SWOT Analysis of Nursing Clinic Professional Career Ladder System (SJKP2K) in Military Hospital Jakarta

Nursing managers must have a strong directing function towards the Professional Clinic Nurse Career Ladder System (SJKP2K). This is to improve the quality of nursing care that will be provided by nurses to patients. The military hospital in Jakarta already has the standard of planning, guidelines and SOP regarding the SJKP2K, but based on the authors' observations for two weeks in one of the rooms in the hospital, the results show that the SJKP2K implementation is not optimal. This problem then analyzed using the SWOT Analysis followed by scoring and weighting through an Internal Factors Evaluation (IFE) and External Factors Evaluation (EFE) matrix analysis. The sum of the scores of each matrix then poured into the IE (Internal and External) matrix to determine the position of the SJKP2K strengths. The calculation result between IFE and EFE in IE matrix shows that SJKP2K is in area V, which means that SJKP2K is in hold and maintain stage so that market penetration and product development strategies are needed so that SJKP2K requires development both in quality and quantity.


PRELIMINARY
Career path is a system through a process of increasing competence to improve performance and professionalism. Nursing careers contribute to making good decisions about patient care, patient safety, policies and procedures, satisfaction, and health service reform 1 . In addition, Career Paths are also very effective and play an important role for individuals and organizations, allowing for the evaluation and competence of nursing professionalism 2 . In line with the research 3 which states that the career development of nurses has an important role because it is expected to improve the competence of a nurse so as to be able to carry out quality nursing care and increase the work motivation of nurses. Career paths in Indonesia are growing with the demands of Hospital Accreditation and the issuance of the Minister of Health Regulation No. 40 of 2017 concerning Professional Care for Clinical Nurses (JKP2K) to become a system that is required to be implemented in all hospitals in Indonesia.
Policies regarding career paths in Indonesia which are regulated in PMK No. 40 of 2017 states that the level of competence at the career level provides accountability and ethical values in accordance with the limits of the authority of nurses in providing nursing care. The success of care must be supported by nurse professionalism 4 One form of support for nurse professionalism is through the development of a nursing career. The development of a nursing career path system is a plan to place nurses at a level that suits their expertise and the application of a nurse's career level will provide good opportunities according to the capabilities and potential of nurses. A nurse's competence provides an important role to improve the quality of nursing care. It is also contained in the competency regulation and staff authority which is regulated in the National Standard of Hospital Accreditation (SNARS) that in order to fulfill the need to provide care to patients the requirements of knowledge, education, skills, experience, authority, and staff competency are determined by the head of the service unit 5 .
Military hospitals in Jakarta achieved national accreditation and JCI in 2017. The hospital has a Bed Occupancy Rate (BOR) of 80.7%, and an Average Length of Stay (LOS) of 5.69 days. The number of nursing staff is 1227 nurses (data as of March 2018) with the number of pre PK 220 people, PK I 142 people, PK II 203 people, PK III 616 people, PK IV 29 people, and PK V 1 person spread over several installations and units . The hospital has twice assessed the competency of clinical authority, the assessor has been re-certified to provide an assessment of 1227 nurses. The results of the author's observation there is a lack of perception and knowledge of nurses towards SJKP2K, besides that the reward calculation system is not optimal based on PK so that the value of service services at various levels of levels becomes significantly less meaningful to the value of services provided.
In addition, the lack of workforce functions and direction by nursing managers also have an impact on the implementation of the SJKP2K. Based on data obtained by previous students who practiced residency at the same hospital stated that the Head of Room stated the importance of quality control of nursing in the management of the ward, but the implementation of monitoring and evaluation as well as follow-up monitoring of perceived quality was not optimal by 40% 6 . The results of the survey related to the management function of the Head of the Room identified the direction function and control of the FSSF still needs to be improved. This makes the writer interested in identifying through SWOT Analysis (Strength, Weakness, Opportunity, Threats) and giving feedback through the External Factors Evaluation (EFE) matrix and the Internal Factors Evaluation (IFE) matrix on the opportunities and challenges of optimizing the clinical nurse professional career system at the Jakarta Military Hospital.

