Occupational Health and Safety (OHS): Protecting the Indonesian Healthcare Workforce during the COVID-19 Pandemic - The Partnership for Australia ...
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
RA PI D RE S E A RCH P RO J E C T F IN AL R E P O R T
Occupational Health
and Safety (OHS):
Protecting the
Indonesian Healthcare
Workforce during the
COVID-19 Pandemic
PAIR:
The Partnership for Australia-Indonesia Research
(PAIR), an initiative of The Australia-Indonesia Centre,
Authors:
is supported by the Australian Government and run in
Professor Daniel Prajogo, Monash University
partnership with the Indonesian Ministry of Research
Professor Amrik Sohal, Monash University
and Technology, the Indonesian Ministry of Transport,
Dr Ratna Sari Dewi, Institut Teknologi Sepuluh Nopember
the South Sulawesi Provincial Government and many
Dr Dyah Santhi Dewi, Institut Teknologi Sepuluh
organisations and individuals from communities and
Nopember
industry.
Dr Adithya Sudiarno, Institut Teknologi Sepuluh
Nopember The Australia-Indonesia Centre:
Dr Retno Widyaningrum, Institut Teknologi Sepuluh The Australia-Indonesia Centre is a bilateral research
Nopember consortium supported by both governments, leading
Dr Arief Rahman, Institut Teknologi Sepuluh Nopember universities and industry. Established in 2014, the Centre
Anny Maryani, Institut Teknologi Sepuluh Nopember works to advance the people-to-people and institutional
Dr Eugene Sebastian, Executive Director, AIC links between the two nations in the fields of science,
Helen Brown, Lead, Communications and Outreach, AIC technology, education, innovation and culture. We do this
through a research program that tackles shared challenges,
Report date: and through our outreach activities that promote greater
June, 2021 understanding of contemporary Indonesia and strengthen
bilateral research linkages.
Disclaimer:
This report is the result of research funded by the To discover more about the Centre and its activities,
Australian Government through the Australia-Indonesia please visit: ausindcentre.org
Centre under the PAIR program. The report was edited
by the Australia-Indonesia Centre (AIC). The report is
not intended to provide exhaustive coverage of the topic. To cite this report:
The information is made available on the understanding This report is the result of research funded by the Australian
that the AIC is not providing professional advice. While Government through the Australia-Indonesia Centre under
care has been taken to ensure the information in this the PAIR program. Visit ausindcentre.org
report is accurate, we do not accept any liability for any
loss arising from reliance on the information, or from Prajogo D., Sohal A., Dewi R.S., Dewi D.S., Sudiarno A.,
any error or omission, in the report. We do not endorse Widyaningrum R., Rahman A., Maryani A., Sebastian E.,
any company or activity referred to in the report, and Brown H., (2021), ‘Occupational Health and Safety (OHS):
do not accept responsibility for any losses suffered in Protecting the Indonesian Healthcare Workforce during the
connection with any company or its activities. COVID-19 Pandemic’, The Australia-Indonesia Centre.
THE PARTNERSHIP FOR AUSTRALIA-INDONESIA RESEARCH (PAIR)
i 3
I am delighted to share our
findings from the Partnership for
Australia-Indonesia Research (PAIR)
COVID-19 Rapid Research Series.
As the COVID-19 pandemic
Analysis and Results������������������������������������9 spreads, it continues to disrupt
Executive Summary ��������������������������������������1
3.1. General Overview of Hospitals in economies, jobs, education and
health systems worldwide. To
1
Indonesia During The Covid-19 address the pressing challenges
Pandemic�������������������������������������������������������9 in Indonesia, we have brought
3.2. The Implimentation of OHS together teams of interdisciplinary
researchers from both countries to
Policy in Hospitals������������������������������ 10 explore COVID’s impact on people.
3.3. Staff awareness of and We focus on three areas: health,
Introduction ������������������������������������������������������������3 connectivity and economic recovery.
compliance with OHS policies
and procedures�������������������������������������12 The report provides the policy
2
3.4. Challenges encountered community with timely access to
the best available evidence. It
by staff ��������������������������������������������������������� 14 also responds to the Australian
3.5. COVID-19 infections among Government’s Partnership for
Recovery strategy. The strategy
healthcare workers ������������������������� 15
aims to understand and support
4
Research Background������������������������������6 Indonesia as it deals with and
recovers from the COVID-19
pandemic.
2.1 Covid-19 in Indonesia����������������������������6
2.2 OHS in Healthcare����������������������������������6
Conclusion and Warm regards,
2.3 OHS and COVID-19�������������������������������� 7 Recommendations������������������������������������� 18
5
References����������������������������������������������������������� 22
Dr Eugene Sebastian
PAIR Program Director
The Australia-Indonesia Centre
RAPID RESEARCH PROJECT FINAL REPORT
EXECUTIVE SUMMARY
Indonesia has one of the highest
rates of death for healthcare
workers from COVID-19 in the
world, with the national medical
association estimating the toll is at
least 718 by early March 2021. The
majority of the deaths have been
doctors and nurses, and this is a grim
fact in a country with an already low
number of healthcare professionals
to serve the population.
Infection rates among a range of healthcare workers are also high,
and this report finds that healthcare institutions need to urgently
address the hazards and gaps in their systems to help bring these
numbers down. It has identified some critical areas for attention
to reduce the risk of transmission and better protect staff who
are working in an often stressful and tiring environment, and
recommends that more can be done to evaluate vulnerable points
and take appropriate prevention and control measures.
The health and wellbeing of these essential frontline workers must
be protected so they can continue to combat the effects of COVID-19
in the broader community.
This research examines the implementation of – and compliance
with – Occupational Health and Safety (OHS) policies in Indonesian
hospitals during COVID-19. It highlights opportunities to improve the
OHS of the country’s healthcare workers, and offers lessons that
can be applied around the globe. Researchers conducted 23 semi-
structured, in-depth interviews with key stakeholders from hospitals
in Surabaya through virtual channels. Respondents belonged to three
Class A hospitals, five Class B hospitals, one Class C hospital, one
Class D hospital and two community health centres/clinics engaged
in treating COVID-19 patients. Researchers analysed interview
transcripts to decipher key themes. The report’s findings focus on
the general conditions of health facilities in Indonesia, OHS policy
development and implementation, awareness of – and adherence to –
OHS policy, challenges encountered by stakeholders, and procedures
for handling infected patients and staff.
