration, the interview questions were developed in accordance with the key principles stipulated by the experience of living in Japan and working in Japan's long-term care system. The researchers requested the participants to first provide their demographic information, and then describe their general understanding of, and opinion about, the experience of working in Japan. FE, an Indonesian researcher in the health workforce area, conducted the face-to-face interviews. The following main topics were asked about: the experiences working as a care worker in Japan; the challenges they have faced, any special needs of Indonesian nurses, and any other thoughts that they would like to share.

      2.2 Sample and setting

      Participants were selected through purposive sampling from a group of Indonesian care workers in Japan who came under the Economic Partnership Agreement (EPA). Purposive sampling is where a researcher relies on the researchers’ knowledge about the population (
      • Polit D.F.
      • Beck C.T.
      Essentials of nursing research: appraising evidence for nursing practice.
      ). The sampling was completed by the Japanese researcher (RO), through Japanese care facilities that employed Indonesian care workers and non-government organisation channels who worked with migrant care workers in Japan. The interview was conducted in native Indonesian language, in a private space within the care facility, without the attendance of the Japanese staff. Since RO, from Chiba University, has engaged extensively in studies concerning care workers, she helped the research team to choose and contact the participants for this study. The inclusion criteria for participation in this study was set as: (i) registered nurse in Indonesia with a diploma or bachelor's degree in nursing; (ii) lived and worked as a care worker in Japan for at least one year; (iii) voluntarily agreed to participate and speak about their life and work experiences as a care worker in Japan. The researchers contacted 18 Indonesian care workers, and all agreed to be interviewed.

      2.3 Data collection

      Data were collected through semi-structured individual interviews with specific questions. The interviews were conducted in Bahasa Indonesia by FE. The duration of each interview was approximately 60 minutes; they were mostly conducted within care facilities, according to the participants’ free time. Other interviews were conducted outside of care facilities which was decided by participants. Data were collected over a period of 2 weeks in four prefectures in Japan. All interviews were digitally recorded and transcribed.

      2.4 Ethical considerations

      The study was approved by the Research Centre and Community Services Universitas Airlangga, Surabaya, Indonesia (Number 1814/UN3.14/LT).

      2.5 Data analysis

      The data were analysed using content analysis, which was used as a tool to enhance the researchers’ understanding of the phenomenon under investigation (Krippendorff, 2018). First, words, sentences, and paragraphs in the transcript that had related elements were identified and extracted (
      • Graneheim U.
      • Lundman B.
      Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness.
      b). Second, the extracted verbatim quotes were translated from Bahasa Indonesia to English individually by the two bilingual Indonesian researchers. Next, the relevant texts were categorised based on words or phrases that best capture their essence. Finally, themes were created to link the underlying meaning of the categories. The process of transcription and coding was aided by the QSR NVivo 10 software. The results were presented in English, shared and discussed collaboratively by all the researchers. To ensure the trustworthiness of the study, credibility was maintained by inviting four participants to review the transcript summary and provide feedback for verification. The four Indonesian care workers confirmed that the findings reflected their experiences working in Japan's long-term care setting.

      3. Findings

      Eighteen Indonesian migrant care workers participated in this study. The participants were aged 24–29 years, with an average age of 26 years. Most participants were female (72%), unmarried (78%), had no children, and lived in Japan. All married participants had Indonesian spouses. Five participants (28%) had a bachelor's degree in nursing, and 44% of them had working experience as nurses in Indonesia. Most participants had been living in Japan for less than 3 years (61%), with monthly salaries ranging from 80,000–250,000 JPY (710–2220 USD). It must be noted that the salary estimate is mixed between the gross and take-home pay. More than 80% of the participants had not taken the national examination for certified care workers (Table 1). Care workers are only allowed to take this exam to become a certified care worker after having at least 3 years of working experience in Japan.
      Table 1Characteristics of study participants
      CharacteristicMigrant care workers (n = 18)
      AgeMean (min, max)26 (24, 29)
      GenderFemale, n (%)13 (72%)
      Marital statusMarried, n (%)4 (22%)
      Nationality of spouseIndonesian, n (%)4 (100%)
      Children in householdOne or more0 (0%)
      ReligionMuslim13 (72%)
      Place of originWest Java7 (39%)
      South Sulawesi2 (11%)
      Central Java2 (11%)
      Other provinces7 (39%)
      Current regionKyushu3 (17%)
      Chugoku13 (72%)
      Kanto2 (11%)
      Highest educationDiploma 3 in nursing13 (72%)
      Working experience prior to migrationYes8 (44%)
      Years of residence in Japan<3 years11 (61%)
      Salary in Japan(Min, max)80,000–250,000 JPY (710–2220 USD)
      Kaigofukushishi examFailed-
      Has not taken the exam yet16 (89%)
      Pass2 (11%)

