Australia Indonesia Partnership for Maternal and Neonatal Health

Australia Indonesia Partnership for Maternal and Neonatal Health Transfers and Skills Retention Post-Training of Clinical Staff October 2014

Australia – Indonesia Partnership for Maternal and Neonatal Health

Transfers and Skills Retention Post-Training of Clinical Staff in AIPMNH-assisted Districts October 2014


Transfers and Skills Retention Post-Training of Clinical Staff in AIPMNH-assisted Districts Asnawi Abdullah, Elizabeth E. Wungouw. U., Ignatius Henyo Kerong, Yuli Butu, Iki Lobo, Louise Simpson, Krishna Hort, Idawati Trisno, Paula Tibuludji, Yustina Yudha Nita, Ester Kana, John Th Ire, Kupang: Australia Indonesia Partnership for Maternal and Neonatal Health, Kupang, October, 2014

All correspondence to: Dr Louise Simpson E: [email protected] T+62 380 820 809, Direct T +62 380 820 799 Australia Indonesia Partnership for Maternal and Neonatal Health, Partnership Office, Dinas Kesehatan Provinsi NTT, Jl Palapa No 22, Oebobo, Kupang NTT 85555

ACKNOWLEDGEMENTS This study was fully supported by the Australian Government through the Australia Indonesia Partnership in Maternal and Neonatal Health (AIPMNH). The results, opinions and recommendations expressed in this presentation is fully the responsibility of the authors and not of the Australian Department of Foreign Affairs and Trade (DFAT). DFAT also does not warrant the accuracy or reliability of the information provided. The authors would like to thank the Provincial Health Office (PHO) of NTT, District Health Office (DHO), AIPMNH DPC Team and Puskesmas Midwife Coordinator in Flores Timur, Timor Tengah Selatan (TTS), Timor Tengah Utara (TTU) and Kota Kupang. The authors would also like to express their gratitude to the advanced trainer team from P2KS Kupang. Photo Front cover: On the job training for Puskesmas midwives in the perinatal unit of the Ngada District Hospital. Photo by Edel Mary Quin Mole


Abbreviations APN

Asuhan Partus Normal (Normal Birth Delivery)

BBLR

Berat Badan Lahir Rendah (Low Birth Weight Babies - <2,500g)

P2KP

Pusat Pelatihan Klinik Primary (Primary Clinical Training Centre)

P2KS

Pusat Pelatihan Klinik Sekunder (Secondary Clinical Training Centre)

PONED

Pelayanan Obstetri Neonatal Emergensi Dasar (Basic Emergency Maternal and Neonatal Care)

PPGDON

Pertolongan Pertama Gawat Darurat Obstetri dan Neonatal (basic Maternal and Neonatal first aid)

KBI/KBE

Kompresi Bimanual Internal / External (compression to arrest haemorrhage)

Table of Contents INTRODUCTION

1

METHODOLOGY

1

RESULTS

1

Respondents characteristics

1

Clinical Staff Transfers and Further Training

1

Knowledge Retention

2

Skills Retention

2

Number of Deliveries and Knowledge Retention

3

Number of Deliveries and Skills Retention

3

CONCLUSIONS AND RECOMMENDATIONS

4

Annex 1. Data Tables for the Study

5


INTRODUCTION The level of knowledge and skills of health workers, especially midwives is an important component in improving quality of health services for mothers and newborns. Since 2009, the Australia Indonesia Partnership for Maternal and Neonatal Health (AIPMNH) has been supporting and funding significant numbers of clinical and non-clinical trainings in the 14 AIPMNH assisted districts. This study was undertaken to determine if those participating in a sample of the trainings remain working in the same place and are still utilising the content of the training (working in the same field). A further question was to what extent participants have retained the knowledge and skills delivered in the trainings. To the best of our knowledge, no similar study has been conducted in the Province of Nusa Tenggara Timur (NTT).

METHODOLOGY Four districts of NTT province were purposively selected to represent urban and rural areas; Kota Kupang, Flores Timor, TTS and TTU. The unit of analysis was health staff who had attended one or more of the key clinical trainings (PONED, management Asphyxia/BBLR, APN and PPGDON) provided with AIPMNH support between 2010 and 2011. Information related to staff transfers and movements was collected by the AIPMNH District Program Coordinators assisted by the Puskesmas midwife coordinators. The level of knowledge and of skills retention post training was evaluated by an advanced trainer team from P2KS Kupang during a workshop in each district.

RESULTS Respondents characteristics The average age of the 166 respondents was 38 years old with a range from 22 to 55 years. Most (60%) had Diploma III, 38% Diploma I, and 2% Diploma IV. The year of graduation varied between 1976 and 2014. The majority (95%) of respondents were working in a Puskesmas; only 5% were working in a Hospital.