RAPID RESEARCH PROJECT FINAL REPORT
Ultimately, the research informed 3. Improve contact tracing 6. Supervise and monitor
seven key recommendations to processes and create accurate, adherence to infection control
reduce the risks for healthcare real-time reporting systems. protocols.
workers during COVID-19:
4. Ensure that physical facilities 7. Evaluate the psychological and
and the environment facilitate physical impacts on healthcare
1. Minimise transmission of infection prevention. personnel who are working in
the virus at critical points in the pandemic context.
hospitals. 5. Provide ongoing training to
staff regarding risk mitigation.
2. Improve screening and testing
processes to identify infected
individuals more rapidly.
THE AUSTRALIA-INDONESIA CENTRE | PARTNERSHIP FOR AUSTRALIA-INDONESIA RESEARCH 2
RAPID RESEARCH PROJECT FINAL REPORT
1.0. I N T R O D U C T I O N
OVERVIEW
While many developed nations are being
severely challenged by the devastating
effects of the COVID-19 pandemic,
resource-limited developing nations face
even more critical challenges (Hopman
et al., 2020). With the fourth largest
population globally, Indonesia is one
developing country that has been heavily
impacted by COVID-19, the disease
caused by a novel type of coronavirus Figure 1.1 COVID-19 in Indonesia (Source: Satuan Tugas Penanganan
– severe acute respiratory syndrome COVID-19, 2020).
coronavirus 2 (SARS-CoV-2). Jakarta, the
epicentre of the pandemic in Indonesia, “The infection and mortality rate of healthcare workers,
has among the highest proportion of particularly of doctors and nurses, is higher than during
deaths to COVID-19 infections globally any other infectious disease outbreak in the history of the
(Asyary & Veruswati, 2020), while country.”
healthcare experts have continually
According to the Indonesian Medical Association, by 2 March 2021,
expressed doubts about the capability of
at least 718 healthcare workers had died from COVID-19, including
Indonesia’s healthcare system to respond
325 doctors and 324 nurses (Pikiran Rakyat). Almost seven in 10
to the pandemic effectively after the first
healthcare workers who have died in Indonesia (68%) were in higher-
positive cases of COVID-19 were reported
risk age groups of between 50 and 79 years of age (Irwandy, 2020).
on March 2, 2020 (Djalante et al., 2020).
These figures are alarming, as the health and wellbeing of healthcare
By 28 January 2021, Indonesia had
staff is critical for the adequate provision of healthcare services, both
reported 1,037,993 cases of the novel
during the pandemic and into a future recovery phase. Other efforts
coronavirus, with a death toll of 29,331
to increase the capacity of the healthcare system will be ineffective if
(Worldometers, 2021). These numbers
adequate resources and a safe working environment are not available
are still rising (see Figure 1 (Satuan Tugas
to healthcare workers.
Penanganan COVID-19, 2020)).
OHS is concerned with protecting the safety, health and wellbeing
The Indonesian government has
of employees, so that they can carry out their responsibilities in a
implemented numerous measures
secure, hazard-free working environment. However, there is evidence
in response, including building new
that the healthcare setting in Indonesia is often characterised by poor
facilities and infrastructure and
OHS management (Gul, Ak & Guneri, 2016). The alarming number of
providing equipment for healthcare
fatalities among healthcare staff due to COVID-19 infections highlights
workers. Across the nation, 132
the OHS struggles of hospitals and risks that these frontline workers
specialist hospitals for handling
face. The many risks healthcare workers have been exposed to during
infectious diseases have been
COVID-19 are the result of factors including a lack of established
established (Kementerian Kesehatan
processes for carrying out their duties safely, shortages of medical
Republik Indonesia, 2020). This
supplies, and inadequate protective equipment. These issues have
includes the conversion of the Athlete’s
caused not just physical and psychological harm to healthcare
Guest House in Jakarta into an
workers but, critically, have also resulted in them transmitting the
emergency COVID-19 hospital with a
virus (Zhao & Jiang, 2020). In the Asia Pacific region, OHS hazards
capacity of 7,426 beds (CNN Indonesia,
and their negative impacts on health and wellbeing among healthcare
2020).
professionals are an ongoing concern. It is vital that we strengthen
Despite these efforts, the pandemic the capability of hospitals to manage OHS challenges so that they can
is having a devastating effect on keep healthcare staff – and, ultimately, the population – safer.
Indonesia’s healthcare sector.
This is especially the case in Indonesia due to the disturbing number
of infections and deaths from COVID-19 among healthcare staff.
The Indonesian Government faces grave challenges in maintaining
the capacity of its healthcare workforce, as well as in maintaining
motivation among healthcare workers, in a context where there is a
relatively small proportion of healthcare practitioners per capita. The
ratio of general practitioners and residents in Indonesia is only four
per 10,000 population (WHO, 2017) and the current ratio for nurses
THE AUSTRALIA-INDONESIA CENTRE | PARTNERSHIP FOR AUSTRALIA-INDONESIA RESEARCH 3
RAPID RESEARCH PROJECT FINAL REPORT
is 10 per 10,000 population, compliance) and understand 1. Provision of a contempo
according to the Indonesian how these attitudes affect raneous overview of the
National Nurses Association workplace safety culture, situation faced by Indo
(Irwandy, 2020). Without perceived risks and job nesian healthcare institutions
adequate healthcare workforce satisfaction. combating the COVID-19
capacity, the government’s efforts pandemic, and an under
to eradicate COVID-19 will be 3. To examine the impact of standing of how this is
severely hampered. The situation OHS implementation on impacting the health and
demands a healthy and safe hospital performance in terms safety of healthcare workers.
working environment in hospitals of service quality, safety
to protect healthcare workers, culture, health and wellbeing 2. Analysis of current
and to enable them to perform of patients and staff, and, approaches used by
their duties at their highest most importantly, COVID-19 healthcare institutions to
capacity. Yet, even pre-pandemic, infections among healthcare manage the health and safety
OHS in Indonesian hospitals was staff. of clinical staff, hospital
reportedly lacking. For example, management and patients.
