Abstract

Evaluation of the implementation of the Standard Laboratory Midwifery Diploma III Program is a study that aims to 1) find problems and laboratory gaps in the study area compared with existing standards. 2) provide inputs to improve the competence of prospective midwives. 3) provide recommendations to the institution to improve the laboratory to be more in line with the standards; and 4) provide recommendations to the Agency for Development and Empowerment of Human Resources Health for the improvement health provider. The ultimate goal is to determine if the standards require revision in order to leverage their use and facilitate their application, which will enhance the skills and competence of prospective midwives. Data were collected from respondents through interviews, observations, document review and records. From the analysis and interpretation of the data known the results showed that; institutions have formulated laboratory objectives with reference to the Laboratory Standards Diploma III Midwifery, and strategies in the application of standards are also met. However, laboratory personnel, Standard Operating Procedures (SOPs) and programs implemented have not complied with the standards. This limitation is a discrepancy at the installation stage and disrupts the program implementation process so that it can be said that at the early stage of the process there is a discrepancy with a predetermined standard. At the product stage, the results of program implementation are in accordance with the standards.

1. Background

The Diploma III Midwifery Study Program is a vocational education, preparing students for jobs with midwifery skills. The graduates produced must be in accordance with the national standard of higher education with minimum competency covering knowledge, attitude and skill. In order to produce skilled and competent graduates before the student performs her clinical competence in the human being who will be her patient, she must first study with models and simulators to avoid mistakes if practiced directly on humans. Once they are able and competent in their model performance, they may perform clinical practice on humans with guidance, until they achieve the expected competence. After that they may conduct themselves without guidance and can be declared competent.

The Diploma III Midwifery Curriculum consists of 60% Practice and 40% Theory. ⁸ The practice is in the laboratory and in the practice field (Hospitals, Public Health Centers, Midwives Private Practice and Community). While the curriculum is strengthened by the group reviewing and improving the existing curriculum, it is also necessary to identify the equipment and materials needed for the application of the curriculum. The tools required are defined by the science and skills to be mastered, in accordance with the teaching methodology used ⁶. Currently the condition of existing laboratory facilities in each institution is different. The average depends on the preparation, readiness and needs of the Laboratory conducted by each Institution on the implementation of existing standards and generally completed gradually. There are institutions that have complete laboratory conditions, but there are many other Institutions that have minimal laboratory conditions. This will greatly affect the quality of the practical learning process in the laboratory.

To improve the quality and accountability of healthcare educators who are able to face challenges in accordance with national and global demands, the Ministry of Health has set a Laboratory Standards of Health Education Laboratories, which aims to encourage all Health Educational Institutions to strive to develop and fulfill equipment and consumables in accordance with the competencies set in the curriculum. It is expected that the quality of Health Care Education graduates will increase and can compete in the global market. (Decree of the Minister of Health of the Republic of Indonesia No. HK.03.05/ IV/14354.1/2010 on the Laboratory Standards of Health Personnel Education) and one of them is the Midwifery Laboratory Standards (Midwifery Diploma III) ¹.

Standard Laboratory of Diploma III Midwifery has policies regarding the mission, vision and purpose of laboratory. Standard Laboratory aims as a reference for managers of the health education providers in the effort to develop laboratory facilities, including the Standard Laboratory Midwifery namely:

1. Planning and development of types and quantities in the procurement and fulfillment of laboratory equipment and consumables expressed in ratios with learners according to the competencies to be achieved by learners based on the curriculum.

2. Determining the uniformity of buildings and laboratory design expressed in ratios with learners.

Since the issuance of the Midwifery Laboratory standard for this Midwifery Program in 2010, until now there has not been a thorough or partial evaluation of the standards already implemented by midwifery education institutions, including private and public midwifery education institutions around the country. General observation reveals that some midwifery laboratory problems can now be summarized as follows;

• The condition of existing laboratory facilities in each institution generally varies.

• Average depends on the preparation, readiness & needs of the Laboratory conducted by each Institution on the implementation of existing standards.

• Generally, the laboratory is completed gradually. Some institutions that have complete laboratory conditions, Yet some have very minimal laboratory conditions.