Clinical Staff Transfers and Further Training The majority of respondents were still working in the same facility as before they attended the training. Overall, only 31 respondents (19%) transferred to other facilities and there was no significant difference in this proportion across districts. Details of the numbers and percentage for each district is in Table 1. For those who transferred to other places, all moved from one Puskesmas to another Puskesmas in the same District. None of them transferred to other districts or provinces. In the new Puskesmas, all of them were still working in a clinical service position. The reasons for transferring were 51% for personal reasons, and 49% for organizational reasons. In the period 2012-2014 (i.e. subsequent to the 2010 – 2011 trainings) approximately 74% of respondents reported that they have attended refresher trainings conducted by the Secondary Clinical Training Centre (P2KS) (60%), Primary Clinical Training Centre (P2KP) (38%) and by a Hospital (2%). In addition, 32% of respondents also reported participating in one or more in-house trainings (i.e. APN, management of BBLR).

1

Australia Indonesia Partnership for Maternal and Neonatal Health Transfers and Skills Retention Post-Training of Clinical Staff October 2014 Table 1. Number of staff moving to other health facilities post-training Respondent current workplace

Kota

Flores

TTS

TTU

Totals

Kupang

Timur

Still in the same facility

41 (87%)

50 (76%)

27 (82%)

17 (75%)

135 (81%)

Moved to other facility

6 (13%)

16 (24%)

6 (18%)

3 (15%)

31 (19%)

Totals

47

66

33

20

166

Knowledge Retention The level of post training knowledge retention was relatively low. The average knowledge retention score was 67.8 (n=111, range: 17.0-87.5), 68.0 (n=50, range: 42-87), 63.2 (n=31, range: 32.5-77.5), and 72.5 (n=56, range: 47.0-85.0) for APN, PPGDON, PONED and BBLR respectively. Using national standard knowledge score categories, approximately 2% achieved a satisfactory result (score above 85) with relatively high proportions below the national standard (score less than 68). The poorest scores were for post-PONED training where the proportion scoring below the national standard was 65% and no one reached a satisfactory score (see Figure 1).

BBLR/ ASPHYSIA

67%

30%

PONED

35%

65%

PPGDON

46%

APN

44% 0%

10%

20%

0%

52%

2%

53% 30%

40%

Below standard (0-68) Figure 1.

2%

50%

60%

70%

Standard (69-84)

3% 80%

90%

100%

Satisfactory (85-100)

Knowledge retention post-training for BBLR, PONED, PPGDON and APN

Only for APN knowledge retention was there a statistically significant difference between D1 and D3/D4 graduates (i.e. not for PPGDON, PONED and BBLR knowledge retention). This was also the case for providers of the APN training (P2KS and P2KP). There was no statistically significant difference in average knowledge retention scores between midwife coordinators (BiKor) and ordinary midwives. See Annex 1 page 5 for data tables.

Skills Retention Levels of skills retention post-training were also found to be relatively low, although higher than the scores for knowledge retention (Figure 2). Overall, the proportion of respondents reaching a satisfactory score (above 85) was around 20%. Skill areas with a satisfactory score ≥ 20%, are APN, BBLR (low birth weight), Manual Removal of Placenta, Neonatal Resuscitation and Kangguru method. 2


Of the eight tested skills, there was a statistically significant difference between D1 and D3/D4 graduates in four areas (APN, shock Management, KBI/KBE and manual removal of placenta). As with knowledge retention, there was no statistical difference between midwife coordinators and ordinary midwives. There were no statistical differences in skills retention based on training providers. See Annex 1, page 5 for the data table.

METODE KANGURU

26%

RESUSITASI PADA BAYI

48% 43%

33%

DISTOSIA BAHU

24%

65%

MANUAL PLACENTA

29%

58%

KBI/KBE

22%

46%

PENATALAKSANAAN SYOK

10%

20%

Below standard (0-68)

30%

12% 14%

15%

57% 0%

20%

34%

61%

APN

6%

42%

52%

BBLR

Figure 2.

26%

23%

22% 40%

50%

Standard (69-84)

60%

70%

22% 80%

90%

100%


Skills retention post-training for BBLR, PONED, PPGDON and APN

Number of Deliveries and Knowledge Retention Of the four clinical trainings (APN, BBLR, PONED and PPGDON) only with PONED knowledge retention was there found to be a small correlation (r =0.46, P value 0.008) with the number of birth deliveries assisted by the midwife. Both in simple and multiple regression (using a model adjusted for educational level, refresher training, on the job training (magang) and age), the number of birth deliveries assisted was found to be statistically associated (P value 0.006) with the level of post training knowledge retention for PONED. This regression model suggested the level of post training knowledge retention increased by approximately one point for every additional two birth deliveries assisted 1. This should however be treated with caution as only 32% (18% in the adjusted model) of the variation in knowledge retention can be explained by the number of birth deliveries assisted.

