Effects of In-services Training Programs on Nurses Performance At Governmental Primary Health Care Settings-Gaza Governorates

Abstract

Background: Employees is considered as the major element of every organization and their success and failure mainly based on their performance.  Training and development is an aspect of human resource practices that help in enhancing employees’ skills, knowledge, and competence capable of improving employees’ ability to perform more efficiently. The general objective of this study is to evaluate training programs and their relationships in improving the performance of nurses in terms of knowledge and skills at the primary health care clinics Gaza governorates. The study design is descriptive, analytical, cross sectional one, The selected sample size was 185 nurses who had participated in training programs and working in different governmental primary health care clinics in Gaza Strip. The study concluded that females constitute 67.6%, while males constitute 32.4% of the sample. Most of the participants were over 35 years old, 40.5%,. More than half of the participants 51.4% had a bachelor’s degree in nursing, and 7.5% of the participants had a master’s degree. also the study result showed that there were no statistically significant differences with regard to gender, marital status, age groups, nurses’ qualifications, job title and years of experience. The results of the focus groups also showed that training programs are important to improve performance and need more attention, monitoring, support and follow-up by management. The study concluded with a set of recommendations, the most important one is that decision-makers in primary health care should pay more attention and pay more effective efforts in monitoring, and evaluating training programs.