METHOD
The method used in this study is the SWOT Analysis approach. SWOT analysis is a systematic identification of factors to formulate an organizational strategy 7 . This analysis is based on thinking that maximizes strengths and opportunities (Opportunity), but simultaneously minimizes weaknesses (Weakness), and threats (Threats). Data from SWOT analysis is then inputted into EFE and IFE Matrixes that are scaled and weighting. The sum of the next weighting is input into the IE (Internal and External) Matrix which focuses on producing feasible alternative strategies by integrating external and internal factors (figure 1). Each matrix region has different alternative strategies. (SBU) in cells I, II, or IV can be described as Grow and Build. Strategic Business Unit located in cell III, V, VII, the best strategy to do is a hold and maintain strategy. While the Strategic Business Unit in cell VI, VIII, IX can use the harvest or divestiture strategy. SWOT analysis is also a tool for matching important data that helps managers develop types of problem solving strategies and efforts to find solutions. The results of the SBU strategy were then analyzed based on the results of residency observations, literature reviews, previous research, journals and existing policies to produce a recommendation for the optimization of the SJKP2K. This study process is a plan of an innovation project that already has a license Number: B / 3846 / IX / 2018.

RESULT
The assessment results from the observation data are then analyzed using the SWOT analysis summarized in the Lead support for nursing staff who wish to continue their education. 3.
The total number of RSPAD Nurses is 1227 people, with details of pre-PK 220 people, PK I 142 people, PK II 203 people, PK III 616 people, PK IV 45 people, and PK V 1 4.
Is an RS that has the trust of RI 1 5.
Almost all of the head of the room have Ners education qualifications 6.
Increasing nursing staff who have specialist Ners education qualifications 7.
There is a joint commitment between Kaur and staff towards the implementation of the clinic's established authority.

1.
Service points Career level is less significant to the number of services obtained. (1 of 10 service assessment indicators) 2.
Implementing nurses are still not optimally socialized about the Professional Nurse Career Path System. 3.
Nursing Resources are still insufficient in each service room based on the calculation of energy requirements.

4.
The number of nurses with vocational education is 73% greater than professional nurses.

5.
Monitoring of the implementation of career paths is still not optimal. 6.
No nursing committee member works full time.

7.
Each assessor has more than 1 position.  After identifying SWOT, the authors then group the critical success factors that exist in the external environment using the EFE matrix and the internal environment in the IFE matrix. This matrix is used to obtain scores that will later be contained in the IE matrix to produce alternative strategy recommendations.   Cell V is the most important SBU region developed with a hold and maintain strategy which means that it needs to be maintained and developed. The strategy commonly used in this V cell is the product development and market penetration strategy which means that the SJKP2K requires development both in terms of quality and quantity, besides that market penetration is intended to encourage or direct management from improving supervision so that the SJKP2K implementation can run optimally.
During the residency period as perceptee in the room x RS military Jakarta, the authors observed and calculated the number of nursing staff needs, based on the results of the calculation by Gillies formula the number of shortage of nurses with total care, partial care and independent patient number of nurses was 6 people, the same with the calculation of the lack of nursing staff at the Inpatient Installation. The author also observed the distribution of nursing staff based on the level of careers in the room as follows:

Table.4 Distribution of nurses based on career level in each shift one day (3 September 2018)
Table.4 describes the number of personnel based on PK in the room in each shift, the schedule is taken on the schedule of 3 September 2018. Each shift is not filled by all PK levels, this of course makes the implementation of quality nursing care not optimal. It is very evident that room x has a quantity problem which is a lack of nursing staff to be able to improve the quality of nursing care based on the established clinical authority. In addition to the quantity problem, the nurse quality problem still needs to be developed through the development of nurse competencies.

DISCUSSION:
SJKP2K optimization in Military Hospital in Jakarta is very possible. Planning regarding guidelines, guidelines and SOPs has been made in complete and detailed but the implementation has not been optimal because SJKP2K has not been well socialized among implementing nurses. The need for a strong direction function from the nursing manager is one of the problems for writers in SJKP2K optimization. A research study states that nursing leadership has a statistically significant effect on decreasing incidence and improving the quality of nursing 8 . So that the efforts of the head of the room to involve staff actively in the implementation of the SJKP2K in the room is very necessary.
In addition, the assessment component of the nursing career level is only 1 of the 10 assessment components so that the number of services does not significantly mean the nominal increase in services obtained. Performancebased remuneration needs to be followed at each increase from one career level to a higher level 9