• The condition of the laboratory will greatly affect the quality of the learning process of clinical practice of midwifery students

• This is reflected in the average of passing grades for competency test of student’s midwives ranging from 40% to 75 % nationally in the year from 2014 to 2017.

Reference ⁴ in his Program Evaluation; described evaluation uses inquiry and judgment method including; (1) determining standards for judging quality and deciding whether those standards should be relative or absolute, (2) collecting relevant information, and (3) applying the standards to determine value, quality, usefulness, effectiveness, or significance. It leads to recommendations intended to optimize of the evaluation object in relation to its intended purpose(s) or to help stakeholder determine whether the evaluation object is worthy of adoption, continuation, or expansion.

Reference ⁷ in his book Discrepancy Evaluation, argues that; At the outset, it is obviously important to determine what is meant by program evaluation. At least five definitions are considered: (1) the judgement of authorities about a program; (2) the opinions of the program staff; (3) the opinion of those affected by a program; (4) a comparison of actual program outcomes with expected outcomes; and (5) a comparison of an executed program with its design.

This gap evaluation model is not intended to prove causal relationships, but to understand the best evidence possible in making plausible assumptions about causes and impacts. Standards are: criteria developed and established with effective results. Performance is; sources, procedures, management and tangible results that appear when policies are implemented. The key to evaluating this gap is comparing performance with predetermined objectives.

The concept of the Discrepancy Evaluation Model (DEM) is similar to the concept of the Goal Based Evaluation Model proposed by Ralph Tyler. This evaluation model generally measures whether the objectives implemented in a program can be achieved or not by focusing on data collection and information aimed at measuring the achievement of policy objectives for accountability and decision-making. ⁹ The model is essentially a troubleshooting procedure to identify weaknesses and to take corrective actions. With this model the process of evaluation depends on the steps and contents of the category as a way of facilitating future comparison.

Reference ⁷ further explains that; evaluation of the DEM model program has five stages known as; a) Design, b) Installation, c) Process, d) Product, and e) Cost. At each stage, comparisons are made between reality and some standards. This comparison often shows the difference between standard and reality; this difference is called a gap.

Basically comparisons are made at each stage, then the information gaps are provided to the program staff, giving them a rational basis for making judgments on their programs. The Discrepancies Evaluation Model was chosen because of it is in accordance with the research charactistics, i.e., a further discrepancy between each component that is evaluated (standard) from the implementation of the Diploma III Midwifery laboratory standard (policy). According to ⁷, evaluation is a tool to enabled judgments about the deficiencies and advantages of a program according to identified standards and measurements of performance.

Reference ⁷ also suggests that the gap evaluation model uses a formative and system-oriented approach that emphasizes the importance of understanding accuracy as a means of facilitating comparisons of program performance with standards. The argument is that all programs have a life cycle consisting of steps to develop an evaluation activity defined by the integration of each component. The evaluation is done by a comparison between the standard and performance, and can be seen as the difference between the standard with the resulting performance to improve the quality of the program. The standard-program-gap cycle is performed by analyzing individual components and sub-components in the context of input-output analysis.

The evaluation of the implementation of Diploma III midwifery laboratories standard in the Jakarta area of Indonesia use Discrepancy Evaluation Model developed by Provus. The model was chosen because it corresponds to the research characteristics, i.e., it dives deeper into the gap between each component evaluated (standard) and the implementation of those standards by the Diploma III Midwifery institution. The evaluation consists of a comparison between Performance (P) and Standard (S). The comparison produces Discrepancy (D) information that can be used as a basis for making an informed decision on the benefits of the object being evaluated. The purpose of evaluation is to improve the program by making the SPD (Standard Performance and Discrepancy) cycle. The implementation of "S" is action-oriented planning and how to implement "S", i.e,. perform component analysis; by dividing the program into the main activities, functions or components. Each component can be subdivided into subcomponents and detailed according to the program needs.

To describe the practical description of each component, an input-output analysis is performed for each component and subcomponent. That is, it assumes a goal-directed program activity and each activity has one or more objectives. These objectives may be conditions, behaviors, real products, or any purpose of an activity to be realized (output). The focus of the gap evaluation is to compare results of performance with the standards/objectives based on the parameters in the formal documents of the program. The key elements in this model are S (standard), P (performance) and D (discrepancy), which refers to the difference between a standard and real performance. Evaluators can modify the standard as M (modify), R (recycle), or T (terminate or stop) as appropriate to the evaluation program at each stage.