1. General framework:
1.1 Introduction
Employee is considered as the major element of every organization and their success and failure mainly based on their performance . Training and development is an aspect of human resource practices that help in enhancing employees’ skills, knowledge, and competence capable of improving employees’ ability to perform more efficiently
It is thought that winning organizations generally spend more in training in contrast with others because training aids workforce to acquire the information of their employment in a finer way and individuals gain knowledge from their viable experience, much healthier performs in contrast with academic, and therefore training is considered to have a major effect’s on health organization efficiency .
It is also noticed that more expense in training has led to more productivity, long ago it had been additionally demonstrated by numerous studies that, there are sound of associations amongst training practices and distinct measures of employee performance. Moreover Devins, et.al found that trained employees often work better as teams because everyone is aware of the expectations and can achieve them together smoothly.
World Health Organization (WHO), expression in-service training refers to training of persons already employed, e.g. health providers working in the public or private sector. The effects of in services training programs activities are to improve the professional practice of nursing and the care that is provided by nurses to patients. All Indian Institute of Medical Science AIIMS, define nursing in-service training, as a need was felt by the nursing administrators that a planned nursing in-service training needs to be started so as to increase the knowledge base of nurses in practice in order to improve & maintain high standard of nursing care at Primary Health Care (PHC). The research findings reported that it needs assessment and an evaluation of in-service training and emphasize the innovative aspects of it.
1.2 General Objectives
The aim of the study is to evaluate the effects of in-service training programs and their contribution in improvement of the nurse’s performance, which could lead to a good quality of care at primary healthcare centers, settings Gaza governorates
1.3 Specific Objectives
1. To identify the effects of in-service training programs on nurse’s knowledge and practice in PHCs
2. To highlight points of strength and weakness of the in-service training programs that are provided.
3. To assess nurse’s perceptions, impressions and opinions about in-service training programs that they have received and how they were affected with the socio-demographic variables.
1.4 Research problem
The ministry of health makes a great effort to meet the clients and community satisfaction, where nurses continuously dealing and contact with the clients in the primary health care.
The researcher feels that in-service training programs provided were repeated and duplicated in addition to the contents of these training activities was unsuitable for different nursing levels also was unsuitable for target groups, time, place, follow-up and monitoring from the administration to evaluate the effect of training program.
Also, the researcher is interested to evaluate the effects of these training activities on the staff performance, regarding knowledge, attitudes, skills, practice and care provided. Therefore, the researcher focuses on the importance of in-service training programs provided which may lead to better nursing performance that will reflect out the quality of services provided.
1.5 Research questions
1. What are the effects of in-service training programs on the nurse’s performance?
2. What are the nurse’s perspective about the effects of training programs provided at PHC?
3. What are the strength and weak points of in-service training programs offered?
4. Are the topics received during in- service training programs, suitable for nurse’s needs?
5. What are the difference responses toward training programs due to socio demographics factors?
6. What are the effective types of training that improve the efficiency of nursing?
7. Does the trainer’s competency affect the improving of the nurse’s abilities and their performances?
2. Literature review
2.1 Concepts of in-service training programs
In-service training includes a set of measures taken to promote empowerment and competency among employees for the better undertaking of their tasks, thus helping .
The organization to achieve its goals in fact, In-service training serves to update the staff’s occupational knowledge and professional skills and improve the best practices for fulfilling various tasks and responsibilities.
Nurses play an important role in improving health standards. Hence, they need to be updated about theoretical and practical knowledge in this field.
Another important point concerning the in-service training of the nursing staff is their active participation in such programs. Active participation of nurses in in- service training can lead to effective learning and development in their field of work. One of the factors contributing to greater involvement of the staff in such programs is the utilization of adult learning principles. Adults are aware of learning objectives, guide their own learning, and they are self-assessor.
Also stated that training is planned action that consists of a set of programs designed to teach human resources how to lead its current high level of efficiency through the development and improvement of performance. Also according to (Douglas). in-service training is the training given by the employer to an employee to enable the employee to perform a specific activity efficiently. It is part of staff development, in-service training is deliberately planned to meet the needs of the employer in order to correct deficiencies in technical and scientific information of an employee, such as teaching of techniques and procedures that the employee has to execute in her/his job
2.3 Importance of training
Training has affected positively on employee performance according to research studies, it’s considered as the process of enhancing skills, knowledge, performance, and abilities in staff member. According to Bowes. training is an investment in achieving productivity and employee retention through providing career development and job satisfaction in the long run. Also (Ndulue). identify that training is fundamentally essential because it improving the institutions ability to adopt and use advances in technology because of a sufficiently knowledgeable staff; building a more efficient, effective motivated staff; and ensuring adequate human resources for expansion into new programs.
The second important point as stated by (Saleem, et.al) . that training is an organized from the know and how skills needed for employees to practice efficiently in the provided care. The study of Abdul (Ghafoor, et. Al). Showed that there is a positive correlation between the two variables training & employee performance area. (While Singh & Mohanty) 2. Explained in their research that training is an important tool for enhancing the workforce performance and it will ultimately increase the worth of an organization but organization ought to be balance amongst training worth and training disbursement. The results revealed that in diverse industry the effect of training are varied
2.4 Impact of training on job performance
As stated by (Muzaffar, Salamat and Ali) 3. that for increasing the individuals performance, it is crucial to inspire the individuals by means of satisfying the needs of skills necessary and the owned or operated by means of staff through delivering applicable training. (Khawaja, et.al) said in their study on topic association of training satisfaction with employee development aspect of job satisfaction that training giving to employees will results in increasing the level of satisfaction of their current jobs. It underlines the needs of company to concentrate on building employee capability and development to achieve job satisfaction. Different analyses were applied to test the research question.
Singh & Mohanty found a significant relationship between frequent on-the-job training and employees’ performance, they stated that frequently training employees resulted in employees making fewer mistakes, getting more work done in a given time period and managers spending less time on supervision of employees.
Also (Devins, et.al.) found that trained employees often work better as teams because everyone is aware of the expectations and can achieve them together smoothly. Trained employees are also more confident in their performance and decision-making skills. In addition, employees who receive regular training are more likely to accept change and come up with new ideas, employees who learn new skills through training make good candidates for promotions because they have shown their ability to learn, retain and use information.
Regarding to the point view of (Akhtar et al) . concluded that training has an optimistic association between motivations along with job engagement involving personnel doing work in organizations. Argued that lack of frequent training is not necessarily the cause of underperformance of employees. He stated the need to determine whether a problem can be solved by training, whenever employees are not performing their jobs properly, it is often assumed that training will bring them up to standard. While discovered that impact of training is to enhance the quality of task process that brings improvement in the performance of staff. (Abay, 2008) . Reported that significant relationship was found between the employees training and their resultant performance in accomplishing different tasks, it was found that those employees who have taken trainings were more capable in performing different task & vice versa, training has direct relationship with the employees’ performance.
3.Materisl and methods
3.1 Study design
The design of this is a mixed- methods one, in which data has been triangulated (quantitative & qualitative). This study is a descriptive, analytical, cross sectional one, This design was used to evaluate the in-service training programs on nurse’s performance. These methods were adopted according to their effectiveness, giving us the most meaningful ways through which a large number of nurses participated in this study. Its anticipated that the quantitative part captures quantifiable perception and the qualitative part attempts to reveal the reality behind these perception through deeper understanding of the participants perspective at their natural settings.
3.2 Study Place
The study was accomplished in the all-governmentally primary health care centers (Rafah Governorate, Khan Younis Governorate, Middle Governorate, Gaza Governorate, North Governorate).
Table (1): The names of health care centers in all governorates
Rafah Governorate KhanYounis Governorate Middle Governorate Gaza Governorate North Governorate
Rafah-Martyrs Center Khan Younis martyrs Center Old Nosirate Center Al-Remal Martyrs Center Bait Hanon Center
Tal Al -Soltan Al-Qrara Masqat The Old Nosirat Al -Zyitoon Abo Shbak
Al- Shabora Bani Sohila Al Zawida Sabha Harazeen Jabalia Martyrs
Al- Shoka Abssan Al Borige El Rahma Al Shyma
Deer Al Balah Al Qouba Hejazi
Al Mousadder Al Darag Jabalia Masqat
Heker Al jama Shek Redwan Bait Lahia
Al Falah Hala Al shawa
Al Shatek JamelaA ashi
Al Sorany
Al Salam