Number of Deliveries and Skills Retention With skills retention, the number of birth deliveries assisted was found to have small statistical correlations with APN (r=0.33, P value 0.0005), BBLR (r=0.27, P value 0.004), and the management of shock (r=0.29, P value 0.04). In the multiple regression model, only APN and BBLR reached statistical significance. The regression model suggested that the level of post training APN skills 1

Number of deliveries measured over the seven-month period January – July 2014. Note: only Puskesmas based midwives were assessed for skills and knowledge retention, not midwives in the villages (bidan desa). Bidan desa often accompany women to the Puskesmas and deliver their infants.

3


retention increased by approximately two points for every additional three birth deliveries assisted (Rsquared and Adjusted R-Squared 23% and 20% respectively). For BBLR, the level of skills retention increased by approximately two points for every additional birth delivery assisted (R-squared and adjusted R-Squared 9% and 5% respectively)

CONCLUSIONS AND RECOMMENDATIONS The study found that movement of clinical staff to other health facilities or to non-clinical positions was relatively low (<20% over 2 – 3 years). Those who did transfer moved to other Puskesmas and all of them were still working in clinical service positions. The proportion transferring due to personal reasons was similar to those moving for organizational purposes. The level of knowledge and skills retention was found to be surprisingly low, especially in light of the majority of respondents reporting participating in further trainings since the 2010-2011 period. Assuming that the assessments undertaken for this study are valid, the findings indicate that either trainings need to be more effective and/or more effective ongoing clinical supervision is needed. In the next phase of the program (PERMATA) it is recommended that detailed assessments of training effectiveness be undertaken. Levels of knowledge and skills retention for some clinical competencies were statistically significantly higher amongst those with higher levels of education (D1 versus D3/D4). This supports the current policy of requiring all midwives to attain Diploma 3 certification. The study found some small associations between numbers of deliveries assisted since the training and knowledge and skills retention. An unexpected finding was the lack of difference in levels of knowledge and skills retention between Puskesmas midwife coordinators and ordinary midwives. Together with the overall findings, this suggests that there is a strong need to focus on improving Puskesmas midwife coordinators competencies so that they can in turn improve knowledge and skills of the midwives they supervise on a day-to-day basis. Given the importance of the role of the Puskesmas midwife coordinators it is suggested that testing of upgrading to Clinical Instructor certification be undertaken.

4


Annex 1. 1 1.a 1.b 1.c 1.d 2 2.a 2.b 2.c 2.d 2.e 2.f 2.g 2.g 3 3.a 3.b 3.c 3.d 4 4.a 4.b 4.c 4.d 4.e 4.f 4.g 4.g 5

Data Tables for the Study

Knowledge retention for different types of training APN PPGDON PONED BBLR Skills retention for different types of training APN BBLR Management of Shock KBI/KBE Dystocia shoulder Manual Placenta Resuscitation Kangguru Method Knowledge retention for different types of training APN PPGDON PONED BBLR Skills retention for different types of training APN BBLR Management of Shock KBI/KBE Dystocia shoulder Manual Placenta Resuscitation Kangguru Method Knowledge retention for different types of training

5.a 5.b 5.c 5.d 6

APN PPGDON PONED BBLR Skills retention for different types of training

6.a 6.b 6.c 6.d 6.e 6.f 6.g 6.h

APN BBLR Management of Shock KBI/KBE Dystocia shoulder Manual Placenta Resuscitation Kangguru Method

Level of education: D1 n Mean (95% CI) 46 62.9 (59.21-66.49) 22 67.3 (63.03-71.59) 2 55.0 15 69.9 (64.85-74.95) Level of education: D1 n Mean (95% CI) 46 52.3 (44.47-60.11) 46 50.9 (41.71-60.20) 22 59.8 (52.12-67.40) 23 58.4 (50.18-66.54) 2 67.0 51 57.1 (49.85-64.42) 15 63.1 (52.17-74.01) 15 69.3 (60.54-78.00) Provider of Training P2KP n Mean (95% CI) 40 63.9 (59.36-68.44) 18 70.1 (66.71-73.51) 8 66.0 (59.44-72.68) 18 71.7 (66.90-76.49) Provider of Training P2KP n Mean (95% CI) 40 57.4 (50.54-64.31) 40 52.5 (42.60-62.38) 18 62.9 (54.27-71.70) 26 62.38 (55.12-69.64) 8 66.1 48 60.9 (54.84-66.88) 18 71.5 (62.04-80.92) 18 71.9 (63.28-80.60) Puskesmas Midwife coordinator n Mean (95% CI) 97 67.9 (65.73-70.26) 42 67.6 (64.71-70.57) 27 62.4 (58.22-66.63) 40 73.1 (71.03-75.27) Puskesmas Midwife coordinator n Mean (95% CI) 97 60.8 (56.11-65.61) 97 65.3 (46.27-84.42) 42 68.5 (63.23-73.72) 63 65.3 (60.74-69.78) 27 65.1 107 63.1 (58.62-67.54) 40 67.9 (62.16-73.67) 40 71.8

