key: cord-0696106-m4ww39wd
authors: Hussain, Mehdi; Begum, Tahmina; Batul, Syeda A.; Tui, Nastaran N.; Islam, Md. N.; Hussain, Bashir
title: Healthcare workers during the COVID‐19 pandemic: Experiences of doctors and nurses in Bangladesh
date: 2021-04-05
journal: Int J Health Plann Manage
DOI: 10.1002/hpm.3154
sha: 1d9a7de83140c9f4c99ff3307a1073afec5c94b7
doc_id: 696106
cord_uid: m4ww39wd

Healthcare workers, who are in low‐resource settings, are critically vulnerable during the COVID‐19 pandemic. The increasing rate of coronavirus infection in a developing country such as Bangladesh caused the highest death rate of doctors among frontline service providers and resulted in fear and anxiety among healthcare workers. Even with the preliminary measures of hospitals and clinics to protect healthcare workers, the growing casualties are alarming. This research uses case study approach to explore the issues doctors and nurses face in ‘priority intervention areas’ (PIA) in order to improve the health system quality. Qualitative in‐depth semi‐structured interviews were conducted from 12 May to 4 June 2020 among doctors and nurses from two different private hospitals in Dhaka city. Data were analysed using thematic content analysis. The two significant areas that required immediate attention were identified from the PIA framework as ‘patient and staff safety, infection control’ and ‘cultural aspects and community engagement’. Each area of the PIA framework showed previously ignored issues in the current health system. The adaptation of the PIA framework helped identify critical health system issues. Possible corrective actions including proper planning and management of isolating the infected patients and provision of adequate personal protective equipment are recommended to management and policymakers to save the lives of healthcare workers and to minimise the spread of infection.

Bangladesh is a low-resource country in South Asia which ranks 8th in population and 17th in the order of COVID-19 infection worldwide; its first case was officially identified on 8 March 2020. 1,2 The doctor to patient disparity is significantly high. The International WHO estimated 3.05 physicians per 10,000 population and 1.07 nurses per 10,000 population in Bangladesh based on the Ministry of Health and Family Welfare Human Resources Development Unit. 3 These numbers show healthcare professionals as among the most vulnerable segment in society who need to be protected in order to continue supporting the healthcare system of the country. However, healthcare professionals are critically affected daily during the pandemic as the increasing numbers of infection and death shows Chan-Yeung. 4 In Bangladesh, among frontlines, doctors hold the highest mortality rate from COVID-19 although the actual figure is not available. Thus, it is essential to protect healthcare professionals.

The research explores the issues that doctors and nurses face during the COVID-19 pandemic in Dhaka city, where 58.35% of all COVID-19 patients in the country are located. 5 The study explored two case hospitals using the 'priority intervention areas' (PIA) framework developed by Brugnara et al. 6 The PIA framework also integrates the quality improvement of the WHO building blocks suitable to improve, monitor and evaluate health systems. The enquiry was made based on the PIA framework identified in six areas: 'surveillance', 'basic infrastructures and wash', 'patient and safety, infection control', 'case management', 'maintenance of other routine services' and 'cultural aspects, and community engagement'. 6 The PIA framework used here to explore the issues that doctors and nurses face will help hospital authorities properly integrate to the building blocks that WHO presented in 2007 to the country's health system 7 and to take preventive measures for quality improvement. The adoption of correct prevention measures for the issues identified can also minimise infection rate. 8 

This research used case studies from two hospitals in Dhaka city, which treat the low-and mid-income population in Bangladesh. Given that Bangladesh is a developing country, the socioeconomic profile of patients and the ratio of doctors to patients of the two selected case hospitals represent the situation of most hospitals in the country. The case hospital names are pseudonymised as XYZ Medical College Hospital (XYZ) and PQR Medical College Hospital (PQR) for privacy and ethical consideration. Both hospitals are located within 5 km from the centre of Dhaka and treat the low-and mid-income population of the country. The average bed numbers of each hospital are around 550. Both hospitals approved this research.

A semi-structured interview guide was prepared in line with the PIA framework, where the first question was about the respondents' workplace and task during COVID-19 in order to build a rapport and put the interviewee at ease. The six primary questions used were aligned with the PIA framework. The final question enquired about any HUSSAIN ET AL.

-175 additional important comment to achieve the research purpose. All questions were translated to Bengali. Two senior physicians of XYZ reviewed the English and Bengali versions of questionnaires, which were revised to improve the translation.