      3.1 Main themes for migrant workers

      The data analysis of the interviews yielded 11 conceptual categories and three themes, as shown in Table 2. The essence of the foreign care workers’ experiences was described using the following three themes: (i) broken dreams; (ii) surviving the struggle; and (iii) supportive environment.
      Table 2Themes and categories of migrant care workers
      ThemesConceptual categories
      Broken dreamsMisunderstanding the job
      Loss of nursing skills
      Career uncertainty
      Making peace with reality
      Surviving the struggleBeing settled in rural areas
      Work pressure
      Communication barrier
      Loneliness
      Supportive environmentCare facilities support
      Peer support
      Emotional bonding

      4. Theme 1: Broken dreams

      From the participants' statements, we established “Broken Dreams,” as most participants shared that some of their expectations had not been entirely met in the face of reality. Despite finding that they may have “misunderstood the job” and experienced a “loss of nursing skills,” they decided to “make peace with reality” while living in Japan.

      4.1 Misunderstanding the job

      The first category reflected the participants’ initial confusion about their job positions in which they had a different responsibility. The participants misunderstood the job of a care worker, based on their prior knowledge and experience either as a nursing student or a registered nurse in Indonesia, and through their own perception of the information provided by recruiters, friends, or seniors.
      “They said that the job is of a care worker. I thought it would be like working as an in-home nurse.” (Case 1)
      “I thought that a care worker is the same as a geriatric nurse working in an elderly care facility. After working here, I realised the difference.” (Case 12)
      “My friends said that the job of a care worker is caring for the elderly. Well, in Indonesia, providing care for the elderly is a nursing job. When I was a nursing student, I observed that a care worker in facilities for the elderly is actually a nurse with more simple tasks than hospital nurses. So, in my understanding, a care worker is a nurse who provides care for the elderly in a long-term care facility. I was shocked and realised the difference after finding out that the care facility I work in employs care workers and nurses.” (Case 13)
      “As foreigners, we need to understand how we work here. Being a registered nurse, I was allowed to administer injections in Indonesia. But that is not my job here; instead, I put diapers on patients. In Indonesia, nurses do not change diapers or help the patients in bathing. The patient's family does.” (Case 10)
      While most participants reported being confused and shocked, three participants (Case 4, Case 5, and Case 11) highlighted being prepared for the care worker job and less shocked. Prior to joining the EPA, these three participants attended a care worker training program in a private institution that not only allowed them to learn the Japanese language, but also provided sufficient information about care work in Japan and undertaking care practice.

      4.2 Loss of nursing skills

      After some time of working in Japan as care workers, all participants recognised the degradation of their nursing skills. Participants expressed that their daily activities, dealing with fulfilling the basic needs of the patients, did not require them to perform nursing tasks. Therefore, the skills that they had gained from nursing schools were compromised.
      “Of course, my nursing skills are declining. I can only perform basic human need interventions. If I go back to Indonesia and want to work in a hospital, I would need a short course in emergency nursing to refresh my skills.” (Case 6)
      “My routine job starts at 7 am by waking up patients, changing their diapers, and giving toilet assistance, (continue describing daily routine). As a nurse, I actually want to perform nursing jobs, not like this current work. Skills I learnt from my nursing school are gone, I have forgotten them.” (Case 3)
      “What I had learnt from the nursing school for four years is not used. So, if you ask me to do suction, injection, or to administer infusion, honestly, I can't do that, I have forgotten.” (Case 12)
      “If I return to Indonesia and work in a hospital, I might be incapable, because I have forgotten my nursing skills. I never administer medicine to patients or give injections here.” (Case 8)