3.2 Study population
The population of this study were all employed nurses who had participated in in-service training programs and already working at the primary health care centers in GGs. The total number of nurses who have been enrolled in such programs is about 321 nurses according to nursing directorate records in the PHC records at Ministry of Health.
3.4 Sample size
The Study samples were selected from different clinic’s levels, the fourth, the third and the second, and from different geographical area. According to the records of nursing directorate of PHC, there are 49 PHC centers distributed in all the Governorates of Gaza, the North, the Mid-Zone, Khanyounis, and Rafah. The total nurse’s number is 321, distributed according to the clinic’s levels as the following; the fourth level 176 nurses, the third level 74 nurses and the second level 71 nurses. The total sample size which was calculated according to the equation below was 178 nurses.
n =
N= Population size
K = Constant factor (1)
e = Degree of error expected
n = Sample size
(https://www.slideshare.net/ludymae/chapter-8sample-sampling-techniques)
3.5 Sampling process
For the quantitative part, stratified proportional sample method was used to select the desired sample size, which was obtained from all PHCs. The number of nurses in this sample is (185) and it was selected from the different levels of clinics, the fourth (101), the third (43) and the second (41) and also from different geographical areas. The sample took in consideration the numbers of nurses in those clinics and also their locations.
For the qualitative part; 24 of nurses were purposively selected and called on voluntary basis to participate in three focus groups. Focus groups discussion (FGDs) were selected in a way that ensures they represent female and male nurses, only female nurses, different managerial positions one of them are head of the in-service training in human resources development at Al- Shifa hospital.
3.6 Ethical Consideration
An ethical approval letters were obtained from School of Public Health at Al-Quds University (Helsinki Committee) and from the directorate of nursing at the PHC.
Every participant was provided with a full written explanatory form attached to the questionnaire. This form included the purpose of the study, assurance about confidentiality of the information gathered. It also included a statement indicating that participation isn’t obligatory and participants have the right to accept or refuse to participate in this study. Anonymity and confidentiality was given and maintained.
3.7 Statistical Methods Used
The questionnaire was unloaded and analyzed through the Statistical Package for the Social Sciences (SPSS) version 23, The statistical tools were used descriptive, analytical statistics, and qualitative data analysis (focus group). Important techniques like t-test for dependent and independent variables and analysis of one-way ANOVA are largely under used in this study.
4. Results and Discussion
This chapter illustrates the findings from analysis of the collected data. The analysis of data shows the descriptive, analytical statistics, and qualitative data analysis (focus group). Important techniques like t-test for dependent and independent variables and analysis of one-way ANOVA are largely under used in this study.
4.1 Descriptive statistics Part
4.2. Personal characteristics
Table (2): Distribution of participants according to their characteristic’s variables.
Items Number %
Gender Male 60 32.4
Female 125 67.6
Total 185 100.0
Age groups Mean ± Mean = 42.89, S.D., 8.018
25-35 years 42 22.7
36-45 years 75 40.5
>45 years 68 36.8
Total 185 100.0
Qualification Nursing Diploma 61 33
Midwifery Diploma 15 8.1
Bachelor of Nursing 95 51.4
High diploma & Master 14 7.5
Total 185 100
Items Number %
Job title Practical Nurse 32 17.3
Staff Nurse 105 56.8
Midwifery Diploma 16 8.6
Managerial positions 32 17.3
Total 185 100
Years of experience Mean ± Mean = 17.96, S.D7.034
1-10 years 31 16.8
11-20 years 93 50.3
>20 years 61 33.0
According to the result given in table (2), It is observed that the distribution of participants according to gender is 32.4% male and 67.6% female, as seen in the above table reflects that the fact majority of nurses at PHC are females, since the female employees are the most needed in most sections at primary health care centers. The Figure1. Bellow shows percentages of nurses according to their gender