4. To identify areas for
incident reporting systems lack
improvement in OHS, including 3. Assessment of the extent
robust infrastructure and need
the integration of OHS policy of compliance with – and
to be improved if hospitals are to
in hospital operations (for the impact of – existing OHS
learn from errors (Dhamanti et al.,
example, scheduling, risk policies and practices during
2019). This further reinforces the
management). the COVID-19 pandemic.
need to establish comprehensive
OHS policies and procedures 4. Recommendations for the
and, even more importantly, BENEFITS OF THE improvement of OHS policies
create rigorous implementation RESEARCH and their implementation in
processes and a culture in which healthcare organisations.
healthcare workers are motivated The findings of this research
and enabled to adhere to safe provide specific recommendations
practices. for creating a safe working REPORT STRUCTURE
environment and an improvement
RESEARCH OBJECTIVES culture for OHS. This will ensure This report begins with a review
that healthcare organisations of the impact of COVID-19 on
To help address these challenges, are safer workplaces, mitigating healthcare, and how OHS is
this research examined the the negative OHS impacts of the applied in healthcare settings. It
implementation of OHS policies, pandemic on healthcare workers. then describes the methods used
procedures and systems in It also ensures that healthcare to collect data. The analysis and
hospitals in Indonesia, as well institutions can best respond to, results sections follow, with the
as hospitals’ OHS performance, and recover from, COVID-19. final section presenting conclusions
with the aim of identifying areas regarding OHS policy and systems
for improvement. Specifically, the The benefits of the research in Indonesian hospitals, alongside
research aimed: findings and report include: seven key recommendations for
future OHS policy.
1. To examine the implementation
of OHS policies and
procedures in Indonesian
hospitals. This includes
reviewing their OHS policies,
procedures and targets, OHS
representative roles, top
management leadership and
commitment to OHS, staff
training in OHS, facilities,
information and resources
for OHS, and OHS auditing,
reporting and reviews.
2. To examine the attitudes of
Source: The Conversation Indonesia.
hospital staff towards OHS
https://theconversation.com/4-gelombang-besar-pandemi-covid-19-
(including awareness and
menghantam-sistem-pelayanan-kesehatan-142049
THE AUSTRALIA-INDONESIA CENTRE | PARTNERSHIP FOR AUSTRALIA-INDONESIA RESEARCH 4
“It is vital that we strengthen the capability of hospitals to manage OHS challenges so that they can keep healthcare staff – and, ultimately, the population – safer.”
RAPID RESEARCH PROJECT FINAL REPORT
2.0. R E S E A R C H COVID-19 has significantly impacted Indonesia’s healthcare sector. The
BACKGROUND sheer scale of infections has presented a substantial challenge to the
capacity and capability of the sector (IBISWorld, 2020). Healthcare
This chapter provides the study personnel handling COVID-19 patients are at high risk of contracting
context, based on a review of available the virus. The continuing rise in both infections and fatalities due to
literature. COVID-19 highlights the importance of the health and wellbeing of
healthcare personnel working in Indonesian hospitals. By the end of
COVID-19 IN INDONESIA January 2021, almost 650 healthcare workers had died of COVID-19
in Indonesia (Coconuts Jakarta, 2021). Doctors, nurses and midwives
make up the largest percentages, followed by other groups including
On On March 2, 2020, the President of
laboratory technicians, pharmacists, radiologists and ambulance
the Republic of Indonesia announced the
drivers.
first confirmed cases of COVID-19 in the
country. The first death followed not long Widespread vaccination remains some way off and the impact of
after, on March 11. Around the same this is still uncertain. As such it is vital to evaluate and improve how
time, the World Health Organisation Indonesian hospitals manage OHS, in order to improve their capacity to
(WHO) announced that COVID-19 was a handle COVID-19.
global pandemic. Between March 2020
and mid-November 2020, infections
O H S I N H E A LT H C A R E
spread across all the provinces of
Indonesia. Some provinces, such as Occupational hazards are the short- and long-term dangers or risks
Jakarta and East Java, have been associated with unhealthy workplace environments (Schulte, Pandalai,
dubbed “red zones” due to their high Wulsin & Chun, 2012). OHS procedures ensure that organisations
infection rates. To control the virus’s reduce the risk of accidents, underpin staff health and satisfaction, and
spread, the government closed schools improve organisational performance and reputation, both in the eyes
and universities and prohibited mass of employees and the broader community (da Silva & Amaral, 2019).
congregations. Inadequate or ineffective OHS policies and procedures can have many
impacts on workers, including pain and suffering due to injuries and
Responding to the spread of the
occupational diseases. This can then result in increased absenteeism
virus in the country, the Indonesian
and lost working time, adverse effects on labour relations, and
Government established the COVID-19
compensation costs (Niu, 2010). In the context of COVID-19, OHS plays
Task Force. Wearing face masks is the
a vital role in maintaining the health and safety of healthcare workers.
main directive of the task force, which
also describes several strategies the OHS hazards and their negative impacts on health and safety are
government has implemented (Wibowo, growing concerns. Healthcare professionals are at a high risk of
2020). The government initially made occupation-related hazards, and experience impairment rates equal
mask-wearing compulsory for medical to, or exceeding, other industries that are traditionally considered
personnel and symptomatic people, later hazardous (Tullar et al., 2010). Healthcare workers face a wide range of
mandating mask-wearing for everybody. OHS hazards, including biological hazards, chemical hazards, ergonomic
As a result, there was a severe hazards, psychosocial hazards and physical hazards (Che Huei et al.,
shortage of surgical masks, leading 2020). Since their occupation involves caring for the sick and injured,
the government to announce that fabric healthcare workers are often viewed as being “immune” to such injury
masks could be used, despite being less or illness and are often expected to sacrifice their own wellbeing for the
effective than surgical masks (Septiani, sake of their patients.
A., 2020). The Indonesian Government
also traces positive cases and their Injuries and illness prevent healthcare workers from carrying out
close contacts, and has provided public their duties effectively, which can have broader negative impacts on
education on infection prevention and the healthcare system (Tullar et al., 2010). Proactive actions such
how to self-isolate when necessary. If as planning, assessment, and the implementation of controls and
individuals are unable to self-isolate, preventative measures can prevent occupational accidents and illnesses
isolation periods can be carried out in a (da Silva & Amaral, 2019). Moreover, protecting the OHS of healthcare
hospital (Wibowo, 2020). workers contributes to the quality of patient care and the strength of
healthcare systems (WHO, 2020). Policymakers, healthcare workers
and administrators have been urged to work together to eliminate or
minimise these hazards by introducing OHS policies and procedures,
and strictly following engineering, administrative and personal protective
equipment (PPE) controls (Che Huei et al., 2020).