      4.3 Career uncertainty

      The third category reflected how Indonesian migrant care workers foresaw their career prospect as care worker or nurse. Some participants expressed their concern regarding their current career and future path.
      “The other day we were complaining among ourselves about the future when we return to Indonesia. Is it possible to work as a nurse if we never use our skills here for some years?” (Case 18)
      “I am used to thinking that after I return home, the chance to implement my work experience in Indonesia might be difficult. So maybe I will only utilise my Japanese proficiency.” (Case 13)
      “I want to work as a nurse, not a care worker. I am not sure what I will do when I return to Indonesia. Maybe I should go back to school and start over from the beginning.” (Case 3)

      4.4 Making peace with reality

      Participants explained various reasons that motivated them to apply as a care worker in Japan. Although an economic motive is among the popular reasons for migration, 14 participants said that gaining work experience and learning elderly care were their primary reasons to migrate and work in Japan. When their expectations to develop nursing skills in elderly care were not entirely met, they tried to make peace with and accept reality. According to them, at the very least, other motives, such as economic, were being fulfilled.
      “A nurse becoming a care worker; it is a bit sad. But this way or that, it may have paid off from the economic aspect. My salary is higher compared to the salary of nurses in Indonesia. Plus, I am fluent in speaking and writing Japanese.” (Case 4)
      “At the beginning, I felt down, thinking why a nurse works like this, what was my purpose coming here? After some time, I got used to this and the feeling ebbed away. This situation won't change if I keep complaining. I looked around and realised. Oh, it is not only me (who experiences this situation), and finally I could accept it.” (Case 5)
      “I just wanted to gain experience, because a developed country has more advanced practice than my own country. Sure, it is for money, but experience too. The salary is good, but the job is very heavy. I don't think I want to stay and work like this in the long-term.” (Case 12)
      “I didn't want to bother my parents and wanted to earn money myself. Although I feel distressed sometimes, I am more resilient now. God sent me here for a purpose. (I am) Always so grateful for that. I remind myself of my initial purpose every time I feel down to get my motivation back.” (Case 15)

      5. Theme 2: Surviving the struggle

      The participants talked about struggling with their life and work in Japan. They expressed experiencing challenges due to being deployed in rural facilities. Living in rural areas limited the participants’ access to religious infrastructure, such as mosques and churches. They also described challenges from the pressure of doing heavy and routine work, communication using the Japanese language and the local dialect, and feelings of loneliness from being far away from family.

      5.1 Being settled in rural areas

      In this study, some of the participants worked at care facilities located in rural areas. Living in rural Japan was considered disadvantageous by some participants, especially pertaining access to religious infrastructure and travelling.
      “The disadvantage is that I am unable to offer my Friday prayer; there is no mosque here. Just once a year can I offer my Friday prayer. Maybe, if my Indonesian co-worker and I coincidentally have our break time together, then we can offer our Friday prayers together. I wish I could perform my usual prayers as I did previously.” (Case 5)
      “The disadvantage working here is probably the location, which is a rural area. For me, going to church is a bit difficult. For those who work in Tokyo and Osaka, churches can be found nearby. Here, the nearest church is located in (named a city), quite far from my place.” (Case 12)
      “Living alone is hard. Moreover, my care facility is located in a rural area, and there is no easy access to go anywhere. If I am bored, sometimes I just go out with friends.” (Case 1).

      5.2 Work pressure

      Participants described how they had to adjust to the perfection-oriented work culture in Japan. They highlighted the high cleanliness standard, heavy workload, and the professional performance that is demanded from a care worker.
      “In terms of cleanliness, everything must be extremely clean. Whatever has been wiped must be wiped again. One person should always be on standby at the nurse station to enable a fast response if something happens.” (Case 2)
      “Working in Japan, you must have a hard-work mentality. You cannot work while doing something else like in Indonesia, like writing or engaging in chit-chat. There, if your work is done then you can sit down and relax. It doesn't work like that here (in Japan). You must keep working during the working hours. Your work is done? Don't just stay still, get other things to do like cleaning the toilet. Chilling at work makes you feel uncomfortable, because it is not what people do here. Just work.” (Case 17)
      “Service is number one. In Japan, patient is the top priority. Back in my home country, a nurse may be resentful to patients when feeling unhappy. Here, no matter how close you are personally with your supervisor outside of work, you must show professional relationship when you work and prepare reports accordingly.” (Case 10)
      “I tried to take my work easy, otherwise I would feel stressed out. The workload is high because a lot of work has to be done by a few kaigofukushishi. It is like constantly chasing time to get everything done. I only manage to sit down during the break time.” (Case 12)