The plan of the evaluation program can also be tested on its comprehensiveness, its compatibility with the situation, relationships with parties and known needs, and others. The program plan serves as a standard (S) for evaluation to be implemented throughout the program life cycle. The program plan determines and directs the program's implementation and serves as a standard (S) for input, process, and outcome evaluation. For example, each program uses different types and resources over time. The program plan determines the amount and type of resources for different activities and objectives. Thus, "P" information can be collected on whether the planned resources are available and the facts are used as needed (input evaluation).

Process evaluation includes determining whether planned activities have been carried out as planned and whether they match the expected quality "S" in the program plan, which defines and explains the process of the program to be implemented. Outcome evaluation refers to determining whether planned outcomes can be achieved. Outcome evaluation is useful when it distinguishes at least 2 outcome classes, interim and terminal.

The interim outcomes or enabling or interim outcomes refer to the milestones or targets that are fundamental to program execution over time. Conversely, the final destination (terminal objectives) refers to the main purpose of a program. The input, process, and output specifications for each component and sub-component must be precisely determined in order to determine the relationship between all subcomponents, and the amount that should be available as a standard (S) for input, process, and outcome evaluation. This allows for ongoing evaluation throughout the life of the program because "P" data can be collected against a larger program character class than only the final destination. Finally, the gap information (D-discrepancies) discovered during the evaluation can be used to support two categories of management actions. Such information may be used to exercise greater control over the operation of the program, in order to ensure "P" meets the "S". On the other hand, management may decide that the standard (S) is in fact unsuitable or less realistic and may have to be changed. (M, R, or T)

The Discrepancy Evaluation Model (DEM) is chosen because it is suitable to be used to find out the program effectiveness by exploring the gap that occurs in the performance of program implementation in the field. There are five stages: The first stage, design, defines the DEM evaluation stage, preparing work plan and preparing research instruments. The second stage, determining the operational step (installation), examines the various literature/data about the carrying capacity of the program. The third phase, interim products/process, is collecting, then analyzing data to discover the relationship between process and interim results. The fourth stage, the end result, (terminal products), compares the results with the finding an alternative solution. The fifth stage, cost benefit, is comparing the cost of the program evaluated with other programs that produce similar results. The theories are then associated with the results of the evaluation obtained in the study to reach meaningful conclusions for the improvement of laboratory quality DIII midwifery.

2. Methodology

This research was conducted in 2017 at Private Institute of DIII midwifery in Jakarta, with two willing institutions that were selected based on having current valid Accreditation Level B in 2016-2017. Other institutions were not elected to participated because they have not been accredited, have not been reaccredited, their accreditation has expired, or they continue to have only a grade C accreditation status.

This qualitative research study, examines things the actual situations and conditions experienced by the object of the research (the laboratories and the people who manage and teach in them), trying to understand or interpret the phenomenon in relation to the given meaning to these things. Reference ⁵ says; "In qualitative research we see that the main features are different in every research process: exploring the problem and developing a detailed understanding of a central phenomenon; making the literature review play a small role but justifying the problem; stating the research aims and questions broadly and broadly including the experience of the participants.

This research uses the evaluation method of program implementation. Reference ² in his Program Evaluation an Introduction, states that program evaluation is a hard practical endeavor, not an academic exercise, and not a major part of an attempt to build a theory or need to develop social science (though it would be great if it happened).

The evaluation is an early check by the program staff to see if all the essential elements are in place or fulfilled and if they go according to plan. With this method, the object of the research, the implementation of laboratory standards Diploma III Midwifery will be described. That is, each stage, design, installation, process and output of the implementation of the program under study will be described and analyzed. With this method also, the causes of incompatibility or gaps (discrepancies) if any, between the purpose and implementation of the program can be illuminated.

Descriptive statistics will be used to explain the object of research to explain and describe the object of the research and the findings made through interpretation of relevant data as well as relationships between the data. To evaluate the implementation of the Diploma III Midwifery Laboratory standard, we must measure the actual gap in the implementation of the Diploma III midwifery laboratory standard.