THE AUSTRALIA-INDONESIA CENTRE | PARTNERSHIP FOR AUSTRALIA-INDONESIA RESEARCH 6RAPID RESEARCH PROJECT FINAL REPORT
The implementation of OHS High costs are associated with O H S A N D C OV I D - 1 9
practices is a gradual process implementing numerous systems
which, over the long term, can simultaneously and in an integrated Historically, infectious diseases
generate positive OHS outcomes. way. Management methods and have been the leading cause of
A literature review reveals the culture may require change and death in humans. The Spanish Flu
importance of leadership for finding time to implement and pandemic of 1918 is recognised
effective safety management, execute all of this can be difficult as the most destructive of recent
and that leadership behaviour (da Silva & Amaral, 2019). times, claiming between 25 million
affects safety culture and safety Resistance to change and the need and 40 million lives (Zhao & Jiang,
performance in the healthcare for better funding and resources 2020). The COVID-19 pandemic
industry. The dedication of the are also key barriers to the uptake has affected more than 200 coun-
leaders of healthcare organisations of such programs (Baumann et tries (Bahl et al., 2020). As of 17
to the success of OHS programs al. 2012). Moreover, defining March 2021, there were more than
is essential (Baumann, Holness, appropriate management indicators 121 million confirmed COVID-19
Norman, Idriss-Wheeler, & Boucher, is difficult in OHS. The failure to cases, and more than 2.68 million
2012; Yang, Wang, Chang, Guo, & accurately assess OHS risks and deaths worldwide (Worldometers,
Huang, 2009). Research finds that create well-functioning control and 2021). Globally, governments
the support of leadership, worker documentation systems can also and health organisations have
training and robust safety reporting be barriers. made enormous efforts to prevent
systems can improve safety infections and support people with
performance in healthcare (Yang et Critically, studies also suggest that COVID-19 and those who treat
al., 2009). management perceives ergonomic them. Despite this, outbreaks have
programs to not be feasible in occurred in aged care facilities,
The most influential factors all areas of healthcare. This is prisons and hospitals, and thou-
contributing to the successful especially true of high-demand sands of healthcare workers have
implementation of OHS clinical areas, where patient needs become infected (Gudi & Tiwari,
management systems are: often take precedence over the 2020).
developing OHS policies and safety of healthcare workers.
programs, setting up hazard Participation in OHS programs may The high rate of infection among
identification and workplace also impose extra work on staff. In healthcare workers is unsurprising
assessment processes, and the post-implementation phase, the given that healthcare staff are at
developing and implementing OHS ongoing availability of resources the frontline of the battle against
risk control strategies (Ramli, and dedicated time often remain COVID-19. They are at high risk
Watada and Pedrycz 2011). Other the most significant challenge. of exposure to the virus due to
critical factors highlighted by the Other barriers include scheduling errors in infection control practic-
literature include the improvement and ensuring attendance at es, or where protective practices
of OHS communication within meetings and training sessions and equipment are inadequate.
organisations, greater commitment (Baumann et al., 2012). Another Healthcare worker infections can
and participation of workers, the issue can be organisational cause not only physical and psy-
development of more proactive leadership’s lack of commitment, chological harm to the healthcare
OHS management, and improved and that it can be difficult for workers themselves, but they can
allocation of financial resources workers to understand the benefits then transmit the virus to patients,
(da Silva & Amaral, 2019). of OHS programs. This creates colleagues, family members and
Some authors also endorse challenges in ensuring adherence other close contacts (Zhao & Jiang,
the promotion of continuous to OHS policies, complicating 2020). The extreme risks associat-
improvement, via performance healthcare policy and culture (da ed with the exposure of healthcare
measurement and monitoring of Silva & Amaral, 2019). A decline workers to COVID-19 highlight the
OHS processes (Yazdani et al., in the authority of governments need for strong OHS policy, risk as-
2015). to implement such rules and sessments and practices in health-
regulations has also impacted OHS care institutions. Indeed, health-
The most significant barrier to in general, and this has meant, at care institutions must urgently
implementing OHS programs times, regulatory bodies have failed identify COVID-19 hazards and gaps
is reportedly the high cost of to protect worker safety (Pringle & in current OHS practices, evaluate
implementation and management. Frost, 2003). their risks and take appropriate pre-
There is often insufficient vention and control measures (Gudi
integration between standards. & Tiwari, 2020).
THE AUSTRALIA-INDONESIA CENTRE | PARTNERSHIP FOR AUSTRALIA-INDONESIA RESEARCH 7RAPID RESEARCH PROJECT FINAL REPORT
PPE is critical to impede transmission
(Jones, 2020). Growing evidence strongly
supports airborne precautions for the
OHS of healthcare workers treating pa-
tients with COVID-19 (Bahl et al., 2020).
Precautionary OHS principles for frontline
healthcare workers should include prop-
erly fitted respirators. Where respirators
are unavailable, masks should be used.
Extended use or reuse of PPE carries
a high risk and may lead to infection of
the wearer and those they contact. To
avoid this, clear instructions regarding
the proper use of PPE must be available
to healthcare workers (Chughtai, Seale,
Islam, Owais & Macintyre, 2020).
The extreme fatigue experienced by Source: Jakayla Toney
healthcare workers during the pandemic https://unsplash.com/photos/nwRoHW4j3gg?utm_source=unsplash&utm_
may make them even more vulnerable to medium=referral&utm_content=creditShareLink
the virus. Many healthcare workers are
unable to have adequate rest, and mental
health issues due to stress and fatigue
are common. These are exacerbated by
poor working conditions, which strong
OHS programs can significantly improve
(Zhao & Jiang, 2020). Critically, staff
must be educated on the implications of
not following OHS policies and proce-
dures, including the likelihood of trans-
mitting the virus to patients, colleagues,
family members and other close contacts
(Ramli et al., 2011).
Although many regulatory documents
and standards for healthcare institutions
and staff existed prior to the current
pandemic in various countries, they Source: Mufid Majnun
were insufficient to prepare for such a https://unsplash.com/photos/ZT2qPWJTANs
major emergency as COVID-19. This has
particularly been the case in Asia and
the Pacific region, where OHS hazards
and their negative impacts on healthcare
professionals are ongoing concerns (Che
Huei et al., 2020).
