Coronavirus disease 2019 (COVID-19) has caused a global health crisis that has required emergency responses in all countries, including Indonesia. As of May 22, 2020, a total of 20,796 people have tested positive for COVID-19 in Indonesia, and the mortality rate has reached 6.4 % (Indonesian Task Force for the Acceleration of Handling COVID-19, 2020). The increasing number of confirmed positive patients and deaths due to COVID-19 has caused an unprecedented health crisis among Indonesian communities, patients, health workers, and the healthcare system. Based on the data from the COVID-19 Handling Team of the Indonesian National Nurses Association (2020), 69 nurses had tested positive for COVID-19, and 21 had died from the disease. Health workers who are at the forefront of handling COVID-19 need to adapt to the new situation in their work environment and try to overcome these stressful circumstances (Liu et al., 2020). This study aimed to examine the factors that cause and reduce health workers’ stress as well as the coping mechanisms used by health workers and to determine what motivates health workers to continue working in the face of the COVID-19 pandemic.
Online cross-sectional surveys via Google Forms were used in this study, which was conducted using snowball sampling through the WhatsApp platform from March 18 to April 30, 2020. This study was approved by the Health Research Ethics Commission of the Faculty of Nursing at Airlangga University (ethical clearance letter No. 2005-KEPK). The participation of the respondents was voluntary, and they were not coerced in any way. The survey questionnaire was an adaptation that was used in the research undertaken by Khalid et al. (2016) for health workers during the MERS-CoV epidemic. The modified questionnaire used in the present study was called the COVID-19 Health Personnel Questionnaire. The questionnaire consisted of 5 sections with 53 question items written in Indonesian. The sections of the questionnaire explored health workers’ feelings (9 items), the factors that caused their stress (17 items), and those that reduced their stress (10 items), the coping mechanisms used by health workers (8 items), and the factors that motivated health workers during the COVID-19 outbreak (9 items).
The descriptive analysis of the 236 health workers who were working in community health centers, hospitals, and volunteers during the COVID-19 pandemic showed that the average age was 33 years, with average work experience of 10 years. The majority of the health workers were women (74.6 %), nurses (65.3 %), married (59.7 %), and living with family (85.2 %). Most of the health workers had received sufficient information related to COVID-19 (94.1 %). Where further information was required, it was obtained from social media/the internet (78.4 %). Furthermore, 73.7 % of the respondents indicated that their activities or work had been disrupted due to the outbreak of COVID-19.
The most prominent results related to the feelings of the health workers felt that they had to do this work because it was their duty, and they were fulfilling their ethical obligations (97.9 %). Additionally, 97.9 % of the health workers appreciated that the hospitals gave special rewards for the work they were doing. The most significant stressor was the requirement to wear personal protective equipment (PPE) every day (96.2 %). In contrast, the main factor that reduced their stress was that all health professionals worked together on the frontlines to overcome COVID-19 (93.7 %). The three coping strategies most commonly used by health workers to deal with the COVID-19 outbreak were adopting a positive attitude to motivate themselves (98.3 %), reading about COVID-19 and its prevention and transmission (98.3 %), and following appropriate self-protection measures (mask, gown) (98.3 %). Family support was a significant factor motivating health workers to deal with the COVID-19 outbreak (98.7 %). The results of the study are more fully described in Table 1 .
Table 1.
Health workers’ feelings (score: 1–5), factors that caused stress among health workers (score: 1–5), factors that reduced stress among health workers (score: 1–4), health workers’ personal coping mechanisms (score: 1–5), and factors that motivated health workers (score: 1–4) during the COVID-19 outbreak.
