The role of continuous education and training in improving hospital nurse performance: case study of employee development program implementation

Continuous education and training play an important role in improving the performance of hospital nurses, which in turn has a positive impact on the quality of health care. This research aims to investigate the key role of continuing education and training in the healthcare context and explore the challenges, strategies, and impacts of its implementation. A descriptive qualitative approach was used with data obtained from relevant previous research results. The research results show that continuous education and training enable nurses to become leaders in best practices, contribute to innovation, and play an important role in improving the quality of health care. The importance of integrating these programs into organizational culture and management and maintaining sustainability through incentives, evaluation, and innovation is also highlighted in this research. This research provides important insights into the strategic role of continuing education and training in improving health care and how hospitals can ensure its sustainability for the benefit of patients and nursing staff.


INTRODUCTION
Improving the quality of health services is a goal that every hospital throughout the world continuously strives for.Hospitals, as the main health service institutions in the health care system, have a vital role in providing effective and quality care to patients.In a hospital environment, the role of nurses is key in providing optimal service to patients.They not only act as providers of care but also as coordinators, educators, and providers of essential information for patients and their families.Throughout its history, the nursing profession has experienced significant development in terms of increasing its competence and role in providing quality care (Alolayyan et al., 2022).Nurse education and training is a very crucial aspect in ensuring that nurses have the knowledge, skills, and competencies needed to face the increasingly complex demands in today's world of health services.However, in the context of rapid changes in the health sector, the formal education provided to nurses in nursing schools may not always be sufficient to prepare them to face current challenges (Mlambo et al., 2021).
One way to meet this need is through continuous education and training for nurses.Continuing education and training provide opportunities for nurses to continually improve their knowledge and skills, keeping up with the latest developments in medical science, technology, and healthcare practice.It also provides an opportunity for nurses to review their practices and ensure that they are always providing evidence-based care following the latest standards in the nursing profession (Beckett, 2023).Skilled and continually evolving nurses will have a significant impact on the quality of care provided to patients.Optimal nursing performance not only influences patient clinical outcomes, but can also reduce complication rates, increase patient satisfaction, and overall provide major benefits to hospitals and the healthcare system as a whole (Stucky et al., 2022).
Improving the quality of health services is a goal that every hospital throughout the world continuously strives for.Hospitals, as the leading health service institutions in the health care system, have a vital role in providing effective and quality care to patients.In a hospital environment, the role of nurses is key in providing optimal service to patients.They not only act as providers of care, but also as coordinators, educators, and providers of important information for patients and their families (Lee & Lee, 2022).Throughout its history, the nursing profession has experienced significant development in terms of increasing its competence and role in providing quality care.Nurse education and training is a very crucial aspect in ensuring that nurses have the knowledge, skills, and competencies needed to face the increasingly complex demands in today's world of health services.However, in the context of rapid changes in the health sector, the formal education provided to nurses in nursing schools may not always be sufficient to prepare them to face current challenges (Pennbrant et al., 2020).
One way to meet this need is through continuous education and training for nurses.Continuing education and training provide opportunities for nurses to continually improve their knowledge and skills, keeping up with the latest developments in medical science, technology, and healthcare practice.It also provides an opportunity for nurses to review their practices and ensure that they are always providing evidence-based care following the latest standards in the nursing profession (Kanwar et al., 2019).Skilled and continually evolving nurses will have a significant impact on the quality of care provided to patients.Optimal nursing performance not only influences patient clinical outcomes but can also reduce complication rates, increase patient satisfaction, and overall provide major benefits to hospitals and the healthcare system as a whole (Labrague, 2023).
This research seeks to look at the role of continuous education and training in improving nurse performance.By looking at the case study of Hospital X, which has implemented an employee development program to improve nurse competency, this research wants to see how the implementation of an employee development program can influence nurse practice and, ultimately, the quality of patient care at Hospital X.

Continuous Training
According to Bernardin and Russell, training is defined as various introductory efforts to develop workforce performance in the work they are responsible for or something related to their work.This usually means making specific or specific changes in behavior, attitudes, skills, and knowledge.The way for training to be effective is that training must include learning from experiences, training must be an organizational activity that is planned and designed in response to identified needs.According to Noe, Hollenbeck, Gerhart, and Wright, training is a planned effort to facilitate the learning of job-related knowledge, skills, and behaviour by employees (Farooq et al., 2021).
According to Dessler, the meaning of training is giving new or old employees the skills they need to carry out their work.Thus, training means showing a machinist how to operate a new machine, a new salesperson how to sell his company's products, or a new supervisor how to interview and assess employees (Parker & Grote, 2022).
The definition of training from several experts can be concluded as any planned effort to improve the performance of those employed in the job currently held or related to it.The result of training is a change in certain knowledge, skills, attitudes, or behaviour.In this case, the change in knowledge referred to is that initially the training participants who did not understand something came to understand it.From not knowing about office administration to understanding and understanding, and being able to implement the knowledge gained both in theory and practice in the world of work (Pambudi & Harjanto, 2020).Then, for changes in skills and expertise, participants who initially only have limited skills become able and even experts in the skills that have been taught or given.The last is a behaviour change, which usually has poor work ethics; even knowing work ethics becomes understanding and understanding.From the above, for the training provided to be effective and efficient, it must involve learning experiences, planned organizational activities, and be designed to respond to identified and required needs (Mikołajczyk, 2022).Some of the benefits of training organized by companies stated by Noe, Hollenbeck, Gerhart, and Wright, namely: a) Increase employees' knowledge of culture and external competitors.b) Helping employees who have the skills to work with new technology.c) Helping employees understand how to work effectively in teams to produce quality services and products.d) Ensure that the company culture emphasizes innovation, creativity, and learning.e) Ensure safety by providing new ways for employees to contribute to the company as their jobs and interests change or as their skills become more refined.f) Prepare employees to accept and work more effectively with each other, especially with minorities and women (Pitafi et al., 2020).