Strong OHS management in healthcare
organisations is a concrete demonstra-
tion of healthcare organisations, authori-
ties and policymakers fulfilling their social
responsibilities (Che Huei et al., 2020).
The safe employment of the healthcare
workers who are combating the pandemic
is a significant responsibility that falls on
the shoulders of governments, including
the Indonesian government, as they en-
deavour to recover from the devastation
of the COVID-19 pandemic. Source: Mufid Majnun
https://unsplash.com/photos/J12RfFH-2ZE?utm_source=unsplash&utm_
medium=referral&utm_content=creditShareLink
THE AUSTRALIA-INDONESIA CENTRE | PARTNERSHIP FOR AUSTRALIA-INDONESIA RESEARCH 8RAPID RESEARCH PROJECT FINAL REPORT
3.0. A N A L Y S I S A N D R E S U L T S H O S P I TA L S ’ R E S P O N S E T O C OV I D - 1 9
3.1. G E N E R A L O V E R V I E W O F With the onset of the pandemic, some hospitals became referral
H O S P I TA L S I N I N D O N E S I A hospitals for COVID-19 specialists, with dedicated facilities including
DURING THE COVID-19 rooms and equipment for treating COVID-19 patients. The number
PANDEMIC
of beds designated as Special Isolation Rooms (SIRs) for COVID-19
OV E RV I E W O F H O S P I TA L S I N varies from one hospital to another. For example, the class A hospitals
INDONESIA participating in this study assigned approximately 120 to 200 beds for
COVID-19 patients while the class D hospital only has eight specialised
The Ministry of Health Regulation treatment beds.
No. 3 of 2020 classifies general
hospitals under class A, B, C and D. To reduce the risk of spreading the SARS-CoV-2 virus, Intensive Care
These classifications are generally Units (ICU) and inpatient room facilities treating COVID-19 patients
distinguished by the number of beds are separated from general (non-COVID-19) patients. The separation
available. The top referral hospitals strategies vary, from the use of separate buildings (as in hospitals B1
that have a minimum of 250 beds and B6) to using different floors in the same building (as in hospitals
are classified as A. Regional Class B B3, B4 and B5) to simply deploying dividing curtains (as in hospital
hospitals have a minimum of 200 beds D). Community health centres and clinics do not have special rooms
and are in every provincial capital in for the treatment of COVID-19 patients. However, they create special
Indonesia. Class C general hospitals screening rooms and separate the waiting rooms for patients arriving
have at least 100 beds and exist with suspected COVID-19 symptoms.
in most regions in Indonesia. Class
D hospitals have a minimum of 50 A variety of specialised equipment in hospitals tests and treats
beds and are usually transitional or COVID-19 patients, including PCR (polymerase chain reaction) machines
temporary hospitals. In addition to for COVID-19 testing and ventilators. The availability of such equipment
general hospitals, there are specialty is generally adequate in Class A and B hospitals, but more limited
hospitals, where the healthcare and sometimes unavailable in Class C and D hospitals as well as in
services provided are more specialised community health centres. Patients who require further intensive care in
based on scientific discipline, patient these hospitals or community health centres must be referred to Class A
age group, body system, type of or B hospitals.
disease or other foci. Examples include
women and children’s hospitals, eye C A PAC I T Y M A N AG E M E N T
hospitals, dental and oral hospitals.
These general and specialty hospitals The occupancy rate of COVID-19 treatment rooms was high during
provide both inpatient and outpatient the early stages of the pandemic. Class A, B and C hospitals reached
healthcare services. There are also 100% of their capacity and were sometimes forced to refuse patients.
teaching hospitals where doctors, Occupancy rates in the Class D hospital were not as significant and,
nurses and other health professionals because these hospitals had spare capacity, they acted largely as a
undergo their training. buffer for the referral hospitals. Their occupancy rate in early November
2020 fluctuated between 40% and 80%. One factor that brought the
The Indonesian healthcare system also reduction in the occupancy rates was the reduction in the duration
has community health centres and of treatment for COVID-19 patients in hospitals. According to the
clinics/polyclinics, mainly providing Guidelines for COVID-19 Prevention and Control Revision 5 (2020),
outpatient services to patients. These patients no longer need to stay in a hospital once the RT-PCR swab
community healthcare centres and returns two consecutives negative results. In cases where swab results
clinics can provide referrals for patients are still positive, patients can be discharged on the assessment and
to obtain further services at general recommendations of the doctor in charge of treatment.
and specialty hospitals.
On the other hand, there was a significant decrease in the number of
non-COVID-19 patients attending both inpatient and outpatient facilities
in hospitals, especially at the beginning of the pandemic. Indeed, the
number declined to around 20% of pre-pandemic rates, as the public
became fearful of attending hospitals and other public healthcare
facilities. This trend created idle resources in terms of healthcare
workers, but it also impacted negatively on hospitals’ incomes, in turn
affecting the ability of the hospital to provide various healthcare facilities
such as free tests and adequate safe and comfortable PPE for staff.
THE AUSTRALIA-INDONESIA CENTRE | PARTNERSHIP FOR AUSTRALIA-INDONESIA RESEARCH 9RAPID RESEARCH PROJECT FINAL REPORT
WORKFORCE MANAGEMENT with suspected exposure to doctors and OHS practitioners. IPC
the COVID-19 virus are usually units in partnership with OHS units
Each hospital adopts different detected through either presenting develop procedures for doctors,
strategies to manage healthcare to a healthcare facility with nurses, patients and families
workers treating COVID-19 patients. specific symptoms, or through to follow (including preventive,
Some hospitals assign dedicated a structured or random testing treatment and rehabilitative) and
healthcare workers to COVID-19 or tracing process. Other health ensure COVID-19 protocols are
patients in SIRs and ICU, while facilities able to carry out tests upheld in the hospital.
others rotate their healthcare are clinics or health polyclinics,
workers between COVID-19 and including special COVID-19 clinics Hospital management has also
non-COVID-19 areas. At the in several hospitals. In hospitals, developed policies for optimal
beginning of the pandemic, several swabs are tested on day one and handling of COVID-19 patients.