3. Result and Discussion

The following explanation of the results of our examination of the two DIII Midwifery Laboratories offers a clearer conclusion about this research effort and is described below.

In this case each institution has formulated the purpose of the laboratory by referring to the Diploma III Midwifery Laboratory Standard, which aims as a reference for the organizer of health education providers (Diploma III Midwifery) in an effort to develop laboratory facilities. From the evaluation it was found that this standard has helped educational managers in implementing and developing midwifery laboratories. Students can learn the maximum in the Lab and have clinical practice on models and simulators before actual practice with humans. The objective is the laboratory as a place to offer students the opportunity to hone their clinical skills before they are said to be competent to practice in humans (their clients). Students are obliged to graduate from the laboratory first, then they can practice under the guidance of a clinical supervisor or preceptor in the field of practice. The laboratory also can be used by lecturers to facilitate their own knowledge and clinical skills.

In formulating objectives there was no discrepancy found in the implementation.

The availability of these 8 standard criteria was followed in regards to the models and simulation equipment as well has the supply of linens and consumables according to their needs. The physical building and the layout of the laboratory are also set up according to this laboratory standard and implemented with respect to comfort and safety in work and study. Room facilities and storage cabinets have been adapted to the technical needs of each laboratory, including recording, administration and security in laboratory work. The laboratory implementation strategy have met all 8 standards, and no discrepancies were found in the implementation of the strategy.

Both study programs are very concerned about the achievement of student learning as they progress toward competence. Lecturers, who are the academic supervisors of students, are the main human resources in moving the learning activities into the laboratory. They do the guidance in the laboratory in accordance with the skills that must be completed by the students. The lecturers are responsible in making sure that the student’s competence is achieved before the student is allowed to practice on real human. This laboratory activity has been arranged and scheduled according to the academic calendar. In fact, sometimes students and supervisors make an additional time on the schedule if deemed necessary; it is very dependent on the skills that can be achieved by students in given period of time, which can vary between different students. Eventually, all of the students in a class or cohort must achieve the required level of competency. Laboratory activities can be done well, if the proper effort and time have been devoted to them; when, all the activities of students and lecturers have been done as planned and recorded, student competence can be acquired before they have the test.

The main resources in the laboratory is the laboratory manager, the head of the laboratory unit, and the laboratory assistant/technician/ staff. Although the laboratory manager is only two people, so far there has been no difficulty in managing the laboratory. In this case no discrepancy was found between standards on human resource activities in the laboratory and its implementation.

The laboratory is headed by the section Head and one staff yet, it is not in accordance with the standards, within the standards there are at least three of laboratory managers. (Above is the activities getting done by only two people, even though the standards say to have 3 people).

In both institutions it was found that the purpose of the laboratory was formulated in accordance with the designated policy. The draft policy is used to meet the needs of the laboratory to match the standard. There was no discrepancy in implementing program design as a standard in implementing program steps.

The programs in the standards must be owned by midwifery laboratories have been installed in accordance with the provisions in the standard. It should be noted, however, that some parts described in the Standard Basic Skill Practice Clinic (e.q,.installation of Huknah and Glycerin syringe) are no longer used. This is in keeping with the up-dated evidence in maternal health services that do not support giving and glycerin because of discomfort in the mother who will give birth and is no longer done. The overall standards listed in the guidelines were not fully implemented by either institution for several reasons, together they had an average of 85% performance compared to the overall standard.

There was a discrepancy in the design and program that was installed. This can be seen from the notes and contents of the inventory items and the existence of the tools in the laboratory under investigation.

Human resources in laboratories in both institutions are only two people, namely the head of the laboratory and a staff person; this is not in accordance with the existing standards which specify that there should be three people who manage the laboratory. As mentioned above, so far there is no difficulty in the management of the laboratory, in this case there is a discrepancy between the implementation of standards with predefined standards.

Financing resources on the implementation of Diploma III Midwifery Laboratory. Regularly the needs of the Laboratory, especially for the needs of student learning is budgeted/submitted to each institution in each semester and according to the value of student budget. The role of the Head of Laboratory and staff is in managing the activities in the laboratory, in the care of instruments and models/simulators, maintaining the instruments in a usable condition, and. Submitting a budget for repairing or replacing the damaged instruments/goods. In the case of this financing there was no standard discrepancy.

