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Occupational Health and Safety (OHS): Protecting the Indonesian Healthcare Workforce during the COVID-19 Pandemic - The Partnership for Australia ...
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
Occupational Health and Safety (OHS): Protecting the Indonesian Healthcare Workforce during the COVID-19 Pandemic - The Partnership for Australia ...
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.
Occupational Health and Safety (OHS): Protecting the Indonesian Healthcare Workforce during the COVID-19 Pandemic - The Partnership for Australia ...
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
Occupational Health and Safety (OHS): Protecting the Indonesian Healthcare Workforce during the COVID-19 Pandemic - The Partnership for Australia ...
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.
Occupational Health and Safety (OHS): Protecting the Indonesian Healthcare Workforce during the COVID-19 Pandemic - The Partnership for Australia ...
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.

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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

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      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

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Occupational Health and Safety (OHS): Protecting the Indonesian Healthcare Workforce during the COVID-19 Pandemic - The Partnership for Australia ...
“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).

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      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).

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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

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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.

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      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,

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RAPID 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

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RAPID 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                                 14
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      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

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