Figure (1): Gender distribution
Regarding age, as seen in Table (2), The majority are between 36-45 years and represented 40.5% of respondents, those who are more than 45 years old, represented 36.8%, while those who are between 25-35 years old represented 22.7%. The mean for all age groups is 42.8 years. These results reveal that, nurses working at primary health care centers and who are relatively older than 36 years, represented 77.3%. Regarding qualifications, the highest percentage of participants 51.4% hold bachelor degrees of nursing, nursing diploma 33%, midwifery diploma and higher studies represent (8.1% and 7.5% respectively). About half of the respondents are bachelor degree holders, which means that the educational level of the study sample is high . These results are consistent with the findings of Ouda1. he found in his study about ” perspective of the MoH hospitals nurse about the impact of training programs on their performance”. Nurses who hold BSN represent 50.5% of the sample

Figure (2): Job title’s distribution
Figure 2 presents the various job titles of the nurses who participated in the questionnaire, the majority of them hold the title” staff nurse” with the percent of 56.8%. Practical Nurse & managerial position 17.3%, and midwifery diploma represented 8.6% . Figure shows percentage distribution of participants according to their job titles

Figure (3): Years of experience’s distribution
Regarding years of experience, the results reveal that the majority of participants 50.3% have years of experience between 11-20 years, those who have more than 20 years 16.8% while those with 1-10 years 33.0%. The finding reveals that about the half of the respondents have a good experience in the PHCs. Thus enriches the study and gives us the opportunity to get to know to the points of views of the nurses regarding their different experiences. Figure 3 shows the distribution of participants according to their years of experience
Table (3): Total distribution of participants according to the training programs they attended.
No. Training courses Frequency Total Percent
Attend Percent Non Percent
1 Vaccination 117 63.2 68 36.8 100%
2 NCD 99 53.5 86 46.5 100%
3 MCH 99 53.5 86 46.5 100%
4 Emergency 77 41.6 108 58.4 100%
5 Mental illness 52 28.1 133 71.9 100%
6 Breast feeding 48 25.9 137 74.1 100%
7 Infection control 38 20.5 147 79.5 100%
8 Nutrition 30 16.2 155 83.8 100%
9 Family planning 22 11.9 163 88.1 100%
10 Management 14 7.6 171 92.4 100%
Total 185 100%
Table (3) shows the total distribution of participants according to the training programs they have attended, the results reveal that vaccination programs take the highest percentage 63.2%, followed by NCD & MCH, which are considered the second pillar with relative percent 53.5%. This indicates that the previous training programs are considered the corner stone of health services at the PHC, therefore every nurse should be trained in such programs to be able to provide the patients with a safe and efficient care.
Regarding the emergency, as shown in the table, it takes 41.6%, this is related to the international organizations that focus and pay attention on the fourth level of PHCs after the first war on Gaza strip.
Regarding mental illnesses, as shown in the table, 28.1% of participants attended special programs about mental disorders that was offered after the first ware on Gaza Strip. The international organizations give attention to mental disorders, so special programs are provided to reinforce and enable nurses to deal with patients who suffer from such cases.
Breast feeding. 25.9% of participants have attended courses about breast feeding, this percent is low, since the breast feeding courses are limited only for female nurse working in MCH clinics.
Infection control, nutrition, family planning and management are the least relative percent of the courses that was attended by participants (20.5%, 16.2%, 11.9% and 7.6%) respectively. The last ranking of these courses is management, because its limited to managerial position.
Table (4): Total nurses mean perceptions of, SD, and ranking of the six domains (n= 185)
No. All study domains No, of items Mean Score (5) ± SD % Rank
1. Programs Design 11 3.92 .4437 78.54 2
2. Contents of training programs 11 3.74 .3785 74.94 4
3. The trainer competencies 15 3.86 .3933 77.26 3
4. Training environment 5 3.61 .6323 72.32 6
5. Effects of training programs 14 4.011 .4451 80.22 1
6. The role of the institution regarding the training 7 3.68 .62634 73.74 5
Total 63 3.81 .36183 76.18
Table (4) shows the results of all study domains with the average mean equal 3.81 and relative percent 76.18%.