Level of education: D3/D4 n Mean (95% CI) 65 71.3 (69.28-73.46) 28 68.6 (65.36-71.96) 29 63.7 (60.54-67.04) 31 73.5 (71.20-75.93) Level of education: D3/D4 n Mean (95% CI) 65 68.1 (63.50-72.72) 66 75.8 (48.35-100.0) 28 73.4 (68.43-78.28) 53 68.5 (64.22-72.81) 29 64.2 (59.43-68.92) 76 66.5 (62.05-71.00) 31 71.6 (65.59-77.56) 31 74.2 (68.78-79.60) Provider of Training P2KS n Mean (95% CI) 69 70.2 (68.29-72.05) 30 67.4 (63.82-71.06) 22 63.0 (58.32-67.73) 27 72.8 (70.44-75.23) Provider of Training P2KS n Mean (95% CI) 69 63.8 (58.04-69.63) 70 72.9 (46.88-98.92) 30 70.5 (64.74-76.25) 48 67.4 (62.47-72.33) 22 63.4 (57.08-69.66) 76 64.3 (58.88-69.74) 27 67.0 (60.18-73.91) 27 73 (67.47-78.53) Non-Midwife coordinator n Mean (95% CI) 14 66.8 (61.31-72.19) 8 70.3 (65.31-75.34) 4 68.6 (58.24-79.01) 6 67.2 (55.30-79.03) Non-Midwife coordinator n 14 15 8 13 4 20 6 6

Mean 66.4 67.2 61.6 66.3 59.5 61.0 74.7 77.9

(95% CI) (53.59-79.20) (51.94-82.51) (51.86-71.30) (58.22-74.39) (44.79-74.36) (51.75-70.27)

P value differences in Means 0.0001 >0.05 >0.05 >0.05 P value differences in Means 0.0003 >0.05 0.0024 0.017 >0.05 0.0218 >0.05 >0.05 P value differences in Means 0.0036 >0.05 >0.05 >0.05 P value differences in Means >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 P value differences in Means >0.05 >0.05 >0.05 >0.05 P value differences in Means >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05

5


Kemitraan Australia – Indonesia untuk Kesehatan Ibu dan Bayi Baru Lahir

Mutasi dan Retensi Keterampilan Pascapelatihan dari Tenaga Kesehatan di Kabupaten Wilayah Kerja AIPMNH Oktober 2014


Transfers and Skills Retention Post-Training of Clinical Staff in AIPMNH-assisted Districts Asnawi Abdullah, Elizabeth E. Wungouw. U., Ignatius Henyo Kerong, Yuli Butu, Iki Lobo, Louise Simpson, Krishna Hort, Idawati Trisno, Paula Tibuludji, Yustina Yudha Nita, Ester Kana, John Th Ire, Kupang: Australia Indonesia Partnership for Maternal and Neonatal Health, Kupang, October, 2014

Korespondensi ditujukan kepada: Dr Louise Simpson E: [email protected] T+62 380 820 809, Direct T +62 380 820 799 Australia Indonesia Partnership for Maternal and Neonatal Health, Kantor Kemitraan, Dinas Kesehatan Provinsi NTT, Jl Palapa No 22, Oebobo, Kupang NTT 85555

TERIMA KASIH Studi ini didukung sepenuhnya oleh Pemerintah Australia melalui program Australia Indonesia Partnership in Maternal and Neonatal Health (AIPMNH). Hasil, pendapat dan rekomendasi yang disajikan di sini sepenuhnya menjadi tanggung jawab penulis dan bukan menjadi tanggung jawab Departemen Luar Negeri dan Perdagangan Australia (DFAT). DFAT juga tidak menjamin keakuratan dan keandalan informasi yang disajikan. Penulis ingin berterimakasih kepada Dinas Kesehatan Provinsi NTT, Dinas Kesehatan Kabupaten, Tim DPC AIPMNH dan para Bidan Koordinator Puskesmas di kabupaten Flores Timur, Timor Tengah Selatan (TTS), Timor Tengah Utara (TTU) dan Kota Kupang. Penulis juga ingin berterimakasih kepada tim pelatih dari P2KS Kupang. Foto Sampul depan: On the job training untuk bidan Puskesmas dari unit perinatal RSUD Ngada. Foto oleh Edel Mary Quin Mole


Daftar Singkatan APN

Asuhan Partus Normal (Normal Birth Delivery)

BBLR

Berat Badan Lahir Rendah (Low Birth Weight Babies - <2,500g)

P2KP

Pusat Pelatihan Klinik Primary (Primary Clinical Training Centre)

P2KS

Pusat Pelatihan Klinik Sekunder (Secondary Clinical Training Centre)