From the two hospitals, 15 in-depth interviews were conducted on 10 doctors and 5 nurses who treated or took care of COVID-19 patients. Given that the research was conducted during critical time (May-June 2020) of COVID-19 pandemic, researchers used convenience sampling to select respondents. Interviews were conducted from 12 May to 4 June 2020. Six doctors and three nurses from XYZ and four doctors and two nurses from PQR were interviewed. In this research, doctors and nurses are referred to as 'D' and 'N', respectively, with a subscript 'x' for XYZ and 'p' for PQR. In addition, copies of published photos in the news bulletins and notice boards of the hospitals were also collected with permission. Also two short video clips of the hospitals showing how doctors should wear personal protective equipment (PPE) were collected. Multiple sources of data collection increased the validity, credibility and triangulation. 9, 10 Given that the interviews were conducted during the lockdown period, a non-face-to-face mode was preferred and recommended by doctors, nurses and hospital authorities. Hence, the interviews were conducted either through direct phone calls or video calls through an instant messenger. Each participant gave their consent to record the interviews as full anonymity was assured with regards to voice or name while reporting.

Multiple waves of data collection from two different groups of samples (doctors and nurses) through in-depth semi-structured interviews helped the researchers explore the issues that doctors and nurses face, which are socially and culturally specific and valid in its local context. Interviews were then transcribed and coded in NVivo 12 to analyse the data following thematic content analysis methods. 11 Transcribed data were imported into NVivo 12 to perform first cycle coding or open coding in line with the PIA framework. In the next stage, data were revisited retrospectively for better understanding and refinement of the initial coding to derive the findings.

Findings derived from the interviews are mapped based on six PIA 6 mentioned (Table 1) : comprising surveillance, basic infrastructure and wash, infection control/patient and staff safety, case management, maintenance of other routine services, cultural aspects and community engagement. 

Although the disinfection system improved compared with past routine cleaning services, infrequent cleaning was still observed in both hospitals (Dx6, Np4). In addition, only one booth was available to conduct COVID-19 test of all the stakeholders in the hospital (Nx1 to Np5; Dx1 to Dp10) and everyone-infected and noninfected-stood in the same line almost adhering to each other (Nx1 to Np5; Dx1 to Dp10). This is reflected in the comment of Dp10, 'There is no prior time slot given; as a result, people are coming randomly to the hospital for test. Also, everyone including infected and noninfected patients standing in the same queue without maintaining distance'.

Nurses received only two sets of unsealed PPE packs weekly. The pack for the nurses included only a gown and shoe cover (Nx1 to Np5) and no gloves, masks, or face shields. To protect themselves, they purchased their N95 masks before entering to medical ward. One nurse cried and told that they purchased two masks to use for 10 days.

The masks got wet when used in a 10-h shift for 5 days. After their daily shift, they put the mask in a packet and spray disinfectant (Nx1, Nx3, Np4, Np5). Nx1 even washed the masks in the assigned accommodation to reuse in the next day. Although they tried hard to dry the masks, they were still wet when they put them on the following day. During the interview period, nurses worked for 10 h daily for 10 consecutive days. Np4 also commented, 'They gave us only gown and shoe cover and nothing else. We had to buy N95 masks and reuse them by washing. They were still wet'. were limited for them to be treated in their hospitals.

There were no coordination and time management in the testing booth to set a schedule for specific COVID-19 patients, as well as for doctor and nurse cohorts (Dx1 to Dp10; Nx1 to Np5). Doctors, infected patients, nurses, HUSSAIN ET AL.

-177 cleaners and other support workers all gathered in a small room in line to be tested. 

Nurses complained that the hospital transformation into a COVID-19 hospital facility was not properly communicated (Np5). Nurses were trained in English by foreign trainers which led to misunderstanding (Nx1, Nx2).

Doctors and nurses were also given short periods to treat patients, which left them dissatisfied with their work performance.

Pharmacies also lacked medicines during the COVID-19 crisis (Nx1, Np3). The high demand resulted in short supply of disinfected materials and routine cleaning services (Dx2, Nx1, Np4). Nx1 commented, 'Hospital does not have sufficient cleaning and disinfecting materials. Sometimes during cleaning schedule no actual cleaning is performed'.

Due to attendants' restriction in hospitals, patients walked around everywhere in the hospital premises, which increased contamination threat (Nx3, Dp7).

Nurses complained that they found COVID-19 infected ward patients walking around the hospital and brushing their teeth (Nx1, Nx2, Np4). Although nurses frequently complained about this behaviour, the situation remained the same. Again, due to lack of medicine, infected patients walked out of the hospital and even went to drugstores without wearing masks in most instances (Nx2, Nx3, Nx5).