. Other
Pra PK PK I PK II PK III PRA PK PK I PK II PK III PRA PK PK I PK II PK III research states that rewards regarding career paths need to be planned carefully in the health care system and the implementation needs to pay attention to institutional capabilities 10 .
Based on observations and interviews with several nursing managers at Military Hospital in Jakarta, it was stated that support for career paths increased when the accreditation and JCI were assessed, in contrast to other hospitals that linked career path systems to rewarding using career paths as a method to appreciate dedication to broaden knowledge and skills with patient care and to recognize and appreciate nurses' skills 11 . Support from leaders and peers is considered good enough to improve nurses' perceptions of the career pathway 4 . This is different from the results of observations during the residency, nurses do not have sufficient support from peers to improve their career perceptions. The empowerment of staff towards SJKP2K optimization is very necessary, in terms of quantity and quality of nursing staff also have not supported the implementation of SJKP2K optimally.
Nursing career paths provide clarity on task hierarchy, transparency in career development, facilitating skills, and rewards 12 . In addition, through nurses 'career paths should also increase nurses' awareness of tasks, the development of nurse education, and patient recovery 13 . Poor manpower, both in terms of quality and quantity, is also a problem found by the author. Phenomenon found by the nurse's nurses to perform nursing actions is not always based on clinical authority that has been set in the guidelines, guidelines and career level SPO in the hospital. However, there is an unwritten commitment or joint agreement approved by the head of the room in terms of clinical authority. The limitation of the energy in the room requires the head of the room to arrange an energy distribution formula in which there is PK III as the person in charge of the shift at that time. So that the clinical authority carried out by nurses in the room is not limited to the SPO that has been set.
Nursing managers often become agents of change within an organization. Planned change is certainly a conscious and deliberate effort that is full of consideration to realize so 14 mething that is produced through change 15,14 . Planned changes are implemented because of the efforts of the change agent (change agent) that implements slowly after consultation with other people 15 . Based on the results of research from previous residency students, 55% lacked fitness function in the application of quality nursing institutions, 35% lack of work function, and 45% lack of control functions. This certainly greatly influences the implementation of SJKP2K in nurses, so that the role of managers is needed in the optimal implementation of the SJK2K.
The results of the IE matrix show that the SJKP2K in Military Hospital in Jakarta requires a hold and maintain strategy with the best strategy, namely product development and market penetration. So that we need a quantity and quality development effort in the SJKP2K optimization efforts at the hospital. There is a regulation on the National Accreditation of Hospital Standards (SNARS) of Competency and Staff Authority standards (KKS) demanding every hospital to continue to improve the competence of its health personnel in every element of the hospital. In addition, the increasing number of patient visits at the hospital also initiated hospital management to continue to create effective, efficient and capable services. Based on the strength of the personnel in the Military Hospital in Jakarta, according to the authors, it has the potential to optimize the Professional Nurse Career Path System (SJKP2K).
The development proposed by the author is in quantity and quality. Quantitatively the author recommends an increase in the number of nursing staff while in quality it is necessary to develop competencies in the implementing nurses. A nurse's competence provides an important role to improve the quality of nursing care. It is also contained in the regulation of Staff Competence and Authority (KKS) which is regulated in the National Standard of Hospital Accreditation (SNARS) that in order to meet the needs of providing care to patients the requirements of knowledge, education, skills, experience, authority, and staff competence are determined by the unit leader service 5 . Supportive management and nursing competencies are key factors in producing a positive work environment besides the development of professional competencies, it requires the support of environmental characteristics namely adequate staff work, nursing competence, supportive management and teamwork 16 .
The quality development proposed by the author is the development of the competency of the nurse executor, according to the writer to do the addition of long-term planning nursing staff which is also very important to be considered. The proposed activity is a Case Reflection Discussion (DRK). DRK is a strategic step in fostering relationships with staff, it is hoped that it can build staff confidence and be able to express their feelings so that there can be an openness between leaders and staff, as well as between staff and other staff. Besides that DRK will motivate participants to be able to argue positively in solving care problems and management of nursing referring to standards with a mutual agreement, standards need to be updated / revised or need to present additional standards. The implementation of DRK will be monitored directly by the nursing committee or nursing department. DRK is carried out once a month by each room, the case discussion can be in the form of successful cases or unsuccessful cases. The implementation of DRK is expected to make the development of nurse competencies, enthusiasm for the latest scientific and cases so that nurses can exercise their clinical authority more optimally and confidently.

CONCLUSION
The results of calculations through SWOT Analysis using the IFE (Internal Factors Evaluation) Matrix, EFE (External Factors Evaluation) and IE (Internal External) shows that the FSSP is in the hold and maintain stage which requires a development strategy. Management needs to pay attention to reward systems that have more influence on service tariffs. Quantitatively, there needs to be a strategy of labor patterns that will be recruited. Whereas in quality it is necessary to develop nurse competencies so as to be able to carry out clinical authority with confidence. In addition, the direction and supervision function of management is very important in the optimization of SJKP2K.

RECOMMENDATION
1. There needs to be a strengthening of support and commitment by top managers in the implementation of career path programs, one form of commitment that can be done is by strengthening the assessment component related to the magnitude of services. 2. Optimization of the guidance function for all nursing managers so that the SJKP2K is well socialized for the nursing nurses. 3. Development of nurses' competency through the Case Reflection Discussion (DRK) activities. 4. Coordinate in the preparation of Guidelines, Guidelines, and SOP DRK.