hospitals did not have a sufficient two to make a diagnosis. If there is These include forming COVID-19
workforce to handle the rapid clinical improvement, the follow-up handling units, creating safe
increase in the number of COVID-19 for patients with severe/critical service procedures, meeting
patients, and were forced to recruit symptoms is carried out again on the PPE needs of doctors and
additional volunteers from cohorts the seventh day to assess the nurses, and creating or adapting
of healthcare students from patient’s recovery. facilities to support the treatment
pharmacy, midwifery and nursing of COVID-19 patients. Generally,
courses. The local government A patient who tests positive to most respondents affirm that
handled the volunteer recruitment COVID-19 based on the result of the OHS policies and procedures
process while the hospital a swab test will undergo isolation established in their hospitals are
delivered their week-long training. either at the hospital or at home, sufficient to minimise the health
The problem is, these additional depending on their symptoms. Both risks and protect healthcare
workforces can only be assigned referral and non-referral hospitals staff from COVID-19 infection in
for a limited time, and hospitals provide special treatment for the workplace. The challenges,
must rely on their permanent staff. COVID-19 patients, but non-referral however, are found in the
Fortunately, the rise of COVID-19 hospitals can only treat COVID-19 implementation of the procedures,
patients was accompanied by patients with mild or moderate which require a strong commitment
a sharp decline in the number symptoms. If the patient’s to adherence from staff and
of non-COVID-19 patients. As a condition worsens, they will be support from management,
result, staff from this area could transferred to a referral hospital which is often hindered by limited
be allocated to handling COVID-19 with a special facility for handling financial resources.
patients. At the time of this COVID-19. Standard monitoring and
research, most hospitals generally evaluation of the patient’s clinical Isolation facilities
have adequate personnel to handle status is carried out by health
both COVID-19 and non-COVID-19 facilities and includes criteria for Hospitals have implemented
patients. defining categories of patients and separate handling procedures
when they should be hospitalised, for COVID-19 and non-COVID-19
transferred, deemed recovered and patients in emergency departments
3.2. THE IMPLEMENTATION discharged. to ensure that patients receive
OF OHS POLICY IN HOSPITALS proper treatment, and for the safety
T H E I M P L E M E N TAT I O N O F of medical personnel. In many
This section describes procedures Class C and Class D hospitals,
OHS POLICY FOR HANDLING
for handling COVID-19 patients, and which do not have dedicated
C OV I D - 1 9
other OHS policies in the hospitals isolation rooms in their emergency
studied. Class A and B hospitals generally departments, separate areas
have OHS units to establish and are used for COVID-19 and non-
PROCEDURES FOR TESTING confirm the standards for handling COVID-19 patients instead.
A N D A D M I T T I N G C OV I D - 1 9 hazard, emergency and fire
P AT I E N T S conditions. Some hospitals (A1, Regarding procedures for
B1, and C in this study) have also COVID-19 inpatient treatment,
In general, the first procedure most hospitals prepare isolation
established Infection Prevention
is clinical management which rooms to provide treatment
and Control (IPC) Units with the
includes early detection of according to patients’ conditions,
primary task of handling infectious
COVID-19 patients through triage which are generally categorised
diseases, including COVID-19.
and monitoring, case history as either deteriorating, requiring
The unit consists of different
including comorbidities and active treatment (haemodialysis,
stakeholders involved in combating
physical examination. Patients surgery, etc.), or asymptomatic. The
COVID-19 including management,
THE AUSTRALIA-INDONESIA CENTRE | PARTNERSHIP FOR AUSTRALIA-INDONESIA RESEARCH 10RAPID RESEARCH PROJECT FINAL REPORT
wards for patients with a deteriorating laundry washed outfits for healthcare workers and also made their own
condition and requiring further treatment hazmat suits for staff.
are usually equipped with negative
pressures and ventilators. The separation Social distancing
of inpatient wards for the isolation of
COVID-19 patients enables healthcare Hospitals apply social distancing rules with a minimum distance of
workers to carry out the treatment 1.5 metres between people, in order to minimise the transmission of
using appropriate health facilities and COVID-19. This rule applies not only in the COVID-19 emergency room
to perform clinical COVID-19 care at the and ward, but also in the emergency room and general inpatient and
highest standard. The isolation facilities, outpatient facilities. Signs are posted in different locations as reminders
however, still vary between hospitals in for all healthcare workers, patients and patient families.
terms of both quantity and quality.
Human resource management and training
Personal Protective Equipment (PPE)
Several hospitals trained their staff on COVID-19 patient handling
Nurses and doctors handling COVID-19 procedures, especially for nurses. Nurses who would be assigned to
patients are required to use Level 3 handle COVID-19 patients were provided with regular intensive training to
PPE, while those treating non-COVID-19 maintain and update their ability to treat COVID-19 patients safely, and to
patients use Level 2 PPE, as stipulated minimise the risk of contracting COVID-19.
by the Ministry of Health regulation on
As part of reducing the health risk for staff, management prioritises staff
COVID-19 handling. This consists of
with ostensibly lower levels of risk from infection; for example, nurses
hazmat clothes, gloves, shoe covers,
under 45 years of age who do not have comorbidities. Type A and B
masks, face shields, goggles and
hospitals provide accommodation for nurses assigned to treat COVID-19
hairnets. Hospitals also provide a
patients to help them concentrate on their work and minimise the risk of
dedicated room and a detailed procedure
transmission to their families and other contacts outside the hospitals.
for fitting and removing Level 3 PPE,
Work rosters are also adjusted, with some providing two full weeks of
since the removal of Level 3 PPE can be
work followed by two weeks off, to reduce staff exposure to the virus.
a point of transmission of COVID-19 to
Nurses who complete the roster undertake a swab test before they can
healthcare workers.
go home.
Hospitals provide PPE for health
However, these procedures and facilities are not available in all
workers with the help of donations from
hospitals. Class C hospitals, as non-referral hospitals, follow the normal
the public or contributions from the
work roster (pre-COVID) conditions and staff work and return home every
government. The quality of the PPE is
day. Rapid tests can be conducted as needed. Doctors and specialists
critical in ensuring the safety of workers.
are not required to stay in the hospital because of limited resources, and
Unfortunately, some PPE received from
they handle non-COVID-19 and COVID-19 patients alike.
donations or contributions did not meet
quality standards and so could not be
used.
“Some hospitals still struggle to
provide enough protective gear due
to limited funding and difficulties in
inventory planning and control. As
a result, staff sometimes need to
provide PPE themselves, especially
N95 face masks.”
Due to the cost, only certain groups
of staff (mainly doctors) can afford to
purchase the masks. Furthermore,
due to the limited stock of PPE, staff
sometimes reuse equipment, which
poses significantly increased risk of
transmission for both staff and patients.