Nurses were the most vulnerable in the hospital as they were frequently subjected to the abusive behaviour of patients (Nx1 to Np5). According to Nx2, 'I am coming every day for the last eight days and none of the day is free from any misconduct by the patients. Such as, visitors are restricted to enter hospital and so they yell. Again, we are very few and patients do not get us when they ask for and so they yell. It is all time scenario'.

Such abusive behaviour is a mental burden for nurses at their workplace. The sad part revealed in the research was that most frontline doctors and all the nurses did not receive 3 months' salary since February until the time the interviews were conducted (Dx2, Dx4, Dx5, Dp7, Nx1 to Np5). However, they continued work in this uncertain time 178of the pandemic with the feeling that they are doing good for the community and with the hope that they will receive their salaries soon.

The present research underpins the PIA framework to investigate issues that healthcare workers faced during the COVID-19 pandemic and to identify critical areas to take preventive measures for quality improvement. The research reveals that, 'surveillance' calls for a well-functioning health information system that ensures the production, analysis, dissemination and use of reliable and timely information on health determinants and issues, as well as health system performance. Hospitals can use e-health and social media strategies to document and monitor the issues or attempts taken by frontline professionals to become informed in the growing pandemic situation. 12 Basic facilities need to be available on time to be operational with particular attention given to the availability of essential medical materials for hygiene and waste disposal; the frequency of spraying disinfection liquids with monitoring the cleanliness; and the required promotion materials such as leaflets distribution, stickers or marks given on the floor to maintain social distancing. [13] [14] [15] The layout of the hospital or clinic can be altered in different zones, and patients can be transferred based on their responses following the flowchart recommended by Kim et al. 16 and supported by Tan. 17 Personal protection of the doctors and nurses can be ensured with a full set of PPE worn properly. The PPE set includes a disposable work hat, an N95 respirator, inner gloves, a protective eye mask, protective clothing, disposable waterproof shoe covers, disposable isolations gowns, outer gloves and a face shield. A monitoring system or infection control system needs to be established to monitor any breach or deviation from the risks associated special attention caution message or stealing PPE from the sealed packet. 18 Shammi et al. 19 found some mismanagement and a lack of coordination among the responsible parties, which can be resolved by introducing a monitoring cell or by using information system technology. 12 They also showed that present national guidelines on the clinical management of COVID-19 lack detailed guidelines for protecting healthcare workers. 20 The 'cultural aspects and community engagement' area is identified as the second critical problem after 'staff safety'. National dailies delivered news about vulnerable treatment facilities for doctors and nurses, fear of getting loved ones infected when living in a small house, and not being able to physically look after their children, which took a lot of mental toll in this critical time 19. At the hospital and national levels, special attention should be immediately given to the safety and treatment of healthcare professional while ensuring that they will be offered emergency services. 21 

The elevated infection during the COVID-19 pandemic in Bangladesh necessitates the protection of healthcare professionals and the improvement of the health system. In health facilities with limited resources, healthcare professionals are the only chief actors to treat the growing number of infected patients. A practical list of issues the healthcare workers face in 'PIA' is identified through in-depth interviews and analyses. By applying the PIA framework, a holistic picture can be portrayed to reflect the known and unknown issues that healthcare professionals face in the workplace during the COVID-19 pandemic. The issues revealed in the research recommend that concerned stakeholders take immediate effective measures to holistically minimise the casualties of healthcare professionals. Ensuring their safety can significantly minimise the spread of infection in the country and improve its health system.

The research is limited to doctors and nurses only. Further research on other cohorts of health support workers such as nursemaids, ward boys, cleaners, gatekeepers and clerks in the same healthcare setting may HUSSAIN ET AL.

-179 strengthen the arguments made here. The PIA framework can also be used to explore issues in rural settings where community health workers are more active. However, this study only included doctors because of the immediate concern about the increasing casualties of both doctors and patients and their high demand in health facilities in the country. Further research needs to be done to advance the discussion and to generate additional evidence on issues from health support workers.

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The authors wish to thank all the doctors and nurses who participated in the interview from the hotel at their quarantine period to share practical experiences they gained while working.

The authors declare that there are no conflict of interest.

Approval was taken by from the hospitals prior to conduct the research. This article is authors' own original work.

This paper reflects authors' own research and analysis in a truthful and complete manner.

https://orcid.org/0000-0001-5544-6219