ORIGINAL ARTICLE
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COVID-19-Related Workplace Bullying and Customer
Harassment Among Healthcare Workers Over the Time of the
COVID-19 Outbreak
A Eight-Month Panel Study of Full-Time Employees in Japan
Mako Iida, MSN, Natsu Sasaki, MD, Kotaro Imamura, PhD, Reiko Kuroda, MD,
Kanami Tsuno, PhD, and Norito Kawakami, MD
Objective: To investigate the prevalences of COVID-19-related workplace bullying and harassment (WBH) and customer harassment
among healthcare workers (HCWs) compared to non-HCWs during
COVID-19 outbreaks. Methods: A baseline (March 2020) and followup surveys (May, August, and November 2020) were conducted of fulltime employees, with an online questionnaire that included items on
COVID-19-related WBH and customer harassment. The prevalences were
compared between HCWs and non-HCWs using generalized linear models
with repeated measures. Results: A total of 800 (56%) respondents
completed all the surveys. Prevalences of WBH and customer harassment
were 5% to 10% and 10% to 13%, respectively, among HCWs during
the follow-up. HCWs had a significantly higher prevalence of WBH
in May (Adjusted OR ¼ 2.3) and customer harassment in November
(Adjusted OR ¼ 2.7), compared to non- HCWs. Conclusions: HCWs
remained at high risk of COVID-19-related WBH and customer harassment during the pandemic.
Keywords: COVID-19, healthcare workers, infection, workplace bullying,
workplace harassment
W
orkplace bullying and harassment (WBH) are negative
and hostile behaviors in the workplace setting. WBH is
quite common, with the global prevalence estimated as 14.6%1
WBH has been associated with mental health problems,
such as depression, anxiety, and stress-related psychological
complaints,2 and physical health problems, such as sleep problems3
and cardiovascular disease.4,5 WBH can occur not only among
From the Department of Psychiatric Nursing, Graduate School of Medicine, The
University of Tokyo, Tokyo, Japan (Ms Iida); Department of Mental Health,
Graduate School of Medicine, The University of Tokyo, Tokyo, Japan (Dr
Sasaki, Dr imamura, and Dr Kawakami); Division for Environment, Health
and Safety, The University of Tokyo, Tokyo, Japan (Dr Kuroda); School of
Health innovation, Kanagawa University of Human Services, Kanagawa,
Japan (Dr Tsuno).
This work was supported by internal funds of the Department of Mental Health,
Graduate School of Medicine, The University of Tokyo.
This work was partly supported by JSPS KAKENHI Grant Number 18H04072
(PI: Norito Kawakami).
NK reports grants from Fujitsu Ltd, and TAK Ltd, personal fees from Occupational Health Foundation, Japan Dental Association, Sekisui Chemicals,
Junpukai Health Care Center, Osaka Chamber of Commerce and Industry,
outside the submitted work.
Any ethical considerations: This study was approved by the research ethics
committee of the Graduate School of Medicine and the Faculty of Medicine,
The University of Tokyo (No. 10856-(2)(3)(4)(5)).
RK reports grants from SATORI electric CO., LTD and ‘‘NXPSemiconductors’’
and ‘‘personal fee from RIKEN, Toyotsu Chemiplas, Mitsubishi Materials
Corporation outside the submitted work.
Address correspondence to: Norito Kawakami, MD, Department of Mental
Health, Graduate School of Medicine, The University of Tokyo, Tokyo,
Japan, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan (nkawaka- mi@m.
u-tokyo.ac.jp).