      5.3 Communication barrier

      Despite receiving Japanese language training for approximately a year, participants expressed difficulties in communicating due to limited understanding of the language and the use of local dialect. The struggle in communication was especially experienced during the initial period as care workers.
      “In the first year, I have a communication problem. Before working here, I did learn basic Japanese for a total of one year training. But patients here speak their local dialect, hogen. I did not understand, totally different. After some time taking care of them, I learnt their habits and needs, and could provide helps. Not because I understand their dialect.” (Case 2)
      “In Indonesia, the Japanese teachers spoke slowly. During the six-month training in Japan, the teachers spoke fast. Then the real problem emerged when I started my job. People do not speak the same Japanese I learnt from the training program, but their local dialect. I completely had no idea. Every time I have communication problems, I reach out other Japanese employees. Sometimes they had no idea either.” (Case 3)
      “I used to feel distressed when I started to work. I lack communication skills. I have poor Japanese and am unable to express my words.” (Case 11)

      5.4 Loneliness

      As they were living alone in a foreign country and away from their families, some participants expressed feeling lonely and sad. One participant felt that she had reached an appropriate age for marrying and consequently did not want to be alone and single.
      “I feel so alone, sometimes I cry. After saying goodbye to my friends in the training centre and coming to this quiet place, there was something missing. Eid Mubarak is especially the saddest day. I realised that my family is very far, and I wanted to go home.” (Case 4)
      “I should not be all alone. At my age, I should have gotten married. I do not want to stay single like busy Japanese people. I want to get married with someone who understands me and knows my religion.” (Case 1)
      “When I tend my patients, occasionally I would remember my family. Then I feel sad and have a desire to return home.” (Case 8)
      “The sad part of working overseas is living far from family. During day offs or holidays, sometimes I feel upset for not knowing what to do.” (Case 11)

      6. Theme 3: Supportive environment

      A positive environment is important for participants to help them succeed in their professional and personal life. Under the EPA scheme, the care facility has a responsibility towards international care workers to facilitate their success in the national exam for certified care workers. Most participants stated that support from the care facility was helpful in preparing them to take the national exam. Support from the care facility can also be considered in the form of understanding and accommodating religious practices. Additionally, it helped participants feel welcome and supported by their peers. The emotional bond that iswas formed between care workers and clients at the care facility also created a supportive environment for the Indonesian nurses and encourages them to continue in their jobs.

      6.1 Care facilities support

      Most participants said that apart from coming to Japan for work, the care facilities provided them with an opportunity to study by flexibility in study and work, mentorship, and participation in training programs. Some participants expressed gratitude towards their care facility as it allowed them to perform daily prayer during breaks and allowed female care workers to wear the hijab.
      “For me, the care facility provides excellent support like Japanese language training for 2 hours in a week. The facility also supports me in other things. If you have any problem, be open to your employer. For example, if you are in a conflict with a senior and it disturbs your mind, go and tell your supervisor.” (Case 1)
      “Each time JICWELS (Japan International Corporation of Welfare Services) conducts training in other cities, my care facility allows me to attend. Through this opportunity I could study, meet other friends and pass the exam.” (Case 2)
      “I am happy working here because my care facility allows me to study during my shift. I can spend two of eight working hours for studying every day. I also can attend a language training for five to six times in a month to prepare for the national exam. A senior was assigned to help me studying.” (Case 4)
      “The care facility is so considerate. After about one month working, I had an emergency call and should go back to Indonesia. The management granted me fourteen days leave, despite very short notice.” (Case 7)
      “In terms of belief, friends must be told that I don't eat pork. The care facility must be told that Muslims pray five times a day and fast during Ramadhan. Thank God, my care facility is supportive. I am given a chance to pray during the break time, no problem. During fasting period, my task is also lightened, such as no bathing duty.” (Case 1)