PONED

Pelayanan Obstetri Neonatal Emergensi Dasar (Basic Emergency Maternal and Neonatal Care)

PPGDON

Pertolongan Pertama Gawat Darurat Obstetri dan Neonatal (basic Maternal and Neonatal first aid)

KBI/KBE

Kompresi Bimanual Internal / External (compression to arrest haemorrhage)

Daftar Isi PENDAHULUAN

1

METODOLOGI

1

HASIL

1

Karakteristik responden

1

Mutasi dan Pelatihan Lanjut Tenaga Kesehatan

1

Retensi Pengetahuan

2

Retensi Keterampilan

2

Jumlah Persalinan dan Retensi Pengetahuan

3

Jumlah Persalinan dan Retensi Keterampilan

3

KESIMPULAN DAN REKOMENDASI

4

Lampiran 1. Tabel Data untuk Studi ini

5


PENDAHULUAN Peningkatan pengetahuan dan keterampilan tenaga kesehatan, khususnya bidan merupakan komponen penting dalam upaya peningkatan kesehatan ibu dan bayi baru lahir. Sejak tahun 2009, program Kemitraan Australia Indonesia untuk Kesehatan Ibu dan Bayi Baru Lahir (AIPMNH) telah mendukung dan mendanai sejumlah besar kegiatan pelatihan baik klinis dan non-klinis di 14 kabupaten wilayah kerja AIPMNH. Studi ini dilakukan untuk mengetahui apakah mereka yang telah mengikuti pelatihan pada tahun 2010-2012 masih tetap bekerja di tempat yang sama dan menerapkan apa yang diperoleh dari pelatihan serta bekerja di bidang yang sama. Lebih lanjut, kajian ini juga ingin mengetahui sejauhmana tingkat retensi pengetahuan dan keterampilan yang diperoleh dari pelatihan. Sejauh yang kami ketahui, belum ada studi seperti ini yang dilakukan di Provinsi Nusa Tenggara Timur (NTT).

METODOLOGI Empat kabupaten di provinsi NTT dipilih sebagai sampel, mewakili wilayah perkotaan dan pedesaan; Kota Kupang, Flores Timur, TTS dan TTU. Unit analisis adalah tenaga kesehatan yang telah mengikuti satu atau lebih pelatihan klinis (PONED, penanganan Asfiksia/BBLR, APN dan PPGDON) yang dilaksanakan dengan dukungan AIPMNH antara tahun 2010 dan 2011. Informasi mengenai mutasi Nakes dikumpulkan oleh DPC AIPMNH dan dibantu oleh Bikor Puskesmas. Evaluasi mengenai tingkat retensi pengetahuan dan keterampilan dilakukan oleh tim pelatih tingkat lanjut dari Pusat Pelatihan Kesehatan (P2KS) Kupang dengan metode lokakarya di masing-masing kabupaten wilayah penelitian.

HASIL Karakteristik Responden Rata-rata usia dari 166 responden adalah 38 tahun, dengan range antara 22 sampai 55 tahun. Kebanyakan responden (60%) adalah tamatan Diploma III, 38% Diploma I, dan 2% Diploma IV. Tahun wisuda bervariasi antara 1976 dan 2014. Mayoritas (95%) responden bekerja di Puskesmas; hanya 5% yang bekerja di Rumah Sakit.

Mutasi dan Pelatihan Lanjutan Mayoritas responden masih bekerja di fasilitas kesehatan yang sama. Secara keseluruhan, hanya 31 responden (19%) yang mutasi ke faskes lain dan proporsi mutasi tidak ada perbedaan yang signifikan antar kabupaten. Rincian mengenai jumlah dan persentase untuk tiap kabupaten terdapat pada Tabel 1. Untuk Nakes yang mutasi ke tempat lain, semuanya mereka hanya mutasi antar Puskesmas dalam wilayah Kabupaten yang sama. Tidak ada satu orangpun dari responden yang mutasi ke kabupaten atau provinsi lain. Di Puskesmas baru, semuanya mereka masih bekerja di bagian klinis – tidak ada yang mutasi/dimutasikan ke bagian administrasi (non-klinis). Alasan mutasi: 51% karena alasan pribadi, sisanya 49% karena alasan organisasi. Selama periode 2012-2014 (yaitu setelah pelatihan yang dilaksankan pada tahun 2010–2011), sekitar 74% responden mengatakan bahwa mereka telah mengikuti pelatihan penyegaran/refresher trainings yang dilaksanakan oleh Pusat Pelatihan Kesehatan Sekunder (P2KS) (60%), Pusat Pelatihan Kesehatan Primer (P2KP) (38%) atau oleh RS (2%). Selain itu, 32% responden juga mengatakan bahwa mereka juga pernah ikut satu atau lebih kegiatan magang (misalnya magang APN, penanganan BBLR).