Copyright © 2022 American College of Occupational and Environmental
Medicine
DOI: 10.1097/JOM.0000000000002511
e300
members of a workplace but also between a worker and his/her
customers or clients,6,7 which has been called ‘‘customer harassment.’’6
Workplace bullying and harrasment among the healthcare
workers (HCWs) may increase in the COVID-19 outbreak.8 For
instance, an anecdotal report described several typical targets of
WBH during the outbreak9: a HCW who received a COVID-19
Reserve Transcription Polymerase Chain Reaction (RT-PCR) test,
even although the result was negative, or a HCW who were in direct
contact with the COVID-19 patients. A previous study showed that
18.1% of HCWs reported that HCWs and their family members had
been harassed because of COVID-19, while only 7.1% of nonHCWs reported being harrased, across geographic regions including
Africa, Asia, Europe, Northern America, Latin America, the Caribbean, and Oceania.10 HCWs have been reported as being exposed to
WBH, as well as bullying from customers (ie, patients and
their families), more frequently than non-HCWs even before the
COVID- 19 pandemic.11 Thus, the COVID-19 pandemic has caused
a greater psychological burden on HCWs through COVID-19related WBH.8
However, previous studies for HCWs did not distinguish
between discrimination from the community and WBH in the
workplace, nor between WBH from supervisors or colleagues
and harassment from customers (ie, patients and their families).10
The distinction of the settings (community or workplace)
and types of perpetrators (from someone within the workplaces,
such as supervisors/colleagues, or someone from outside of
the organization, such as customers or patients) is important
because the legal and ethical frameworks for developing countermeasures to prevent WBH are different depending on these
characteristics of WBH.12 We previously reported that the prevalence of COVID-19-related WBH among HCWs was 6.3% and
9.9%, respectively, as measured early (March 2020) and in the
middle (May 2020) of the first outbreak of COVID-19 in Japan,
and that the prevalence for HCWs was greater than for nonHCWs.13 Another previous study reported the prevalence of
COVID-19-related customer harassment experienced by HCWs
was 10.8%.14 Furthermore, as the situation of COVID-19 infection changes, it is essential to monitor the time trend of
the prevalence of COVID-19-related WBH among HCWs.
Previous studies, including ours, addressed COVID-19-related
WBH among HCWs only in an early phase of the COVID-19
outbreak (before May 2020).10,13 Further research is needed
to investigate changing patterns of COVID-19-related WBH
and customer harassment experienced by HCWs during
later outbreaks.
The purpose of the present study was to investigate changes
in prevalence of COVID-19-related WBH and customer harassment
among HCWs, compared to non-HCWs, over the course of the
second and third COVID-19 outbreaks in Japan (March to November 2020), expanding our previous report in the early phase of the
outbreak.13
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JOEM Volume 64, Number 5, May 2022
METHODS
Study Design and Participants
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This was a prospective cohort study using the data from an online
survey. The data were retrieved from the Employee Cohort Study in the
Covid-19 pandemic in Japan (E-COCO-J). A total of 4120 full-time
workers living all over Japan were recruited for the survey from more
than 500,000 registered members of an Internet survey company in
February 2019. Participant inclusion criteria were as follows: (a) reside
in Japan, (b) be between the ages of 20 and 59, and (c) be currently
employed. There were no exclusion criteria. Members who met the
inclusion criteria received an e-mail invitation from the company and
completed the questionnaire. The questionnaire was closed once the
target sample (around 4000 participants) was obtained. Participants
were asked to answer whether or not they were HCWs. A self-report
questionnaire survey was conducted on March 2020 (T1), May 2020
(T2), August 2020 (T3), and November 2020 (T4), from early in the first
wave to early in the third wave of the COVID-19 outbreak. We analyzed
the data from participants currently employed and who responded to all
four surveys. The Research Ethics Committee of the Graduate School of
Medicine/Faculty of Medicine at the University of Tokyo approved this
study [No. 10856- (2)(3)(4)(5)].
COVID-19-Related Workplace Bullying and Customer Harassment
logistic regression or a generalized linear model with repeated
measures, adjusting for gender, age, marital status, and education.
Time (T1 to T4) occupation (HCWs vs non-HCWs) interaction
terms were also calculated. Statistical significance was defined as a
two-sided P < 0.05. Statistical analyses were conducted by SPSS
27.0 Japanese version (IBM Corp., Armonk, NY) for Windows.
RESULTS
Figure 1 shows the participant flowchart. A total of 4120
fulltime workers were recruited for the survey, and 1448 completed
the baseline questionnaire (response rate ¼ 35.1%). After excluding
27 unemployed respondents, we followed the remaining 1421
respondents. A total of 1032 participants (response rate ¼ 72.6%)
completed the T2 survey, excluding 36 unemployed respondents.