      6.2 Peer support

      Participants spoke positively about their co-workers who helped them with their studies and provided support to manage their physical and mental health.
      “My Japanese colleagues are caring people. They understand we are far from home. If I am absent from work and taking a sick day, they would call and ask whether I am okay, and offer some help.” (Case 9)
      “People here are nice. The environment is supportive. I think, it is solely our mental condition that need to be properly managed for survival.” (Case 16)
      “My senior helps me studying. Sometimes she takes me out for dinner and discuss my study progress.” (Case 18)
      “My colleagues like the way I wear hijab, I am the first who does it. They would ask why you cover your hair, and I just said because my hair is short. I also have a senior here, so it makes a lot easier.” (Case 10)

      6.3 Emotional bonding

      Participants said that after working for a period of time and adjusting to their co-workers, they managed to build emotional bonds with their clients.
      “Now I just enjoy it. What motivates me to keep working is the people I work with. I am happy with co-workers and friends. Elderly patients are also amusing.” (Case 11)
      “I used to have a patient with speech impairment. It took months to gain his trust and finally we had a very good relationship. We made jokes together and understood each other. When I told him that I am going to move to another facility, he said, “why don't you stay? If you move out, I am going to be lonely.” At that point, I thought that this is the right example of building a good relationship between a patient and a care facility employee. Quality of care must be taken very seriously.” (Case 9)

      7. Discussion

      For Indonesian care workers in this study, misunderstanding the job, loss of nursing skills, career uncertainty, and making peace with reality were all part of the journey of broken dreams. The findings revealed how this group of nurses constructed their feelings and emotions as they struggled to achieve their professional goals in Japan. At the outset, all these migrant care workers started working in the care facilities after having Japanese language training. Indonesian nurses responded differently to the expectations of employment in a technologically advanced and sophisticated health system; some felt confusion and dissatisfaction with their identities and skills while others were able to cope with the new situation. Based on the Health's law 36 formulated in 2014, Indonesian government recognises some health professions including nurses with a minimum education level of a 3-year diploma (

      MoH. (2012). Regulation of the health minister of the republic of Indonesia number 27 year 2012 concerning utilization of nurses to foreign countries.

      ). However, this law does not recognise care workers as health professionals as Indonesia's health system differs from that of Japan's. Long-term care in Indonesia is based on voluntary activities, which can be conducted by professional or informal workforce such as family, neighbour, and cadre (

      WHO, & JDC-Brookdale Institute. (2002). Long-term care in developing countries ten case-studies. world health organization.