1

Australia Indonesia Partnership for Maternal and Neonatal Health Transfers and Skills Retention Post-Training of Clinical Staff October 2014 Tabel 1. Jumlah staf yang mutasi ke faskes lain pascapelatihan Tempat kerja responden saat ini

Kota

Flores

TTS

TTU

Total

Kupang

Timur

Masih bekerja di faskes yang sama

41 (87%)

50 (76%)

27 (82%)

17 (75%)

135 (81%)

Pindah (mutasi) ke faskes lain

6 (13%)

16 (24%)

6 (18%)

3 (15%)

31 (19%)

Total

47

66

33

20

166

Retensi Pengetahuan Tingkat retensi pengetahuan pascapelatihan relatif rendah. Rata-rata nilai retensi pengetahuan adalah 67,8 (n=111, range: 17,0-87,5), 68,0 (n=50, range: 42-87), 63,2 (n=31, range: 32,5-77,5), dan 72,5 (n=56, range: 47,0-85,0) masing-masing untuk APN, PPGDON, PONED dan BBLR. Dengan mengacu pada standar penilaian nasional, hanya sekitar 2% responden yang mencapai nilai memuaskan (nilai di atas 85), proporsi nilai di bawah standar nasional masih relatif tinggi (nilai di bawah 68). Skor nilai paling buruk ditemukan untuk retensi pengetahuan PONED, 65% responden mempunyai nilai di bawah standar nasional dan tidak ada satu respondenpun yang mencapai nilai memuaskan (lihat Gambar 1).

BBLR/ ASPHYSIA

30%

67%

PONED

2%

65%

PPGDON

46%

APN

44% 0%

10%

20%

35%

0%

52%

2%

53% 30%

40%

50%

60%

70%

3% 80%

90%

100%

standard (0-68) Standard (85-100) Gambar 1. Retensi pengetahuanBelow pascapelatihan untuk BBLR, PONED,(69-84) PPGDON danSatisfactory APN Hanya retensi pengetahuan APN secara statistik terdapat perbedaan yang signifikan antara tamatan D1 dan D3/D4 (tidak ada perbedaan secara statistik ditemukan untuk retensi pengetahuan PPGDON, PONED dan BBLR). Hal yang sama juga ditemukan, adanya perbedaan yang signifikan untuk tingkat pengetahuan APN menurut pelatihan yang dilaksanakan oleh P2KS dan P2KP. Lebih lanjut, tidak terdapat perbedaan signifikan rata-rata nilai retensi pengetahuan antara Bidan Koordinator (BiKor) dan bidan non-Bikor. Lihat Lampiran 1 halaman 5 untuk tabel data.

Retensi Keterampilan Tingkat retensi keterampilan pascapelatihan juga relatif rendah, meskipun sedikit lebih tinggi nilainya dibandingkan dengan retensi pengetahuan (Gambar 2). Secara keseluruhan, proporsi responden

2


yang mencapai nilai memuaskan (di atas 85) hanya sekitar 20%. Skore nilai memuaskan ≥ 20%, hanya ditemukan untuk retensi keterampilan APN, BBLR (berat lahir rendah), penanganan placenta secara manual, Resusitasi Bayi dan metode Kangguru. Dari delapan keterampilan yang analisi, perbedaan tingkat retensi keterampilan ditemukan berbeda bermakna antara responden lulusan D1 dengan lulusan D3/D4 untuk empat bidang pelatihan (APN, penanganan shock, KBI/KBE dan penanganan placenta secara manual). Sama seperti tingkat retensi pengetahuan, tingkat retensi keterampilan juga tidak ditemukan adanya perbedaan secara bermakna antara Bikor dan non-Bikor. Hal yang sama juga ditemukan, tidak terdapat perbedaan bermakna tingkat retensi keterampilan antara mereka yang dilatih oleh P2KS dan P2KP. Lihat Lampiran 1, halaman 5 untuk tabel data.

METODE KANGURU

26%

RESUSITASI PADA BAYI

48% 43%

26% 33%

DISTOSIA BAHU

24%

65%

MANUAL PLACENTA

29%

58%

KBI/KBE

22%

46%

PENATALAKSANAAN SYOK

10%

20%

Below standard (0-68)

30%

14%

15%

57% 0%

12%

34%

61%

APN

20%

42%

52%

BBLR

6%

23%

22% 40%

50%

Standard (69-84)