Variables
A scale of COVID-19-related WBH was developed according
to other bullying scales,15 through a discussion among three occupational physicians (NS, RK, and NK) who engaged in responding to
COVID-19 at the workplace, and a researcher of workplace bullying
(KT).13 Five items assessed WBH related to COVID-19 (eg, being the
target of sarcastic comments related to COVID-19). All items were
rated ‘‘Yes’’ or ‘‘No.’’ Any WBH related to COVID-19 was defined as
experiencing any of these items. Both the T1, T2, T3, and T4 surveys
were used to collect the data on the variables. Reliability and validity
have not been confirmed.
A scale of COVID-19-related customer harassment was also
developed through a discussion among three occupational physicians and a professional in workplace bullying.14 Four items
assessed customer harassment related to COVID-19 (eg, being
the target of sarcastic comments related to COVID-19 from users
or customers). All items were rated ‘‘Yes’’ or ‘‘No,’’ and any
customer harassment related to COVID-19 was defined if participants endorsed any of these items. Only T2, T3, and T4 surveys
collected the data on customer harassment variables. Reliability and
validity have not been confirmed.
Information about sociodemographic and occupational characteristics included gender, age, marital status, having a child,
educational status, and occupation (whether or not they were
HCWs). Sex was classified as male or female. Age was categorized
as 20 to 29 years, 30 to 39 years, 40 to 49 years, and over 50 years.
Marital status was classified into ‘‘not married’’ or‘‘married.’’
Having achild wasclassifiedas ‘‘none’’ or ‘‘one or more.’’ Educational status was classified into ‘‘high school, vocational school, or
junior college diploma or less’’ or ‘‘bachelor’s degree or higher.’’
Occupation was categorized into HCWs and non- HCWs. Sex, age,
marital status, having a child were retrieved from T1, and education
and occupation were collected at T2.
Analysis
First, descriptive statistics were compared between HCWs
and non-HCWs by chi-squared test. The prevalence of COVID-19related WBH at T1 to T4 and customer harassment at T2 to T4 were
tabulated separately for HCWs and non-HCWs. McNemar’s test
was used to compare the difference from the baseline (T1 for WBH;
T2 for customer harassment). The odds ratio of COVID-19-related
WBH and customer harassment among HCWs compared to nonHCWs at each survey and overall were calculated by multiple
FIGURE 1. Flowchart of participants.
© 2022 American College of Occupational and Environmental Medicine
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JOEM Volume 64, Number 5, May 2022
Iida et al
TABLE 1. Sociodemographic and Occupational Characteristics at T1 of Full-time Employees who Completed Surveys at T1
(March 2020), T2 (May 2020), T3 (August 2020), and T4 (November 2020) During the COVID-19 Outbreak in Japan
(N ¼ 800)
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HCWs (N ¼ 80) n (%)
Non-HCWs (N ¼ 720) n (%)
P for difference
0.007
Sex
Male
Female
Age, years old
20–29
30–39
40–49
50þ
Marital status
Unmarried
Married
Having at least one child
None
One or more
Educationa
Junior college diploma or less
Bachelor’s degree or higher
31 (38.8)
49 (61.3)
393 (54.6)
327 (45.4)
12 (15.0)
25 (31.3)
22 (27.5)
21 (26.3)
115 (16.0)
191 (26.5)
204 (28.3)
210 (29.2)
40 (50.0)
40 (50.0)
361 (50.1)
359 (49.9)
43 (53.8)
37 (46.3)
420 (58.3)
300 (41.7)
48 (60.0)
32 (40.0)
323 (44.9)
397 (55.1)
0.833
0.981
0.431
0.010
SD, standard deviation.
a
The variable was measured at T2.
P < 0.05 as a result of chi-squared test.
Among the remaining 996 participants, 938 respondents completed
the T3 survey (response rate ¼ 94.2%). After excluding 63 unemployed respondents, we followed the remaining 875 workers. A total
of 869 respondents completed the T4 survey (response
rate ¼ 99.3%), excluding 69 respondents who did not work at T4.