One respondent reported that in the
early days of the pandemic, the hospital
Source: Viki Mohamad
https://unsplash.com/photos/hYcSP6SpoK0?utm_source=unsplash&utm_
medium=referral&utm_content=creditShareLink
THE AUSTRALIA-INDONESIA CENTRE | PARTNERSHIP FOR AUSTRALIA-INDONESIA RESEARCH 11RAPID RESEARCH PROJECT FINAL REPORT
3.3 S TA F F AWA R E N E S S safe when at a distance from isolation area of a hospital, and
OF AND COMPLIANCE COVID-19 patients, even though staff were aware of the conditions
WITH OHS POLICIES AND they were still in the red zone. Non- of risk. Monitoring was carried out
PROCEDURES compliance by doctors tended to using CCTV, resulting in individuals
occur in the form of their arriving at becoming more compliant with
PROBLEMS OF the hospital without using PPE. infection control protocols. This
AWARENESS AND NON- hospital carried out daily monitoring
COMPLIANCE OF OHS A C H A N G E I N AT T I T U D E of adherence to health protocols
and reported this to management
An interview with a manager in a To address these problems, the monthly. Compliance with OHS
class D hospital suggests that at hospital provided education and protocols in the laboratory was
the beginning of the pandemic, advice to all staff, to remind regarded by a respondent as good,
some medical personnel neglected, each other to adhere to the OHS resulting in no employees being
or even refused, to comply with protocols. This was shown to be exposed. Access restrictions,
hospital OHS policy standards. effective in gradually improving decontamination standards, PPE
Three doctors noted a similar staff compliance with safety use and the application of health
observation: that in the early measures. Compliance also protocols are all believed to have
days of the pandemic, awareness increased after the number of led to this outcome. In contrast,
among medical personnel of the cases in the COVID-19 pandemic the staff external to the SIR, such
risks of COVID-19 was low. Some increased. According to one as administrators, were exposed
doctors were even reluctant to respondent, medical personnel to COVID-19 as health protocols
comply with PPE use. There were began to feel worried or afraid of were not explicitly implemented
also instances where medical exposure to COVID-19 and became for them, because they considered
personnel would congregate increasingly compliant with the their work less risky. Employees
together and not wear masks. This use of PPE, except for several in all areas understood the risks,
appeared to happen when doctors defiant medical personnel. Another but transmission occurred due
interacted with their colleagues, interviewee also said that PPE use to carelessness in non-COVID-19
but not when dealing with patients increased when medical personnel areas.
when they did use PPE. Similarly, began being exposed to COVID-19,
another interviewee reported that and fatality rates started rising. Overall, hospitals have made
administrative officers who visited Respondents reported that periodic significant efforts to ensure staff
the SIR often did not use standard compliance checks have been are aware of the risks of exposure
PPE (appropriate hazmat, goggles, regularly undertaken to minimise to COVID-19 and in promoting
and masks). These staff members the occurrence of COVID-19 adherence to safety protocols.
usually thought that they did not transmission. A manager and two However, awareness of the risks
need to use complete PPE as doctors reported that medical and compliance with OHS protocols
they would not be entering the personnel are required to adhere has varied over time, and across
treatment room, and so they felt to OHS protocols from arrival at different staff groups.
safe. the hospital to departure and that
It appears that over the course of
medical personnel have made
There were other problems with the pandemic, healthcare workers
efforts to confront their colleagues
awareness and non-compliance have become more conscious of
about non-compliance with OHS
regarding social distancing. In the dangers of infection as they
protocols. This cautiousness
general, interviewees reported that have seen firsthand the morbidity
increased after they experienced
doctors displayed a greater level of and mortality associated with the
the loss of a number of their
awareness of and compliance with virus. However, there appear to be
colleagues. Medical personnel
OHS policies and procedures than differences in compliance between
have also required mental health
nurses. A doctor said that several doctors and nurses. Moreover,
support to deal with associated
nurses were found having meals there are indications that non-
grief.
together. Another respondent also clinical workers may perceive their
conveyed similar concerns about According to a manager , the risk of contracting and transmitting
the poor level of adherence with specialised staff who handled the virus as low, resulting in less
OHS policies as they observed COVID-19 cases were highly careful adherence to infection
healthcare staff gathering and compliant, and there was a control practices.
even eating in the SIR. However, low number of infection cases
staff were very disciplined in using reported. Another interviewee
complete PPE when dealing with reported strong compliance of
patients. Staff tended to feel medical personnel in the COVID-19
THE AUSTRALIA-INDONESIA CENTRE | PARTNERSHIP FOR AUSTRALIA-INDONESIA RESEARCH 12“Overall, hospitals have
made significant efforts
to ensure staff are aware
of the risks of exposure
to COVID-19 and in
promoting adherence to
safety protocols. However,
awareness of the risks
and compliance with OHS
protocols has varied over
time, and across different
staff groups.”RAPID RESEARCH PROJECT FINAL REPORT
3 . 4 CHALLENGES ENCOUNTERED PSYCHOLOGICAL BURDEN
B Y S TA F F
Healthcare workers experienced psychological burdens from treating
PHYSICAL WORKLOAD COVID-19 patients and the large numbers of deaths they witnessed.
An increased psychological burden was reportedly felt most acutely at
Interviewees reported that during the the beginning of the pandemic, around March-April 2020, due to the
pandemic, healthcare workers faced developing understanding of the new disease, and through the transition
challenges related to workload, including as healthcare organisations and workers learned how to deal with the
increased mental burdens and physical virus. Staff report varying experiences of psychological stress. Some of
workload. This is attributed to the large the psychological effects include feeling worried, fearful and stressed.
number of COVID-19 patients, especially Some staff members have become paranoid, have experienced trouble
at the beginning of the pandemic (March- sleeping and have become sadder more easily, while experiencing
April). Physical workloads increased decreased work motivation. Their concerns about contracting COVID-19
because the availability of healthcare from patients and transmitting it to their families and other close
workers was limited. contacts added to the psychological burden.