60%

70%

22% 80%

90%

100%


Gambar 2. Retensi keterampilan pascapelatihan untuk BBLR, PONED, PPGDON dan APN

Jumlah Persalinan dan Retensi Pengetahuan Dari empat pelatihan klinis utama (APN, BBLR, PONED dan PPGDON) hanya retensi pengetahuan PONED yang ditemukan mempunyai sedikit korelasi (r =0,46, P value 0,008) dengan jumlah persalinan yang ditolong oleh bidan. Baik dari hasil analisis simpel regresi maupun multipel regresi (menggunakan model adjusted untuk tingkat pendidikan, refresher training, magang dan umur), ditemukan adanya korelasi signifikan (P value 0,006) antara jumlah persalinan yang ditolong oleh Nakes dengan retensi pengetahuan PONED. Model regresi ini menunjukkan bahwa skor nilai retensi pengetahuan PONED meningkat sekitar satu poin untuk setiap peningkatan dua persalinan yang ditolong oleh Nakes2. Namun, hasil statistik ini perlu diinterpretasi sacara hati-hati karena karena

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Jumlah persalinan diukur selama tujuh bulan, periode January – Juli 2014. Catatan: penilaian retensi keterampilan dan pengetahuan hanya dilakukan untuk bidan yang bertugas di Puskesmas dan bukan bidan desa. Sementara Bidan di desa yang sering mendampingi ibu hamil ke Puskesmas dan membantu persalinan.

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hanya 32% (18% untuk adjusted model) variasi retensi pengetahuan yang dapat dijelaskan dengan jumlah persalinan Nakes. Jumlah persalinan yang ditolong oleh nakes juga memiliki korelasi yang signifikan dengan retensi keterampilan APN (r=0,33, P value 0,0005), BBLR (r=0,27, P value 0,004), dan penanganan shock (r=0,29, P value 0,04) walaupun korelasinya relatif lemah (<0.5) dan dalam model multipel regresi, hanya APN dan BBLR yang ditemukan mencapai nilai bermakna secara statistik. Model regresi tersebut menunjukkan bahwa tingkat retensi keterampilan pascapelatihan APN meningkat sekitar dua poin untuk setiap peningkatan tiga persalinan yang ditolong oleh nakes (R-squared dan Adjusted RSquared masing-masing 23% dan 20%). Untuk BBLR, tingkat retensi keterampilan meningkat sekitar dua poin untuk setiap peningkatan jumlah persalinan yang ditolong oleh nakes (R-squared dan adjusted R-Squared masing-masing 9% dan 5%).

KESIMPULAN DAN REKOMENDASI Studi ini menemukan bahwa proporsi mutasi tenaga kesehatan ke tempat lain atau ke bagian nonklinis lain itu relatif rendah di wilayah kerja AIPMNH (hanya <20% selama lebih dari 2 – 3 tahun). Mereka yang dimutasi ke Puskesmas lain semuanya masih bekerja di bagian pelayanan klinis. Proporsi mutasi karena alasan pribadi hampir sama dengan mutasi karena alasan organisasi. Yang mengejutkan bahwa tingkat retensi pengetahuan dan keterampilan pasca pelatihan itu cukup rendah, waluapun banyak dari antara responden yang pernah mengikuti pelatihan kembali setelah mengikuti pelatihan pada tahun 2010-2011. Dengan beranggapan bahwa penilaian yang dilakukan dalam studi ini valid, maka temuan ini menunjukkan bahwa efektifitas pelaksanaan pelatihan selama ini perlu dikaji ulang dan atau supervisi klinis perlu dilakukan secara lebih efektif dan perlu dilakukan secara berkelanjutan. Disarankan agar dalam fase program berikut (PERMATA), kajian mengenai efektivitas pelaksanaan pelatihan perlu dilakukan secara lebih komprehensif dengan menggunakan metodologi yang lebih regorous. Tingkat retensi pengetahuan dan keterampilan untuk beberapa kompetensi klinis ditemukan berbeda bermakna menurut tingkat bependidikan; retensi lebih tinggi bagi mereka yang berpendidikan D3/D4 dibandingkan dengan D1. Temuan ini mendukung kebijakan pemerintah yang mensyaratkan agar semua bidan untuk menyelesaikan pendidikan Diploma 3. Studi ini menemukan adanya hubungan bermakna antara jumlah persalinan yang ditolong oleh Nakes dengan tingkat retensi pengetahuan dan keterampilan dari tenaga kesehatan, walaupun korelasinya relatif lemah. Temuan yang mengejutkan adalah tidak adanya perbedaan tingkat retensi pengetahuan dan keterampilan antara Bikor Puskesmas dengan bidan non-Bikor. Bersama dengan hasil temuan secara keseluruhan, hal ini menunjukkan bahwa fokus program ke depan harus diarahkan pada upaya peningkatan kompetensi Bikor Puskesmas sehingga nantinya mereka mempunyai kemampuan untuk meningkatkan pengetahuan dan keterampilan bidan yang disupervisi. Mengingat pentingnya peran dari Bikor Puskesmas, juga disarankan untuk dilakukan uji kompetensi untuk sertifikasi Instruktur Klinis.

