Improving the Competence of Health Students in Hospital Practice Areas during the Covid-19 Pandemic: Case Study

The COVID-19 pandemic requires changing the learning system in health education institutions. Delayed laboratory practice makes students less skilled in providing nursing actions. This situation was exacerbated when students were required to conduct clinical learning in practical areas during COVID-19. Lack of knowledge and skills, anxiety about the health of themselves and their families, and the absence of an image of caring for patients directly become challenges. The methods case study focuses on articles conducted during clinical learning at the Regional General Hospital (RSUD) X in Jakarta. There were challenges and obstacles when students did clinical learning. Challenges a present internally and externally. Cooperation is needed from both the institution and the field of practice to assist and guide students. However, students must take the initiative and be critical to creating a gradual increase in skills followed by new things learned while in practice.


BACKGROUND
The Covid-19 pandemic has occurred in the past 2 years significantly, although there has been a decline it has not ended. The pandemic that occurred throughout the world, including Indonesia, certainly had an impact on the entire order of life (Rahma, Wulandari & Husna, 2021). The part most affected is health (Zendrato et al., 2021). The impact of the health department is not only on health care procedures but on health education as well. The COVID-19 pandemic doesn't always have a negative impact. However, it is undeniable that significant changes in the order of life affect the final quality of each part (Sugiarto, 2020).
The current condition makes health education institutions experience a dilemma. The limitations of activities set by the government make educational institutions have to be responsive to change the learning system. Changes in the learning system set by educational institutions pose a risk to the quality of knowledge and practice because students are required to quickly adapt to new learning systems (Diah Hastuti, Rizki Andriani, 2022). Until now, there are still institutions that enforce online learning. However, some have implemented 50% online and 50% offline. Offline learning is carried out to laboratory practices even with minimal capacity and practice hours (Suryaman, Fahmi & Ganefianty, 2021).
Even though it has been implemented, some health students still feel that it is lacked compared to the skills they have to learn. If the laboratory practice is conducted online, students are required to demonstrate the action in the form of a video. This condition makes students feel that they do not have the maximum ability and expertise because of the limitations of medical devices at home. This situation gets worse when students are required to do clinical learning in health services (Suryaman, Fahmi, and Ganefianty, 2021). The Covid-19 pandemic which is gradually decreasing has forced students to do clinical learning in hospitals. One of the health education programs must carry out a clinical learning process to create professional and competent health workers (Harun, Herliani, and Setyawati, 2019). Students begin to feel worried and even trigger anxiety due to a lack of knowledge and action skills, communication and interaction skills in the work environment, and feelings of inadequacy due to a qualified learning system and the environment and situation during clinical learning. The reality on the ground is that health students have to reduce practice hours during clinical learning from 8 hours for 1x shift to 4 hours per 1x shift. This is done to reduce the risk of being infected with COVID-19. During clinical learning, students are required to use Personal Protective Equipment (PPE).
When undergoing clinical learning, students are required to become health professionals who are said to be the 'main actors' in the health sector and must be ready to face health challenges (Damayanti and Bachtiar, 2020). Students seem to be forced to understand the performance process in health services that has never been done before. The discrepancy between the theory learned at the institution and practiced in the field adds to the burden on students to quickly adapted to these conditions. The focus of students is also divided when they have to think about and pay attention to the health of themselves and their families at home. Reviewing the challenges and obstacles during clinical learning requires great attention from health education institutions to modify learning to continue to provide maximum knowledge and skills. Students also need to collaborate with institutions to find an effective and efficient learning system to continue to produce quality graduates. As the aims and objectives of the institution are to carry out clinical learning to create competent health workers. It is necessary to establish good cooperation between clinical supervisors, institutional supervisors, and health students to guide students during clinical learning. This is a form of reducing the risk of unexpected events during clinical practice.

METHODS
The method used is a case study. Clinical learning was carried out during the COVID-19 pandemic at one of the regional hospitals in Jakarta for different periods, depending on the provisions of the health service and educational institutions. Clinical learning is carried out to improve the competence of health students. The focus of this study is to review the clinical learning process, challenges, and obstacles while in practice.