The fifth domain “Effects of training programs” holds the highest rank 80.22% of the respondents , and relative mean 4.011, this percent reveals that the respondents working in the PHCs are satisfied with the training programs and they also have a positive perspectives towards in-service training programs, that is consistent with study (Odah’s, 2011) . perspective of the MoH hospitals nurses about the impact of training programs on their performance , he found that 77.0% of nurses at MoH hospitals are satisfied with the training programs that were provided.
The two domains “The role of the institution regarding training and Training environment” hold the last rank with mean score ( 3.68, 3.62) respectively, and relative percentages (73.7%, 72.3%) respectively.
This reflects that, the role of the institution regarding the training programs, needs more attention and support from the institution management, and also an improvement to the environmental conditions of the training regarding place, ventilation, and space.
Table (5): Total Nurses mean perception about the Effects of training programs
No. Effects of training programs Strongly disagree % Disagree% Neutral% Agree% Strongly agree% Mean % Rank
1 I have gained new skills that can be applied in my work 1.1 2.2 9.2 74.1 13.5 3.97 79.4 9
2 I have the ability to make the right decision in my work 1.6 2.7 12.4 69.2 14.1 3.91 78.2 12
3 Training programs bridge the gaps between the theory and practice .5 6.5 15.1 63.8 14.1 3.84 76.8 13
4 I apply most of the skills I have gained from training programs .5 4.9 11.9 66.5 16.2 3.93 78.6 10
5 The training programs helped me to benefit my colleagues in the field of work .5 3.2 8.1 71.9 16.2 4.00 80 8
6 I feel that I am thinking more deeply about professional matters .5 3.8 11.9 70.3 13.5 3.92 78.4 11
7 The training help me to develop my performance .5 3.2 7.6 70.8 17.8 4.02 80.4 6
8 Training is very important to raise the level of professionalism 0 1.1 5.4 63.8 29.7 4.22 84.4 1
9 I recommend my colleagues to attend training program in future .5 1.6 3.2 64.9 29.7 4.22 84.4 1a
10 The training helped me do things I had not done before 1.1 2.2 10.3 64.3 22.2 4.04 80.8 7
11 My mistakes reduced at work because of training 1.1 4.9 19.5 57.8 16.8 3.84 76.8 13a
12 I feel that my performance is improving .5 1.1 10.8 63.3 24.3 4.10 82 3
13 I feel more confident in myself 1.1 1.6 14.1 56.8 26.5 4.06 81.2 5
14 My performance assessment became better after training 0 2.7 13.5 57.8 25.9 4.07 81.4 4
Total 4.01 80.2
Table (5) illustrates that the total mean score of this domain is about (14) statements. Nurses who agreed and strongly agreed that the ” Training is very important to raise the level of professionalism, & ” I recommend my colleagues to attend training program in future” represented 84.4%. While they agreed and other neutrally that “Training programs bridge the gaps between the theory and practice”&” My mistakes reduced at work because of training” represented 76.8%.These results are consistent with the findings of (Gaith, 2014) . that he found training programs help the staff and improve their performance with mean score 4.14 and relative weight 82.8%. Also the result is congruent with the study of (Muzaffar, Salamat and Ali, 2012) . they emphasize that for increasing the individuals performance, it is crucial to inspire the individuals by means of satisfying
4.3 Inferential analysis
This part represents the relationships between study domains and its relation of participant socio-demographic variables regarding gender, marital status, age groups, qualifications, job title and clinic levels. The results given in Tables (6-8)
Table (6): Differences in perceptions about the study domains according to gender N = (185
No. Domains Gender N Mean Score (5) t Sig. value
1. Design the programs Male 60 3.9136 -.289 .773
Female 125 3.9338
2. Contents of training programs Male 60 3.7045 -1.056 .293
Female 125 3.7673
3. The trainer competencies Male 60 3.8511 -.294 .769
Female 125 3.8693
4. Training environment Male 60 3.5639 -.779 .437
Female 125 3.6413
5. Effects of training programs Male 60 4.0310 .425 .671
Female 125 4.0011
6. The role of the institution from training Male 60 3.7238 .560 .576
Female 125 3.6686
Total Male 60 3.7980 -.274 .785
Female 125 3.8136
Table (6) shows the results of independent t-test to compare mean differences of nurse’s perceptions between male and female of the study domains. There are no statistical significance difference between all the domains ( p=.785) This could be due to that male and female nurses are takes the same subjects content of the training programs which offer’s through the in-service training units at the PHC.
Table (7): Difference in perception about the study domains according to age groups N = (185)
No. Domains Age groups Mean df Mean Square F Sig.
1. Programs design 25-35 years 3.913 2 .136 .690
.503