Both Midwifery laboratories studied are air conditioned and have enough furniture, comfortable for students and lecturers who are working in the laboratory. Sufficiency of equipment, models and simulators, client bed, equipment trolley, instrument and consumables are also fulfilled. On the evaluation findings both study programs have adequate equipment and consumables for their respective students. There is no discrepancy between standards with both institutional Laboratories examined for work and equipment.

3.2.3.4.1. Laboratory management personnel should be staffed by at least three people, but only two personnel were installed.

3.2.3.4.2. In the Standard Basic Skill Practice Clinic Installation, 85 % of the standard were met. Standards not met includes some are now considered outdated practice, e,g., huknah and administration of glycerin syringe which is no longer implemented in Program Study Diploma III, including crockery no longer held, because based on the research evidence these are not recommended for use, because discomfort to the maternity patient.

3.2.3.4.3. Tool storage at institution B, is far away from the laboratory room (approximately 150-200 m), so the preparation for the use of laboratory equipment is constrained especially if it is raining.

The number of students using the laboratory may be increased at certain times in institution B, because in addition to Midwifery Diploma III, they also have a Diploma IV Midwife Educator, so that in the 1st half, the laboratory has a tight schedule in order to accommodate all students. However, there is no discrepancy among the gap data in each institution because all students are able to be accommodated in the laboratory.

The implementation of leadership in accordance with the needs of the implementation of laboratory standards: The DIII Midwifery, Chairman/Director of Study Program with her staff, academic supervisors, students, and laboratory management officers, become a united team in working together to achieve the goal. Both institutions found good cooperation in managing and leading the students' learning needs in the laboratory. There is no discrepancy between the leadership process and the need for the implementation of laboratory standards.

The process of implementation of student practice, adapted to the curriculum and academic calendar, are sufficient for both Study Program which can use the laboratory in accordance with their academic schedule and calendar. The problem is in Program Study B, because they also have Diploma IV midwifery educators program, who in their courses have midwifery care, who also need and use the laboratory for practice, especially this same building. This requires a tight coordination and a very solid schedule in the use of laboratories, and the difficulties are the main obstacles, especially if students have to study independently; students are allowed to borrow equipment and take the items to the dorm so they can learn together and, deepen their skills. There is a discrepancy with a predefined standard. That students should be able to study safely, comfortably and able to achieve competence well, without looking for schedules and opportunities to learn and time to use the Laboratory.

In the implementation of the standards, which consist of 8 criteria, it was found that both institutions of DIII study program have implemented and implemented well. All the skills that must be achieved by students are measured by their competence. The eighth standard can be installed properly, and tested according to the study program curriculum. In this case there was no discrepancy between the standard conformity with the implementation.

3.3.4.1. There is progress data on student skill learning achievement in each academic counselor and in Study Program. Academic advisors have been set that they can only guide students up to 8 students maximum. For a class of 30-40 students on average they guide 5-6 students, so in such a class only 5-6 academic supervisors are required. The advisors continue to follow the development of students until completion of their education at the institution.

3.3.4.2. In the laboratory leader’s reports, both institutions utilize an inventory of laboratory equipment. Laboratory equipment and consumables data are required every semester for each student cohort, which includes the use of equipment, borrowings, and consumables as well as reports of submissions and purchases. This data is periodically reported to the Director/Head of the Study program regularly and continuously. There was no discrepancy in this case with the standard

The midwifery laboratory objectives have been formulated in accordance with the design of the policy. With this determination, the goal of midwifery laboratory is understood, as well as the competency targets of the laboratory. The document under study obtained a clear formula in determining the purpose of the laboratory, which is also reflected in the statement in the interview. Achievement of the objectives as formulated was assessed to be effective in achieving the objectives of the existence of this laboratory. Since the commencement of the National Competence Test three years ago, the students of both study programs have achieved satisfactory results, as shown in the average Grade Point Average (GPA) achieved. Results Achievement Prodi studied. Institution Result of Cumulative Performance Index (CPI) competency test Average last 3 years.