The remaining 800 workers completed all the surveys and were
included in the further analyses.
Table 1 shows the sociodemographic and occupational characteristics of the respondents. Most were non-HCWs (90.0%). As a
result of the Chi-squared test, HCWs were more likely to be women
(P ¼ 0.007) and had lower education (P ¼ 0.010) than non-HCWs.
Table 2 shows the prevalence of COVID-19-related WBH in
T1 to T4, and customer harassment in T2 to T4 separately for HCWs
and non-HCWs. The proportions of respondents who experienced
any COVID-19-related WBH among HCWs vs non-HCWs were as
follows: 5.0% vs 2.2% at T1,10.0% vs 5.1% at T2,10.0% vs 6.8% at
T3, and 7.5% vs 5.6% at T4. The proportions of respondents who
experienced any COVID-19-related customer harassment among
HCWs vs non-HCWs were as follows: 10.0% vs 6.4% at T2, 12.5%
vs 6.9% at T3, and 12.5% vs 5.0% at T4. As a result of McNemar’s
test, the prevalence of COVID-19-related WBH of T2 to T4 among
non-HCWs was significantly higher than the prevalence of baseline
(T1) (P ¼ 0.004, P < 0.001, P ¼ 0.001, respectively). The prevalence of COVID-19-related WBH among HCWs and customer
harassment among HCWs and non-HCWs was not significantly
changed from baseline (T1 for WBH and T2 for customer harassment).
Table 3 shows the odds ratio of COVID-19 related WBH and
customer harassment among HCWs compared to non-HCWs at each
survey and overall adjusting for sex, age, marital status, and education.
Regarding COVID-19-related WBH, HCWs had a significantly
higher risk than non-HCWs at T2 (odds ratio [OR], 2.31; 95%
confidence interval [CI], 1.01 to 5.25). Regarding COVID-19- related
customer harassment, HCWs had a significantly higher risk than nonHCWs at T4 (OR, 2.70, 95% CI, 1.26 to 5.82), and overall (OR, 2.08,
95% CI, 1.12 to 3.86). In addition, Time occupation interaction
TABLE 2. Prevalence of COVID-19-related Workplace Bullying at T1-4 and Customer Harassment at T2-4 Among Currently
Employed Full-time Workers During the COVID-19 Outbreak in Japan (N ¼ 800)
T1
March
2020
n (%)
COVID-19-related workplace bullying:
Healthcare workers
4 (5.0)
Nonhealthcare workers
16 (2.2)
COVID-19-related customer harassment:
Healthcare workers
–
Nonhealthcare workers
–
T2
May
2020
n (%)
T3
August
2020
n (%)
T4
November
2020
n (%)
8 (10.0)
37 (5.1)
8 (10.0)
49 (6.8)
8 (10.0)
46 (6.4)
10 (12.5)
50 (6.9)
P value for the difference from the
baseline (T1 for workplace bullying;
T2 for customer harassment)
T2
T3
T4
6 (7.5)
40 (5.6)
0.289
0.004
0.289
<0.001
0.727
0.001
10 (12.5)
36 (5.0)
–
–
0.754
0.703
0.754
0.519
P < 0.01.
P < 0.001, for the difference between T1, T2, T3, and T4 (McNemar’s test).