| No | Feelings of Health Workers during the COVID-19 Outbreak | Yes (%) |
No (%) |
Average Mean (SD) |
|---|---|---|---|---|
| 1 | Feel that you have to do work because this is your job as a health professional, and you need to fulfill your ethical obligations. | 97.9 | 2.1 | 4.22 (0.69) |
| 2 | You appreciate that hospitals give special rewards for your work. | 97.9 | 2.1 | 4.19 (0.868) |
| 3 | You appreciate the existence of financial compensation during this pandemic. | 91.5 | 8.5 | 3.64 (1.259) |
| 4 | You don’t like to do overtime work. | 83.9 | 16.1 | 2.91 (1.213) |
| 5 | If you could choose, you would choose not to work in a unit where you are exposed to this COVID-19. | 82.2 | 17.8 | 2.86 (1.230) |
| 6 | You have noticed that health workers outside your unit avoid suspect/positive COVID-19 patients. | 78.8 | 21.2 | 2.73 (1.263) |
| 7 | You feel angry because your workload is increasing compared to staff who are not exposed to COVID-19. | 67.8 | 32.2 | 2.18 (1.132) |
| 8 | You feel that staff who are not directly exposed to this disease stay away from you. | 47.5 | 52.5 | 1.76 (0.978) |
| 9 | During this pandemic, you at least once to take time off due to illness. | 46.6 | 53.4 | 1.78 (1.042) |
| No | Factors That Caused Stress among Health Workers during the COVID-19 Outbreak | Yes (%) |
No (%) |
Average Mean (SD) |
|---|---|---|---|---|
| 1 | You have to wear PPE every day. | 96.2 | 3.8 | 3.96 (1.053) |
| 2 | You hear reports of new cases in the media. | 92.4 | 7.6 | 3.46 (1.097) |
| 3 | There is a lack of staff. | 87.7 | 12.3 | 3.29 (1.255) |
| 4 | You do not know when COVID-19 will be brought under control. | 87.3 | 12.7 | 3.17 (1.253) |
| 5 | You feel that there are no adequate protective measures (e.g., PPE) against COVID-19. | 86.4 | 13.6 | 3.23 (1.321) |
| 6 | You see that your coworkers are stressed or scared. | 85.2 | 14.8 | 3.00 (1.203) |
| 7 | A small mistake or losing concentration for a short time can cause you to contract the disease. | 84.3 | 15.7 | 3.19 (1.301) |
| 8 | You could transmit the virus to your family or friends. | 83.1 | 16.9 | 3.2 (1.343) |
| 9 | You feel emotionally tired. | 82.2 | 17.8 | 2.95 (1.252) |
| 10 | You feel stressed every time you are exposed to a new patient. | 82.2 | 17.8 | 2.78 (1.145) |
| 11 | You feel conflicted between carrying out your tasks and maintaining your personal safety. | 81.4 | 18.6 | 2.96 (1.254) |
| 12 | You are experiencing stress/physical fatigue. | 81.4 | 18.6 | 2.89 (1.233) |
| 13 | You feel stressed when you see your coworkers being treated for the disease. | 80.1 | 19.9 | 2.81 (1.211) |
| 14 | You feel stressed when taking care of coworkers who are sick because of COVID-19. | 73.3 | 26.7 | 2.52 (1.225) |
| 15 | You feel stressed when a colleague displays the same symptoms as the symptoms of COVID-19. | 59.7 | 40.3 | 2.10 (1.112) |
| 16 | You have experienced symptoms of respiratory distress and are afraid of suffering from COVID-19. | 54.7 | 45.3 | 2.15 (1.302) |
| 17 | You have a viral infection from a patient in the hospital. | 36.0 | 64.0 | 1.67 (1.053) |
| No | Factors That Reduced Stress among Health Workers during the COVID-19 Outbreak | Yes (%) |
No (%) |
Average Mean (SD) |
|---|---|---|---|---|
| 1 | All health professionals work together on the frontlines to overcome COVID-19. | 93.7 | 6.4 | 3.46 (0.680) |
| 2 | No staff has contracted the virus after taking strict precautions. | 93.2 | 6.8 | 3.24 (0.609) |
| 3 | Your colleagues in your department have a positive attitude. | 91.5 | 8.5 | 3.22 (0.692) |
| 4 | Improved patient health conditions | 90.7 | 9.3 | 3.21 (0.608) |
| 5 | Clear guidelines from the hospital regarding infection prevention | 86.4 | 13.6 | 3.17 (0.704) |
| 6 | Your family members and friends outside the hospital are not infected with the virus. | 85.2 | 14.8 | 3.17 (0.722) |
| 7 | Your infected partner gets better. | 84.7 | 15.3 | 3.09 (0.690) |
| 8 | The hospital provides self-protection equipment to staff. | 81.8 | 18.2 | 3.15 (0.814) |
| 9 | The decreasing number of cases reported in the news | 75.0 | 25.0 | 2.92 (0.842) |
| 10 | You trust the staff in your hospital to care for you if you find that you are infected with COVID-19. | 61.0 | 39.0 | 2.71 (0.866) |
| No | Personal Coping Mechanisms Used by Health Workers during the COVID-19 Outbreak | Yes (%) |
No (%) |
Average Mean (SD) |
|---|---|---|---|---|
| 1 | You motivate yourself to face COVID-19 by adopting a positive attitude. | 98.3 | 1.7 | 4.42 (0.792) |