One important product is that up to now the Diploma III graduates of midwifery in both institutions have been worked approximately 93%. Reference ³; students are the main reason for the establishment of an educational institution and the reputation of the educational institution itself is on the shoulders of the students. The conclusion is that there is no discrepancy to the effectiveness of standard setting.

Both institutions have made periodic improvements to equipment, furniture and consumables, in Institution A except for buildings, in Institution B there has been a building renovation since the laboratory is installed. Repairs to the equipment are always done damaged, or unusable, or regularly repaired, or new items are bought. No discrepancies were found in improving efforts to address gaps with standards.

The standard criteria that must be met are the 8 standards of KDPK, ANC, INC, PNC, Neonatology / Infant and Toddler, Reproductive health/Family Planning, Midwifery Pathology and Midwifery Community ¹, both Prodi said they already have the eight criteria, and have been taught to students, because the eight criteria are compulsory competencies that must be achieved by all students.

Student competency will be tested against the eight criteria before they are graduated. Both institutions have maximized the need for practice both in the laboratory and in the field and use innovations to optimize student learning needs both in laboratories and in practice areas. There is no discrepancy in terms of the fulfillment of the 8 aspects contained in this laboratory standard by those implemented by the institution. Both institutions do some innovations in order for the implementation to be maximal and work well.

4. Conclusion and Recommendation

4.1. Implementation of midwifery laboratory greatly affect to the quality of competent midwife graduates in individual clinical practice. With the high quality of clinical competence of midwife graduates there is an increased ability to provide maximum services to mothers and babies, especially in Indonesia, which until now the maternal and infant mortality is still among the highest in the ASEAN countries. Therefore, an accurate up-to-date and easy-to-follow guide for a midwife education laboratory is the most essential.

4.2. Educational institutions need to implement all the standards contained in this manual, which should be transparent and accountable, so as not to harm students and graduates.

The lecturers should be able to uphold the objectivity of the assessment of the students' skills in achieving their competence. The objectiveness of student performance assessment in clinical skills will impact their high confidence to study harder in mastery of their competence. The proportion of DIII Midwifery Study Programs who graduated from National Competence Tests is under 10%, therefore it can be assumed that this indicates that they lack of adequate clinical training in both laboratories and in practice areas.

4.3. The implementation program of midwifery laboratory should be supported by all parties; Educational institutions of Diploma III Midwifery Programs are jointly implemented and complete all student learning needs in terms of study space, electronic learning media, charts, and other media such as models, simulators, clinical work equipment, linen and consumables needed. These tools and materials should be used according to a predetermined schedule, in accordance with the academic calendar and the number of students, as well as the student's learning schedule with their peers in a team (peer-reviewed)

4.4. The implementation of the midwifery laboratory needs the support of all parties with the supervision of the University, Faculty, College or Academy. This will ensure the implementation of the laboratory is sufficients, it would be better if this standard became one of the standards in the re-accreditation of Study Program by Lam-PT-Kes (Accreditation Health Institute of Independent Higher Education) or BAN PT (National Accreditation Board of Higher Education). Similarly, AIPKIND (Association of Indonesian Midwifery Education) and IBI (Indonesian Midwives Association) are fostering their members to be engaged in the field of the education of Midwives.

4.5. Some improvements will be required if these standards are revised or corrected, including;

In the standard issued by The Ministry of health; the 8 standard criterion can be made into 4 standards, so that it can save space, according to the authors. The time and space needs of students learning the 8 standards are available at any time, but making it a 4 standard course will make students queue to use the laboratory and its equipment in a more efficient manner.

For example, some standards that have been studied based on evidence such as the provision of huknah and syringe glycerin no longer need to be included in the standard. While the imperative of sound proofed rooms for OSCA/OSCE (Objective Structured Critical Assessment/Objective Structured Critical Examination) is not included in the guidelines, both institutions have used new developments in clinical education, regarding OSCA/OSCE using sound proofed rooms. The Ministry of Health has issued its own guidance in the implementation of OSCA /OSCE, which needs to be integrated and related to the guidelines of this laboratory.

The number of staff in the Laboratory requires a review, for private education institutions Human Resources personnel are expensive post, and the effectiveness of the work needs to be reviewed in the required amount.

References