      ). The lack of familiarity of migrant care workers with the workforce in long-term care should be considered and clear explanations regarding long-term care positions should be provided during pre-departure training. There is also a possibility that they perceive the received information differently. The health system and infrastructure in Indonesia are different from the ones in Japan. Indonesia established nursing as a profession during the colonial period (
      • Sciortino R.
      Perawat puskesmas di antara pengobatan & perawatan [puskesmas nurses between curing and caring].
      ). Registered nurses are graduates of a nursing program that is authorised by the licensing body and the practice is determined by legislation (
      • Indonesia G.
      Undang-undang republik Indonesia nomor 38 tahun 2014 tentang keperawatan [law of the republic of indonesia number 38 year 2014 on nursing Act].
      ). On the contrary, “care worker” is a newly created occupation developed in response to the growing care needs in developed countries. There is no universally agreed upon definition of care workers and care work is experienced differently depending on the context (
      • Ogawa R.
      • Chan R.K.H.
      • Oishi A.S.
      • Wang L.-R.
      Gender, care and migration in East Asia.
      ). Japan established the certified care worker in 1987 based on the long-term care model, which was developed separately from the medical model. A previous online survey also reported that most Indonesian nursing students had insufficient knowledge of EPA and poor understanding regarding this care worker position (
      • Efendi F.
      • Oda H.
      • Kurniati A.
      • Hadjo S.S.
      • Nadatien I.
      • Ritonga I.L.
      Determinants of nursing students’ intention to migrate overseas to work and implications for sustainability: the case of Indonesian students.
      ). The differences between these two positions should be highlighted, not only to candidates, but also to the Indonesian nursing society.
      Nursing practice, which is different between Japan and Indonesia, makes the work and lives of migrant care workers difficult and overwhelming due to their lack of familiarity with the practice. Japanese caregiving practice expects every care worker to constantly assess and follow up with patients’ basic human needs. These Indonesian care workers are exposed to a very different scope of care practice than in their homelands. In Indonesian medical fields, basic human needs are the responsibility of the patient's family. Even if these nurses perform activities related to the basic human needs, it is considerably small and they tend to conduct other independent nursing or collaborative interventions (
      • Efendi F.
      • Chen C.-M.
      • Nursalam N.
      • Indarwati R.
      • Ulfiana E.
      Lived experience of Indonesian nurses in Japan: a phenomenological study.
      ). Therefore, it is not surprising that migrant care workers were found to be stressed and have lost their skills due to the limited familiarity of care work in Japan with their own practice at home. Since Japan is well-known for its advanced technology, Indonesian nurses who migrated as care workers had an idea and assumption that they would be practising nursing using modern technology. However, the exposure to advanced practice did not satisfy the expectation of migrant care workers due to the lack of medical care authority in the caregiving position. Being unable to deliver proper nursing care could make nurses feel frustrated and stressful (
      • Digby R.
      • Lee S.
      • Williams A.
      The experience of people with dementia and nurses in hospital: an integrative review.
      ). The policy makers and recruitment agencies from both countries should provide a transparent job information and eliminate the disinformation regarding the job differences between nursing and caregiving.
      Some migrant care workers had prepared and adjusted to this new situation. These migrant care workers had trained in Yayasan Bina Mandiri ASEAN (BIMA), which is under the management of the Japan-Indonesia Association for Economy Cooperation (
      • BIMA Y.
      Yayasan bina mandiri asean.
      ). This foundation particularly supports the capacity of nurse and care worker candidates under the EPA (
      • BIMA Y.
      Yayasan bina mandiri asean.
      ). Length of the training is 10 months comprising of 8 hours of study in a week during which time the participants are provided with Japanese language and culture lessons. By joining this program, participants had to live in a boarding house and learn the Japanese way of life (
      • BIMA Y.
      Yayasan bina mandiri asean.
      ). Participants who joined this program learnt about the basic differences in responsibilities between a nurse and a care worker and practised how to perform their new roles. Therefore, they were well prepared for their jobs in Japan. Improving cooperation between public and private initiatives to work on the pre-departure training program will likely improve the desired outcome.
      The lived experiences of Indonesian migrant care workers in this study reveal that working in Japanese long-term care was not easy. Participants highlighted remoteness, workload, communication, and loneliness as part of their daily struggles. Formal long-term care settings in Japan are recognised with heavy workloads due to a large disparity in the number of care workers and patients (
      • Asis E.
      • Carandang R.R.
      The plight of migrant care workers in Japan: a qualitative study of their stressors on caregiving.
      ). Accordingly, communicating with the patient and people around the workplace was identified as one of the stressors (
      • Asis E.
      • Carandang R.R.
      The plight of migrant care workers in Japan: a qualitative study of their stressors on caregiving.
      ), and barriers among health care worker candidates in Japan (
      • Kaneko K.
      The Inflow of Southeast Asian Healthcare Worker Candidates in Japan: Japanese Reactions to the Possibility of Cultural and Ethnic Diversity.
      ). Language proficiency is a crucial component in communication. Language challenges were also found in a study by
      • Alam B.
      • Wulansari S.A.
      To stay or not to stay: diverse and conflicting interactions between Indonesian nurses’ socio-cultural backgrounds and their work environment International migration of southeast Asian nurses and care workers to Japan under economic partnership agreemen.
      which reflects inadequacy of language competency in the workplace. The mental health status of certified care worker candidates in Japan has been correlated with job satisfaction, struggling with current working status, and sociocultural adaptation (
      • Nugraha S.
      • Ohara-Hirano Y.
      The mental health predictors of Indonesian EPA nurses and certified care worker candidates in Japan.
      ). Most Indonesian migrant care workers shared feeling lonely and isolated in Japan. They attempted to mitigate these feelings by annually visiting and regularly calling their loved ones in Indonesia. Using communication applications in smartphones enabled them to maintain their familial relationships. Visiting each other, either in person or virtually by phone, depicted the journey to survive in Japan's long-term care setting. Perhaps providing migrant care workers opportunities to build a professional association would help them feeling more connected.
      The Indonesian care workers in this study received full support from various parties, care facilities, friends, co-workers, and elderly at the workplace. Support from the care facilities such as housing support, managing administrative procedures, enhancing communication and mental health, and adapting to a new culture, enabled the care workers to work and live in a supportive environment (
      MHLW
      Guidebook for care service providers on employment of foreign care workers.
      ;
      • Tsubota K.
      • Ogawa R.
      • Ohno S.
      A study on the cost and willingness to recruit EPA foreign nurses and care workers in Japan: from the angle of hospitals and care facilities.
      ) and revealed the cost burden associated with accepting a foreign care worker from the angle of care facilities. Therefore, the cost of migrant care workers is borne by both the Japanese government and care facilities (
      • Ogawa R.
      Conceptualizing transnational migration of care workers: between ‘skilled'and ‘unskilled.’ ASIEN.
      ). Peer support from Japanese co-workers and people around migrant care workers should help ease the transition of becoming a certified care worker candidate in Japan.