| 2 | You have read about COVID-19, how to prevent it, and how it spreads. | 98.3 | 1.7 | 4.30 (0.798) |
| 3 | You follow the appropriate steps to protect yourself (mask, gown, etc.) | 98.3 | 1.7 | 4.19 (0.967) |
| 4 | You avoid public places to minimize exposure to COVID-19. | 97.9 | 2.1 | 4.24 (0.873) |
| 5 | You keep yourself busy at home to stay away from COVID-19. | 97.5 | 2.5 | 3.94 (0.989) |
| 6 | You store your clothes for work separately and wear hospital clothes to minimize transmission. | 91.9 | 8.1 | 4.04 (1.259) |
| 7 | You avoid overtime to reduce exposure to patients with hospital infections. | 89.0 | 11.0 | 3.34 (1.198) |
| 8 | You carry out health checks to ensure you are not infected. | 83.9 | 16.1 | 3.30 (1.389) |
| No | Factors That Motivated Health Workers during the COVID-19 Outbreak | Yes (%) |
No (%) |
Average Mean (SD) |
|---|---|---|---|---|
| 1 | Family support | 98.7 | 1.3 | 3.81 (0.478) |
| 2 | Adequate protective equipment at the hospital | 98.3 | 1.7 | 3.79 (0.483) |
| 3 | Drugs or vaccines available for the disease | 97.5 | 2.5 | 3.72 (0.536) |
| 4 | Compensation for families if staff die due to disease infection | 95.3 | 4.7 | 3.58 (0.637) |
| 5 | Financial appreciation for the efforts that have been made | 94.9 | 5.1 | 3.51 (0.649) |
| 6 | Psychiatric help and therapy to reduce stress and anxiety | 94.9 | 5.1 | 3.46 (0.661) |
| 7 | Acknowledgment from management and supervisors for the efforts that have been made | 89.8 | 10.2 | 3.34 (0.729) |
| 8 | Not forced to do overtime work | 89.4 | 10.6 | 3.31 (0.692) |
| 9 | Consequences for staff who do not participate in dealing with the disease | 77.1 | 22.9 | 3.04 (0.829) |
Health workers are at the forefront of dealing with health problems due to the COVID-19 outbreak. Health workers have an obligation to provide health services during the COVID-19 pandemic. It is important to recognize that health workers have been doing difficult and invaluable work during this time of the pandemic (Cox, 2020). Health workers in clinical settings have an important role in the early detection and treatment of patients, so they are required to use PPE every day as the best protection of healthcare workers (Ha, 2020; Sharma et al., 2020). However, using PPE everyday causes discomfort, so it becomes a stressor for health workers. Discomfort from using PPE includes adverse skin reactions, respiratory difficulty, heat stress, dizziness, and nausea (Yuan et al., 2020). One of the strategies that can be done to overcome this problem is by providing adequate PPE training to increase safety and comfort (Herron et al., 2020).
In these challenging times, health workers need adequate support to increase their productivity and keep them motivated (Pathania et al., 2020). This study indicated that for healthcare workers in Indonesia, family support is the main factor that motivates healthcare workers to provide health care services during the COVID-19 outbreak. So it is important to provide opportunities for healthcare workers to make contact and gather with families to provide mutual support. If it is impossible to meet family members, then each family member needs to communicate regularly by sending positive messages and motivating health workers to deal with the COVID-19 outbreak in a good psychological condition. Notwithstanding, good collaboration between professionals, effective preventive measures, and a positive attitude when dealing with the pandemic also play an important role in reducing stress. The availability of adequate information and support from hospitals also helped motivate the health workers in this study to deal with the outbreak.
Financial disclosure
This work was supported by Professor and Doctor Grant 2020, funded by the Faculty of Medicine, Universitas Brawijaya (Number: 3394.1/UN10.F08/PN/2020).
Contributions
All authors conceived the presented idea, developed the theory and concept, and carried out the research. All authors contributed to the statistical analysis and interpretation of data. All authors discussed the results and contributed to the final manuscript. The manuscript has been seen and approved by all authors.
Declaration of Competing Interest
The authors report no declarations of interest.
Acknowledgements
The authors would like to express their gratitude to all who contributed to this research, particularly the respondents, the East Java Provincial Health Office, and Universitas Brawijaya.
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