Challenges for health students during the pandemic
As we know before the Covid-19 pandemic, health students were able to carry out their lectures smoothly. Students can easily access and use campus laboratories or conduct clinical practice in the field. However, due to the Covid-19 situation, all access has been closed to suppress the increasing number of Covid-19 spreads. The Indonesian government has implemented a large-scale social restriction (PSBB) policy. In the economic aspect, implementing Work From Home (WFH) and in the education aspect, the government issued a Distance Learning (PJJ) policy with an online system for students from elementary, middle, upper, to tertiary levels (Deliviana et al., 2021). In this case, all students in Indonesia experience a "forced" educational transformation, including health students who previously studied onsite to online. Why was the transformation forced? UNICEF, WHO, and IFRC in the COVID-19 Prevention and Control in Schools (March 2020) stated that when the situation of the virus spreads faster, schools must be closed and the education process must continue through online learning activities using various media. To put it simply, all transformations are done because they want it or not. The transformation of learning that was very slow becomes very short. The whole world is changing the conventional face-to-face-based learning pattern in schools into distance learning (PJJ) that relies heavily on technology (Luthra & Mackenzi, 2020), (Tam and El Azar, 2020) Changes in learning methods that were originally conservative to all online learning, will bring significant changes in the learning process. Lecturers as lecturers and students must adapt to the obstacles that may arise during the online learning process. This is certainly a challenge for students, including health students.
The first challenge is in the form of readiness in learning with technology. Some health students and even teaching lecturers experience difficulties with the gadgets used, network problems, and so on (Subedi et al., n.d. in Zendrato et al., 2021;Aulia Akbar, D., 2021).) especially for health students who do not, it can only be theory, it must be accompanied by practice. As a result of this PJJ, students only rely on videos from teaching lecturers to find out how to act on patients properly and correctly. This is considered less effective, instead of understanding, but due to network problems, quotas, and gadget difficulties, it makes students more confused, less enthusiastic, lose interest, and even leads to stress (Aulia Akbar, D., 2021; Ramadhanti, L. R., & Nafiah, H., 2021).
The second challenge is still related to the first but the difference lies in the balance between knowledge and skills that branch out in the dilemma situation of the health student education institution itself. In online learning, students do get knowledge, but not all skills are also found. As mentioned in the previous paragraph, online learning has caused health students who should have practiced in the laboratory directly to video, given the conditions of the Covid-19 pandemic. Institutions have a responsibility to produce competent and quality graduates so that there is a desire to continue the learning process and field practice to meet competency targets (Suryaman, Fahmi, and Ganefianty, 2021). But on the other hand, the learning process is very risky to the safety of learning participants so other options emerge to attract learning participants from nursing field learning centers both hospitals and communities, and change learning methods (Suryaman, Fahmi, and Ganefianty, 2021). For health students, knowledge and skills need to be balanced, so students need to practice directly both in the STRADA : Jurnal Ilmiah Kesehatan DOI: https://doi.org/10.30994/sjik.v11i2.927 ISSN: 2252-3847 (print); 2614-350X (online) Vol.11 No.2 November 2022 Page. 126-132 laboratory and in hospital practice areas. Based on the statement above, the Covid-19 pandemic has had a considerable impact on making health students experience difficulties in developing and improving competencies, especially in the field of skills due to the blurry picture of reality that students will face when taking direct action on patients. This is in line with research conducted by (Morin, 2020) which states that changing learning from face-to-face to online or online can lead to disparities in abilities, both knowledge, and practical skills. The third challenge is related to clinical practice in health students. The dilemma felt by the institution has found a way out where health institutions must dare to take risks to send their students to practice in the field (Dewart et al., 2020). The institution's concern is that after graduating students become incompetent and will endanger patients, so the postponed clinical practice is finally carried out with conditions in the form of health protocols and the use of PPE (Personal Protective Equipment) (Ulenaers et al., 2021). This is a challenge because we will not know whether the health students carry out health protocols properly and correctly and the immunity of a person is also different. Although the use of PPE can minimize the possibility of students being exposed to Covid-19.
Furthermore, the fourth challenge comes from within the health students themselves. It was mentioned about the stress and anxiety that hit the students due to PJJ. PJJ causes students to experience several psychological problems such as anxiety, stress, and depression (Novitasari, Kurniawan, and Kanita, 2020). Stress is a condition that can be caused by inappropriate physical demands and environmental and social situations. Stress can cause illness if not treated properly. If someone experiences stress, it will affect students' lives (Wahyu and Simanullang, 2020).
The anxiety and stress felt by students will refer to the performance of health students in clinical practice, how these students can survive in carrying out their clinical practice, and whether they can achieve the competency targets that have been given by their educational institutions. In addition to the health of students who already feel stressed due to a lack of understanding of the theory and practice of direct action, the demands for competence or competency achievement targets provided by the institution contribute to increased stress on students while when students agree to carry out the clinical practice, they want to or not. willing to have the courage to take all these risks (Adnan M. et al, 2021). Although postponement of clinical practice can reduce anxiety and stress in students (Lovrić et al., 2020) but other stress and anxiety arise in the form of large expenditures for students' personal needs in their daily lives such as buying protective equipment, boarding, meals, and assignments. In addition, other causes of anxiety arise due to feelings of not being able to communicate with patients, not being able to carry out health care actions for patients, not achieving competency targets, and because this is the first time practicing in a hospital. This opinion is in line with research (Anis Chaeruman, Wibawa, and Syahrial, 2018) that there is a significant relationship between psychological aspects of competency achievement where individual competence will increase with an increase in psychological aspects which include perception, personality, motivation, learning ability, and attitude. The anxiety suffered by health students does not stop there. The Covid-19 pandemic that is hitting the world at this time of course also affects the level of anxiety that afflicts health students (Marzuki et al., 2021). Anxiety can cause various bodily reactions, such as having trouble sleeping, tense muscles, headaches, dizziness, weakness, frequent urination, and even concentration can be easily distracted. Symptoms of stress experienced by these students can have an impact on disrupting sleep patterns or difficulty sleeping, headaches, anxiety, irritability, and physical fatigue (Kartika, 2020).