e302
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JOEM Volume 64, Number 5, May 2022
COVID-19-Related Workplace Bullying and Customer Harassment
TABLE 3. Odds Ratio of Covid-19 Related Workplace Bullying and Customer Harassment Among Health Care Workers
(HCWS) Compared to Non-HCWS at Each Survey (Multiple Logistic Regression) and for Overall (Generalized Linear Model
With Repeated Measures) Adjusting for Sex, Age, Marital Status, and Education Among Full-time Workers During the COVID19 Outbreak in Japan (N ¼ 800)
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T1
(March 2020)
OR
95%CI
T2
(May 2020)
P
COVID-19-related workplace bullying:
Non-HCW
1
HCW
2.42 0.77, 7.63 0.13
COVID-19-related customer harassment:
Non-HCW
HCW
T3
(August 2020)
T4
(November 2020)
Overalla
OR
95%CI
P
OR
95%CI
P
OR
95%CI
P
OR
95%CI
P
1
2.31
1.01,5.25
0.046
1
1.46
0.65, 3.25
0.36
1
1.31
0.53,3.23
0.56
1
1.72
0.88, 3.32
0.12
1
1.67
0.75, 3.72
0.21
1
1.92
0.91, 4.04
0.09
1
2.70
1.26, 5.82
0.01
1
2.08
1.12, 3.86
0.02
a
Generalized linear model with repeated measures of each bullying outcome on time of survey and occupation (HCWs vs non-HCWs). Time occupation interaction terms were
not significant for workplace bullying and customer harassment (P ¼ 0.768, df ¼ 3; P ¼ 0.341, df ¼ 2, respectively).
P < 0.05.
terms were not significant for COVID-19-related WBH and customer
harassment (P ¼ 0.77, df ¼ 3; P ¼ 0.34, df ¼ 2, respectively).
DISCUSSION
The present study aimed to investigate changes in prevalence of COVID-19-related WBH and customer harassment
among HCWs, over the course of the second and third COVID19 outbreaks in Japan. Although significant increases in the
prevalence of COVID-19-related WBH from March 2020 were
observed only for non-HCWs, the prevalence tended to increase
from March to May 2020 and stay high in August and November
2020 both among HCWs and non-HCWs. HCWs had a significantly higher risk of COVID-19-related WBH at T2 than nonHCWs even after adjusting for sex, age, marital status, and
education. In addition, HCWs had significantly higher risks of
COVID-19-related customer harassment than non-HCWs at T4
and overall. Time occupation interaction was not significant for
COVID-19-related WBH.
HCWs had a significantly higher prevalence of COVID-19related WBH than non-HCWs at T2 (May 2020), as we already
reported earlier.13 The present study additionally found that the
prevalence of COVID-19-related WBH was non-significantly but
consistently greater among HCWs than non-HCWs at T3 (August
2020) and T4 (November 2020). HCWs were at high risk of
COVID- 19 infection,16 which increased worry about COVID-19
among HCWs.17 High levels of worry about COVID-19 may make
HCWs more sensitive to the disease, and lead to COVID-19-related
WBH, such as demanding colleagues to strictly follow preventive
measures or discriminating against a colleague who had a sign of
possible infection. In addition, HCWs experienced increased job
demands to take care of their patients in unusual circumstances.18
High job demand is known as a factor of WBH in general.19
Increased job demands in the COVID-19 pandemic may also
increase COVID-19- related WBH. These situations that HCWs
faced may remain during the COVID-19 pandemic, despite the
changing levels of the epidemic, and chronically increased COVID19-related WBH among HCWs; therefore, psychosocial mechanisms of COVID-19-related WBH among HCWs should be investigated in future research.
HCWs had a significantly higher prevalence of COVID-19related customer harassment than non-HCWs at T4 (November
2020) and overall. While it was non-significant, the prevalence
was higher among HCWs than non-HCWs in other follow-up
points as well. HCWs have been reported to have a higher
prevalence of harassment and violence from patients/clients and
their families than non-HCWs before the COVID-19 pandemic.20,21 Even limited to COVID-19 related customer harassment, this tendency may apply to HCWs under the COVID-19
pandemic. HCWs often have to take care of patients and their
families face to face.10 They may also have to respond to phone
calls or e-mails from patients and their families who are worried
about the infection. Such difficult situations may have chronically
continued over the COVID-19 pandemic despite the situation of
infection. More attention should be given to COVID- 19 customer
harassment of HCWs, and countermeasures should be used to
mitigate harm to HCWs.