A doctor said that staff experienced “Some healthcare workers experienced anxiety about roles, especially
fatigue due to mental and physical those working in units with large numbers of infected patients such as
pressures. Mental fatigue occurred when respiratory units. These healthcare workers said it could feel as though
dealing with patient behaviour, explaining they were entering a war zone.”
patients’ conditions and providing
treatment for patients. Meanwhile, the The psychological stress has also been aggravated by patients or
discomfort associated with PPE caused families refusing to accept diagnosis and treatment. Their non-
physical fatigue. At the start of the compliance with COVID-19 protocols can also cause stress, both
pandemic, staff often wore PPE for eight while patients are in hospital and during the process of handling the
hours at a time. Hazmat suits cannot deceased. A doctor said that healthcare workers experience dishonesty,
easily be changed in and out of safely, threats, protests, anger or unpleasant actions. Healthcare workers
so healthcare workers often endured also said they lacked support, since others tended to avoid them and
thirst, hunger and heat. They often wore COVID-19 patients due to stigma surrounding infections. This, in turn,
continence aids because they could increased the stress they experienced. Evaluation of the workload levels
not remove their hazmat to use the of healthcare workers, especially during the pandemic, needs to be
toilet. The tropical climate in Indonesia, explored further to obtain a more comprehensive picture of how and
with its high level of humidity, presents why the COVID-19 pandemic causes psychological impacts for health
challenges for workers wearing hazmat workers.
suits for long periods. Fortunately, some
hospitals adjusted their policies and staff
went from wearing hazmat suits for eight
hours per shift to four hours per shift.
Despite the fatigue, interviewees
reported that this did not negatively
impact on their ability to discharge their
duties in serving patients. Respondents
attributed this to their high levels of
commitment to, and empathy for, their
patients. Respondents also reported
that healthcare workers tried to
overcome stress through humour and
playful interactions. Some healthcare Source: Merdeka.com
workers found creative solutions to https://www.merdeka.com/peristiwa/idi-catat-kematian-tenaga-medis-
overcome fatigue, stress or boredom by, akibat-covid-19-di-indonesia-tertinggi-se-asia.html
for example, developing social media
material. However, it is widely agreed that
fatigue can reduce concentration and, in
turn, affect staff performance. It needs to
be carefully addressed.
THE AUSTRALIA-INDONESIA CENTRE | PARTNERSHIP FOR AUSTRALIA-INDONESIA RESEARCH 14RAPID RESEARCH PROJECT FINAL REPORT
FINANCIAL PRESSURES Workload management understandable, given the higher
levels of exposure to COVID-19
Financial pressures also When healthcare workers become patients. This section provides a
presented challenges for both infected and need to be treated detailed description of the potential
healthcare workers and hospitals. or self-isolate, this impacts the sources of the spread of COVID-19
Interviewees reported that several level of staffing available at the among healthcare workers,
hospitals experienced decreases in hospital. As a consequence, the transmission mechanisms, the
the number of patients presenting workload of the remaining staff impact on hospitals of staff
during the pandemic, reducing increases. To reduce workloads, infections, handling procedures for
the income of their workers. This hospitals have made some efforts when a healthcare worker becomes
decrease was due to people’s to reorganise staff allocation infected, and the facilities provided
reluctance to seek treatment and work shift rotations by, for to infected healthcare workers.
or visit healthcare facilities, example, reassigning workers from
especially when they did not require other units or organising specific
SOURCES OF THE SPREAD
immediate care. The exception is work shifts and leave times to
O F C OV I D - 1 9 I N F E C T I O N S
for those with severe conditions overcome worker shortages.
A M O N G H E A LT H W O R K E R S
requiring urgent care, such as Several hospitals have been
chemotherapy patients or those fortunate enough to acquire The potential spread of COVID-19
with kidney failure. The reduced volunteer assistance and support among healthcare workers is high
income posed serious challenges from interns through the Specialist and exacerbated when staff are not
in providing equipment and Doctor Education Program, but not diligent enough in adhering to the
facilities for staff treating COVID-19 all. The expertise of healthcare OHS protocols, including wearing
patients, although no hospital has workers cannot always be replaced masks and keeping adequate
had to reduce their workforce or by others, however. Healthcare physical distances.
staff salaries. Financial challenges, workers in the operating theatre,
however, have become severe for instance, cannot simply be “One key source of health worker
for some staff. Such situations substituted, due to the specialist infection in hospitals is the use
require the support of various skills required. of various shared facilities for
groups, including incentives and staff, such as changing rooms,
donations of high quality, safe and Mental health support dining rooms (where workers
comfortable PPE. The government often eat together in enclosed
also provides additional support Specific task forces have been set spaces), prayer rooms, lifts and
for healthcare workers assigned up in some hospitals to provide bathrooms.”
to COVID-19 SIRs. However, the access for staff to psychologists
or psychiatrists. These mental According to one hospital manager,
respondents quoted in this study
health professionals are many COVID-19 infections in
suggest that the amount provided
provided to ensure that staff are hospitals occurred in the locker
does not adequately account
psychologically healthy, monitor room. Some healthcare workers
for the risks faced by healthcare
the level of psychological burden appear not to follow protocol when
workers.
on staff, and provide treatment/ removing PPE, especially if they feel
psychotherapy to help them fit and healthy. A doctor reiterated
H O S P I TA L S ’ M A N A G E M E N T overcome psychological challenges. that changing rooms turned out
RESPONSES TO THE to be one of the critical areas for
CHALLENGES the transmission of COVID-19.
3 . 5 C OV I D - 1 9 I N F E C T I O N S Infections can occur when staff
Special provisions for infected staff A M O N G H E A LT H C A R E remove their masks and lower
WORKERS their vigilance in the vicinity of
Hospitals also carry out regular asymptomatic colleagues who are
free swab tests for staff at high risk The number of healthcare workers not yet known to be infected.
of infection and perform contact infected by COVID-19 continued to
tracing should staff become increase during this study. Infected Transmission in healthcare workers
infected. Some hospitals provide healthcare workers included also occurs outside the workplace.
free temporary housing facilities doctors, nurses, midwives and There have been several cases
for infected staff such as hotels other administrative personnel. where healthcare workers were
or other accommodation so they The number of infections varied exposed to COVID-19 while off-duty.
can safely carry out self-isolation. between each hospital, although, Healthcare workers have been
However, not all hospitals that in general, the referral hospital infected by family or neighbours.
provide these facilities do so for class (Class A and B) reported When travelling, a high-risk activity,
free. a higher number of infections – these healthcare workers may
THE AUSTRALIA-INDONESIA CENTRE | PARTNERSHIP FOR AUSTRALIA-INDONESIA RESEARCH 15You can also read