      8. Conclusions

      This study's findings provide critical insights on the lived experiences of Indonesian nurses working in Japan as care workers. Results of this study suggest that misunderstanding of the care worker position had cost the Indonesian nurses losing their nursing skills and lowered their expectations in career and nursing practice advancement. The two positions are differently constructed; they only realised later that they had lost nursing skills after working as care workers and had to accept it. Neglected nursing skill was obviously seen by participants when working as care workers, therefore, they should be informed prior in making the decision. Despite having challenges as foreign care workers, Indonesian nurses reported having some coping strategies and received supports from their workplace to survive.
      This study has a few limitations to be considered. First, although coming from the same cultural background, the interviewers were not known by interviewees. The participants might have been cautious or hesitant to speak openly in such situations. Second, the majority of participants were from Chugoku region, thus ignoring diversities among regions in Japan.
      This research extends our knowledge of a career move intertwined with migration among Indonesian nurses seeking to become care workers in Japan's long-term care industry. A clear career path needs to be charted for these care workers and their employment terms need to be flexible in order to facilitate their employment and provide them with opportunities for professional development. The career movement of nurses as a foreign care worker into different levels or positions requires further scrutiny.

      Authorship contribution statement

      All authors contributed to the data analysis and drafting or revising the article. All authors have agreed on the journal of submission, given final approval of the version to be published, and agreed to be accountable for all aspects of the work. Ferry Efendi: Conceptualisation; Formal analysis; Funding acquisition; Investigation; Methodology; Resources; Software; Validation; Writing - original draft; Writing - review & editing. Ching Min Chen: Data curation; Formal analysis; Methodology; Resources; Software; Supervision; Validation; Writing - review & editing. Anna Kurniati: Conceptualisation; Formal analysis; Investigation; Methodology; Resources; Software; Validation; Writing - original draft; Writing - review & editing. Yuni Sufyanti Arief: Conceptualisation; Formal analysis; Investigation; Methodology; Resources; Software; Validation; Writing - original draft; Writing - review & editing. Reiko Ogawa: Data curation; Formal analysis; Methodology; Resources; Software; Supervision; Validation; Writing - review & editing.

      Funding

      This study was funded by Ministry of Education, Culture, Research and Technology of Indonesia through “World Class Professor Program 2021″ Scheme (Grant number 2817/E4.1/KK.04.05/2021 ).

      Ethical statement

      The study was approved by the Research Center and Community Services (LPPM) Universitas Airlangga, Surabaya, Indonesia (Number 1814/UN3.14/LT).

      Conflict of interest

      The authors report no conflicts of interest in this work.

      Acknowledgements

      This study received support from the World Class Professor program (Fine tuning manuscript program) which was funded by Ministry of Education, Culture, Research and Technology of Indonesia.

      Appendix. Supplementary materials

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