HCWs had a significantly higher risk than non-HCWs at T2
regarding COVID-19-related WBH, while they had a significantly
higher risk at T4 and overall regarding COVID-19-related customer
harassment. The high risk of COVID-19 infection and increased job
demands related to the COVID-19 pandemic may threaten HCWs,
especially in the early phase of the outbreak. It might be because
there was little personal protective equipment and little information
on preventing COVID-19.18 Such a specific situation for healthcare
settings at T2 may make a significant difference in COVID-19related WBH among HCWs. On the other hand, hospitals worldwide have imposed visitor restrictions to reduce the transmission of
COVID-19.22 Patients and their family’s worry were prolonged,
leading to COVID-19-related customer harassment for HCWs at T4
and overall.
Among non-HCWs, the prevalence of COVID-19-related
WBH also significantly increased from March to May 2020 and
remained significantly higher in August and November 2020
(compared to March 2020). While the prevalence was lower than
for HCWs, COVID-19-related WBH also seems to be an issue in
the COVID-19 pandemic among non-HCWs. For example, 19.4%
of general workers who experienced COVID-19-WBH reported
that they had been verbally abused or had excessive pressure to
take leave from their workplace because they had infected
COVID-19 even after they had been cured.23 Providing accurate
and timely information about COVID-19 has been proposed to
minimize COVID-19-related WBH.24 The Government of Japan
made an effort to do this since an early phase of the epidemic
(January 2020)25; new legislation that mandated employers to
establish a plan to prevent WBH at the workplace has been in
effect since June 2020.26 However, the sustained pattern of
COVID-19-related WBH indicates that this effort might not be
successful to date. A booster countermeasure to prevent COVID19-related WBH is needed. On the other hand, the prevalence of
COVID-19-related customer harassment among non-HCWs
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decreased from T3 to T4 in this study—even though non-HCWs
could experience it (eg, drug store staffs have been yelled for
missing items, such as masks, that were stockout due to COVID19).27 The products and services temporarily missing by the rapid
spread of infection gradually returned to normal at T4, and
customers’ complaints may decrease. Also, this may be due to
a decreased opportunity to meet customers face to face in the
COVID-19 pandemic to keep social distancing. For instance, half
of the companies in Tokyo adopted telework.28
The present study has several limitations. First, since the
COVID-19-related WBH and customer harassment measurements
used in this study have been developed originally, and the reliability
and validity of the measurements were not demonstrated. Second,
since we used a self-report questionnaire to measure COVID-19related WBH and customer harassment, the findings could reflect selfreport bias. Third, as several non-HCWs who did not interact with
customers may be included in the analysis, the results of our study may
be underestimated. Fourth, COVID-19-related WBH and customer
harassment may vary by country, culture, and pandemic situation;
however, the reported prevalence of this study was similar to the
prevalence in other countries.10 Thus, our findings might not be very
different from the general prevalence rate. Fifth, since we recruited our
sample from an internet survey company and the participants consisted only of full-time workers, the generalizability of the findings to
the whole population of workers is limited. Sixth, the low response rate
(19.4%) may indicate selection bias, with a risk of underestimating the
prevalence of WBH if potential respondents who had experienced
WBH were less willing to participate in the study. Seventh, part-time
workers and temporary workers may be more likely to be experienced
COVID-19-related WBH than full-time workers. A previous study
reported that temporary workers were at high risk of experiencing
workplace bullying before the pandemic in Japan.29 Also, part-time
workers among males and temporary/ contract workers among
females had a higher risk of poor mental health than permanent
workers in Japan.30 Since only full-time workers are included in
our analyses, the results may be underestimated. Eighth, we did not ask
whether the participants were infected with COVID-19 or not because
the internet survey company did not allow us to due to ethical
considerations for the survey participants. Because COVID-19 positive patients tend to be stigmatized,31 future studies should adjust the
factor in the analyses. Ninth, the extent to which their occupation was
affected by COVID-19 might be a confounder. We have to interpret the
results carefully whether HCWs are likely to experience COVID-19related WBH and customer harassment or any occupation (ie, not only
HCWs) that was greatly affected by COVID-19 are likely to
experience them.
CONCLUSION
This study found that as the spread of COVID-19 infection
continued, HCWs were likely to experience COVID-19-related
WBH and customer harassment from March to November 2020.
Therefore, it is necessary to provide psychological care for HCWs
and disseminate correct knowledge at the national level.
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