Lived experiences of frontline healthcare workers serving in Indonesia's COVID-19-designated hospital

The study explores how frontline healthcare workers in Indonesia’s largest COVID-19-designated hospital experienced providing patient care amid sustained high infection rates and system overload. Despite vaccine rollout, Indonesia continued to report substantial case numbers during the study period, straining a health system with suboptimal worker-to-patient ratios. The research aims to deepen understanding of healthcare workers’ lived experiences during the COVID-19 crisis to inform evidence-based policy and practice that prioritize worker well-being and strengthen public health infrastructure.

The background situates Indonesia within the global COVID-19 context, highlighting persistent high case prevalence and system strain compared to some Western countries transitioning to sustained management. Prior literature notes intensified pressures on healthcare workers worldwide, with particular emphasis on burnout, resource scarcity, and stigmatization. Comparative insights reference China’s deployment of experienced experts versus Indonesia’s reliance on voluntary and assigned personnel (including military and police), potentially affecting expertise levels and turnover. Ethical challenges around healthcare rationing and decision-making autonomy are noted as pervasive issues, intertwined with political priorities and patient autonomy, shaping frontline experiences. These works frame the study’s focus on the intersection of resource limitations, organizational structures, and worker well-being in a Global South context.

Design: Interpretivist paradigm with a qualitative exploratory-descriptive approach informed by van Manen’s hermeneutic phenomenology. Focus on rich, meaning-oriented accounts of lived experience. Setting: Indonesia’s largest first-line COVID-19-designated hospital in Jakarta, a repurposed apartment complex (10-hectare site, ~7,000 apartments across 10 buildings; total capacity ~22,000). Four buildings converted to COVID-19 facilities with zoned areas: red (patients), yellow (healthcare worker housing/occupation), green (non-service activities). Personnel contracts were temporary/rotational, with monthly rotations and transfers common. Study period: June–August 2021. Participants: Purposive and snowball sampling recruited 13 frontline healthcare workers (8 male, 5 female). Age: 21–30 (n=7), 31–40 (n=3), 41–50 (n=3). Roles: 3 general practitioners, 2 pulmonologists, 2 clinical psychologists, 4 nurses, 2 dieticians. Prior work experience: 1–10 years (n=10), 11–20 years (n=2), >20 years (n=1). Service duration at hospital: >12 months (n=7), 7–12 months (n=3), 1–6 months (n=3). Data collection: In-depth, semi-structured, face-to-face interviews (45–90 minutes), following ethical approval and informed consent. Interviews progressed from exploratory to in-depth probes on care experiences, patient/family encounters, working conditions, and motivations. Audio-recorded; observational notes, memoing, and reflexive journaling supported contextual understanding. Data analysis: Verbatim transcription followed by iterative, inductive thematic analysis guided by van Manen’s holistic, selective, and detailed readings. Authors reflected collaboratively to enhance trustworthiness. Writing/rewriting supported deeper interpretive understanding and consolidation of essential themes capturing the phenomenon.

- Eight interconnected themes emerged from 13 interviews: 1) Succumbing to the system asymmetry: Confusion and dissatisfaction with absent/weak systems and inadequate infrastructure; frequent personnel changes and contract renewals created instability, emotional exhaustion, and frustration. Workers often adapted out of habituation or powerlessness. 2) Becoming subjected to burnout: Heavy workload, especially in swabbing (e.g., 600–700 people/day; mass swabbing ~3,000 staff), and psychological absorption of patients’ distress led to emotional and physical exhaustion. 3) Fears of being infected and infecting others: Strong adherence to precautions; reluctance to return home; social stigma and exclusion from communities when returning. 4) Growing a sense of relatedness with patients: Shared isolation fostered empathy and kinship; efforts to emotionally support patients, including humor and treating patients “as family.” 5) Facing dilemmas with healthcare rationing: Scarcity (e.g., ventilators) forced prioritization (e.g., younger, healthier patients over older with comorbidities); moral distress, guilt, and challenges in breaking bad news. 6) Developing negative emotions in patient interactions: Feelings of inadequacy, blame, anxiety, and guilt; traumatic events (e.g., suicide attempt; ICU deaths); limited autonomy intensified distress. 7) Coping through spirituality and religiosity: Faith-based meaning-making (ikhtiar, ikhlas) supported acceptance of limits, resilience, and commitment to serve. 8) Finding meaning in a life of service: Altruism, calling, and professional identity motivated continued service despite risks (e.g., contracting COVID-19 twice) and burnout. - Operational details: Common red-zone scheduling of 8-hour shifts followed by 32-hour breaks (except swabbing department working 8 a.m.–5 p.m. daily).

The findings illuminate multifaceted burdens on Indonesian frontline healthcare workers in a mega makeshift COVID-19 hospital, where resource scarcity, unstable staffing, and organizational constraints intensify burnout and moral distress. Comparisons to contexts deploying experienced specialists underscore how staffing models and political priorities shape on-the-ground experiences. Social isolation policies both strained workers (family separation, stigma) and fostered patient-worker connectedness, buffering isolation effects. Ethical dilemmas in rationing (scarce ventilators/ICU beds) highlight tensions between equity and efficacy, with downstream emotional toll and perceived blame from families. Restricted autonomy and rigid systems compound stress and undermine perceptions of competence. Coping via spirituality and a sense of calling provides meaning-making that sustains service. These insights argue for systemic, not solely individual, interventions: robust public health investment, human resource management improvements, mental health support, participatory decision-making, and ethical frameworks for rationing that consider patient autonomy and transparent communication.

Frontline healthcare in resource-constrained crisis settings presents complex challenges that exceed structural fixes alone. Sustainable improvements require prioritized public health investment, attention to human resources (stability, expertise, staffing), mental health supports, and ethical, transparent approaches to rationing and communication. Policy must center healthcare worker well-being to sustain care delivery and improve patient outcomes. Future research should broaden sampling beyond a single site, include governmental perspectives to unpack political-institutional dynamics, and further examine interventions that strengthen resilience, autonomy, and ethical practice in crisis care.

- Qualitative hermeneutic phenomenology with purposive sample (n=13) from a single emergency hospital limits generalizability. - Potential underreporting of politically sensitive issues due to governance by state/military authorities and possible repercussions for speaking out. - Temporary/rotational staffing and unique hospital organization may limit transferability to other settings. - Interpretive analysis influenced by researchers’ preconceptions; international collaboration may introduce differing perspectives; however, reflexivity was employed. - Future studies should expand recruitment for broader, more nuanced perspectives and include governmental stakeholders.