36-45 years 3.972 182 .198
>45 years 3.886 184
2. Contents of training programs 25-35 years 3.734 2 .081 .560
.572

36-45 years 3.782 182 .144
>45 years 3.717 184

The trainer competencies 25-35 years 3.824 2 .090 .579
.561

36-45 years 3.810 182 .155
>45 years 3.850 184
4. Training environment 25-35 years 3.607 2 .414 1.035
.357

36-45 years 3.691 182 .400
>45 years 3.539 184
5. Effects of training programs 25-35 years 4.029 2 .009 .046
.955

36-45 years 4.004 182 .200
>45 years 4.007 184
6. The role of the institution regarding the training programs 25-35 years 3.752 2 .148 .375 .688
36-45 years 3.688 182 .395
>45 years 3.645 184
Total 25-35 years 3.807 2 .077 .584 .559
36-45 years 3.839 182 .132
>45 years 3.774 184
3.809
One-way ANOVA test used to figure out the differences between the scores of perceptions of the age groups are given in Table (7) There are no statistical significant differences between all domains (P-value >0.05). While there are a difference means in these domains between age groups, its observed that older participant (36 to 45) have the highest mean score in most domains, this means that this age groups are more experienced, more knowledgeable, more manageable and more oriented nurses.
Table (8): Difference in perception about the study domains by years of experience N = (185)
No. Domains Years of experience Mean df Mean Square F Sig.
1. Design the programs 1-10 years s 3.8856 2 .201 1.023
.362

11-20 years s 3.9736 182 .197
>20 years 3.8778 184
2. Contents of training programs 1-10 years s 3.6950 2 .073 .506
.604

11-20 years s 3.7713 182 .144
>20 years 3.7362 184
3. The trainer competencies 1-10 years s 3.8602 2 .026 .166
.847

11-20 years s 3.8789 182 .156
>20 years 3.8415 184
4. Training environment 1-10 years s 3.5538 2 .487 1.220
.298

11-20 years s 3.6882 182 .399
>20 years 3.5383 184
5. The impact of training programs 1-10 years s 4.0115 2 .002 .009
.991

11-20 years s 4.0146 182 .200
>20 years 4.0047 184
6. The role of the institution from training 1-10 years s 3.8618 2 .577 1.477
.231

11-20 years s 3.6575 182 .390
>20 years 3.6417 184
Total 1-10 years s 3.8113 .061 .460 .632
11-20 years s 3.8307 .132
>20 years 3.7734 .
3.8085

One-way ANOVA test was used to figure out the differences between the scores of perceptions of participant regarding the total years of experience are given in Table (8) There are no statistical significant differences between all domains (P-value > 0.05), which means that years of experience has no impact on nurses’ perception, toward training,
5. Conclusion and recommendation
5.1 Conclusion
• This study was conducted to evaluate the effects of in-service training programs on nurses’ performance at governmental primary health care centers, the study could help in improving the in-service training programs in future, particularly in the PHCs, the study explores more characteristics of the training programs regarding programs design, contents of the training programs, trainers, effects of the training programs & the role of institution regarding training programs. The study could fill the gap between the theory and its application.
• The sample of the study consists of 185 nurses 60 male and 125 female, it was divided as the following: 32 practical nurse, 16 midwifery diploma, 105 staff nurses and 36 from managerial positions
• The interesting results of this study is regarding the work experience at the PHC, the results revealed that more half of the participants 50.3% having experience from 11-20 years, on the other hand 51.9% and 18.9% of the study sample are living in Gaza and north respectively. Also regarding clinics levels, revealed that more than half of the nurses 55.7% work at level 4 clinic.
5.2 Recommendation
• Administrators of PHC needs to pay more attention of follow up and monitor the effects of training programs. Evaluation of the effects of training programs should be given a priority and training should be reference to performance, during and on completion of each training programs.
• Adopt the concept of training programs as part of the organizational culture, and formulate standards to measure the effect on employees performance..
• Offering equal chances for staff development, growth, and incentives, which increase their feeling of equity, fairness and satisfaction.
• Act toward improving the work environment and conditions that enhance nurses to maintain high performance
• Support and strengthen the in-service training programs to bridge the gap between theory and practice.
• Involvement and sharing nurses in selecting the in-service training program which matching their own professional needs
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