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Lampiran 1. Tabel Data untuk Studi ini 1 1.a 1.b 1.c 1.d 2 2.a 2.b 2.c 2.d 2.e 2.f 2.g 2.g 3 3.a 3.b 3.c 3.d 4 4.a 4.b 4.c 4.d 4.e 4.f 4.g 4.g 5

5.a 5.b 5.c 5.d 6 6.a 6.b 6.c 6.d 6.e 6.f 6.g 6.h

Retensi pengetahuan dari pelatihan APN PPGDON PONED BBLR Retensi keterampilan dari pelatihan APN BBLR Penanganan Shock KBI/KBE Dystocia bahu Manual Placenta Resusitasi Metode Kangguru Retensi pengetahuan dari pelatihan APN PPGDON PONED BBLR Retensi keterampilan dari pelatihan APN BBLR Penanganan Shock KBI/KBE Dystocia bahu Manual Placenta Resusitasi Metode Kangguru Retensi pengetahuan dari pelatihan APN PPGDON PONED BBLR Retensi keterampilan dari pelatihan APN BBLR Penanganan Shock KBI/KBE Dystocia bahu Manual Placenta Resusitasi Metode Kangguru

Tingkat Pendidikan: D1 n Mean (95% CI) 46 62.9 (59.21-66.49) 22 67.3 (63.03-71.59) 2 55.0 15 69.9 (64.85-74.95) Tingkat Pendidikan: D1 n Mean (95% CI) 46 52.3 (44.47-60.11) 46 50.9 (41.71-60.20) 22 59.8 (52.12-67.40) 23 58.4 (50.18-66.54) 2 67.0 51 57.1 (49.85-64.42) 15 63.1 (52.17-74.01) 15 69.3 (60.54-78.00) Penyaji Pelatihan P2KP n Mean (95% CI) 40 63.9 (59.36-68.44) 18 70.1 (66.71-73.51) 8 66.0 (59.44-72.68) 18 71.7 (66.90-76.49) Penyaji Pelatihan P2KP n Mean (95% CI) 40 57.4 (50.54-64.31) 40 52.5 (42.60-62.38) 18 62.9 (54.27-71.70) 26 62.38 (55.12-69.64) 8 66.1 48 60.9 (54.84-66.88) 18 71.5 (62.04-80.92) 18 71.9 (63.28-80.60) Puskesmas Midwife coordinator n Mean (95% CI) 97 67.9 (65.73-70.26) 42 67.6 (64.71-70.57) 27 62.4 (58.22-66.63) 40 73.1 (71.03-75.27) Bikor Puskesmas n Mean (95% CI) 97 60.8 (56.11-65.61) 97 65.3 (46.27-84.42) 42 68.5 (63.23-73.72) 63 65.3 (60.74-69.78) 27 65.1 107 63.1 (58.62-67.54) 40 67.9 (62.16-73.67) 40 71.8

Tingkat Pendidikan: D3/D4 n Mean (95% CI) 65 71.3 (69.28-73.46) 28 68.6 (65.36-71.96) 29 63.7 (60.54-67.04) 31 73.5 (71.20-75.93) Tingkat Pendidikan: D3/D4 n Mean (95% CI) 65 68.1 (63.50-72.72) 66 75.8 (48.35-100.0) 28 73.4 (68.43-78.28) 53 68.5 (64.22-72.81) 29 64.2 (59.43-68.92) 76 66.5 (62.05-71.00) 31 71.6 (65.59-77.56) 31 74.2 (68.78-79.60) Penyaji Pelatihan P2KS n Mean (95% CI) 69 70.2 (68.29-72.05) 30 67.4 (63.82-71.06) 22 63.0 (58.32-67.73) 27 72.8 (70.44-75.23) Penyaji Pelatihan P2KS n Mean (95% CI) 69 63.8 (58.04-69.63) 70 72.9 (46.88-98.92) 30 70.5 (64.74-76.25) 48 67.4 (62.47-72.33) 22 63.4 (57.08-69.66) 76 64.3 (58.88-69.74) 27 67.0 (60.18-73.91) 27 73 (67.47-78.53) Non-Midwife coordinator n Mean 14 66.8 8 70.3 4 68.6 6 67.2 Non-Bikor n Mean 14 66.4 15 67.2 8 61.6 13 66.3 4 59.5 20 61.0 6 74.7 6 77.9

(95% CI) (61.31-72.19) (65.31-75.34) (58.24-79.01) (55.30-79.03) (95% CI) (53.59-79.20) (51.94-82.51) (51.86-71.30) (58.22-74.39) (44.79-74.36) (51.75-70.27)

P value differences in Means 0.0001 >0.05 >0.05 >0.05 P value differences in Means 0.0003 >0.05 0.0024 0.017 >0.05 0.0218 >0.05 >0.05 P value differences in Means 0.0036 >0.05 >0.05 >0.05 P value differences in Means >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 P value differences in Means >0.05 >0.05 >0.05 >0.05 P value differences in Means >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05

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Australia Indonesia Partnership for Maternal and Neonatal Health

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