DISCUSSION
Obstacles for health students in the practice field during the pandemic The obstacles experienced by health students in the field of practice are related to the challenges previously described by the authors. The limitations of the provision of learning are that have not been maximized, do not have experience, and sometimes actions are found that have never been carried out in the laboratory or have never even been shown how through learning videos that make students less motivated and active in the practice area even though the practice area is a hospital. type A which is equipped with facilities and infrastructure as well as many and varied cases. In addition, according to research from (Amar, Mita, and Ernawati, 2019), students who have carried out clinical practice feel that there is a difference between the theory learned and the actions taken during practice in the hospital, so sometimes students have difficulty taking action. Even though they have been given practical training before, there are still students who find it difficult to carry out the clinical practice. This is in line with the anxiety felt by the students. If anxiety continues in the field of practice, it can affect student actions toward patients and can even endanger patient safety. Clinical practice in hospitals is a significant source of anxiety for students, especially when students take direct action against clients for the first time (Melo, William & Ross, 2010). When entering the field of clinical practice, students are expected to prepare well, students' anxiety factors are influenced by motivation, hospital environment, and experience (Sulistyowati, 2009). Anxiety barriers are related to students' self-confidence. Lack of selfconfidence occurs due to a lack of learning both in theory and in practice. There are times when students are given assignments by the room's medical staff to provide services to patients, feel nervous, and unable to do it quickly and efficiently so that students are scolded. This will also become a new stressor for health students who are practicing. In addition, it has been mentioned previously that students experience anxiety and stress. If the stress coping of each student is not adaptive, it will affect their performance in the clinic as found in research conducted by (Amar, Mita, and Ernawati, 2019) on nursing students that the results of students who are in clinical practice feel stress, anxiety, and anxiety. depression is what affects the clinical practice experience of nursing students (Rajeswaran, 2017). When practicing nursing students many times experienced disturbances and errors in carrying out nursing care. Students make direct contact with patients. Students make mistakes, one of which is an error in the flow of one of the injection drugs that cause the patient to go into shock, but this is immediately reported and treated immediately so that the patient can be helped. This is what causes the importance of student experience and guidance from supervisors so that students do not make fatal mistakes (Sari, 2018).
Another obstacle is the limitation of physical contact of students with patients which aims to prevent the transmission of Covid-19. Efforts have been made to reduce practice hours and there are also experiences from nursing students who stated that in addition to reducing practice hours, the rest were replaced with simulations (National Student Nurses Association, 2020). A meta-review study showed results that there was no significant difference between the abilities of students who experienced direct clinical practice and students who only received simulations when practical learning hours were replaced with simulations (National Student Nurses Association, 2020 in Suryaman, Fahmi and Ganefianty, 2021) In several other countries such as America, nursing education curriculum regulatory agencies have reduced the percentage of clinical practice. They use a laboratory with mannequins that are close to the original can be used as a way to meet the competency targets that must be achieved. However, the reduction of direct clinical practice in Indonesia was not carried out, because this clinical practice was replaced with learning simulations with videos and scheduled laboratory practices that minimize contact between students and teachers (Suryaman, Fahmi, and Ganefianty, 2021). The limitation of hours is an obstacle for health students because it makes it difficult for students to study further about their patients, cannot further explore actions that so far may only be seen from learning videos, and may cause failure to achieve all competency targets required by educational institutions.

CONCLUSION
The COVID-19 pandemic is still ongoing. Health education institutions are making gradual adjustments to the learning system. Some educational institutions have implemented 50% online and 50% offline. Offline is conducted for laboratory practice students. Students feel worried and anxious when they are required to do clinical learning due to a lack of skill preparation. Practicum was replaced with video screenings during lectures which did little to help students improve their skills. Because there needs to be direct practice to get used to it. Clinical learning poses a challenge for students, so there needs to be attention from educational institutions to modify the learning system. Students still find it difficult to develop competence and do not yet have a picture of reality when giving direct action to patients.
Clinical learning cannot be postponed because it is scheduled according to the curriculum. Therefore, there is a need for collaboration between practical field supervisors, institutional supervisors, and the students themselves during clinical learning to reduce anxiety in students. It is also necessary for the initiative of students to be critical when in practice to minimize the risk of unexpected events in patients. Communication and coordination both at institutional and clinical supervisors are required to create a gradual increase in skills following the current practice.