Performance
Bernardin and Joyce state employee performance as "Performance is defined as the record of outcome produced on a specified job function or activity during a specified time period".This means that employee performance is an output produced by the employee which is the result of the work assigned within a certain time or period.The emphasis is on the results that employees have completed which are the result of the work assigned within a certain time or period (Aad et al., 2020).Hasibuan explains "Employee performance is a work result that a person can achieve in carrying out the tasks assigned to him which are based on skill, experience, seriousness and time".Work performance is a combination of three important factors, namely, the ability and interest of a worker, the ability and acceptance of explanations of task delegation, and the role and level of motivation of a worker.The higher the three factors above, the greater the work performance of the employee concerned (Kulikowski et al., 2022).
Mangkunegara explained, "Employee performance is a term derived from the words job performance or actual performance" (work performance or actual achievements achieved by someone).The definition of employee performance is the quality and quantity of work results achieved by an employee in carrying out his duties following the responsibilities given to him.Handoko explained "the definition of employee performance as the final measure of an employee's success in carrying out their work" (Akdere & Egan, 2020).Mitchell and Larson explained that "employee performance shows a behavioural result that is assessed by several criteria or standards for the quality of a work result."This quality issue is related to the good and bad results carried out by employees.If employee behavior produces work results that are following the standards or criteria set by the organization, then the employee's performance is classified as good, and vice versa, if employee behavior produces work results that are less or not following the standards set by the organization, then the employee's performance can be said to be poor (Riyanto et al., 2021).
According to Mahmudi, factors that influence employee performance include: a) Personal/individual factors which include the knowledge, skills, abilities, self-confidence, motivation, and commitment possessed by each individual b) Leadership factors include the quality of encouragement, enthusiasm, direction, and support provided by managers and team leaders.c) Team factors include the quality of support and encouragement provided by teammates, trust in fellow team members, cohesiveness, and closeness of team members.d) System factors include work systems, work facilities or infrastructure provided by the organization, organizational processes, and performance culture within the organization e) Contextual factors include pressure and changes in the external and internal environment (Albornoz-Arias & Santafé-Rojas, 2022) According to Mathis and Jackson, many factors influence employee performance, including an employee's ability to do the job.Employee performance is also related to the level of effort devoted and organizational support.In traditional performance appraisal systems, performance is only associated with personal factors, but in reality, performance is often caused by other factors outside of personal factors such as systems, situations, leadership, or teams (Sungu et al., 2019).
Based on several definitions of employee performance that have been put forward, it can be concluded that performance is the result achieved by an employee during a certain period of time based on their respective jobs that the company has determined.An employee who has high performance can support the goals and objectives set by the company.The performance of an employee varies from one another (Narayanamurthy & Tortorella, 2021).This is because each employee has a different level of ability in carrying out their work tasks.Employee performance depends on their abilities and skills.To produce high performance, an employee completing the work for which he is responsible must be supported by expertise and skills that are appropriate to his job (Parker & Grote, 2022).

Employee Development Program
According to Gouzali, human resource development is an activity that organizations must carry out so that their knowledge, abilities, and skills match the demands of the work they do.With this development activity, it is hoped that we can improve and overcome deficiencies in carrying out work better, following developments in science and technology used by the organization.Furthermore, according to Malayu S.P Hasibuan, development is an effort to improve employees' technical, theoretical, conceptual, and moral abilities following job/position requirements through education and training.The development concept according to Andrew F. Sikula refers to staff and personnel issues as a long-term educational process using a systematic and organized procedure by which managers learn conceptual and theoretical knowledge for general purposes (Piwowar-Sulej, 2021).
Then I Komang Ardana, Ni Wayan Mujiati, and I Wayan Mudiartha Utama stated that this development concept is the second operational function of human resource management.The development of new or old employees needs to be carried out in a planned and continuous manner.To be able to carry out development well, an employee development program must first be established.This employee development program should be carefully prepared and based on scientific methods and guided by the skills needed by the company now and in the future.This development aims to improve employees' technical, theoretical, conceptual, and moral abilities so that their work performance is good and achieve optimal results (Yong et al., 2020).
Human resource development is always accompanied by workforce training.Quite a few people equate the two.Henry Simamora explained that training is directed at helping employees fulfill their current employment better, while development represents a future-oriented investment in employees.Training has a fairly narrow focus and provides skills quickly, but development is a long-term investment (Meijerink et al., 2021).
According to Hasibuan in his book Human Resource Management, employee development is an effort to improve employees' technical, theoretical, conceptual, and moral abilities following job/position requirements through education and training.A dynamic company will try to anticipate and adapt to all influences from the macro and micro environment (Kamaruzaman et al., 2019).One effort to anticipate changes in an organization or company is to develop the quality and capabilities of human resources through development programs.Existing employee development activities, and human resource development seek to reduce the company's dependence on the appointment of new employees.If employees are developed appropriately, information vacancies exist through human resource planning activities, which will be able to side internally (Surya et al., 2021).

RESEARCH METHOD
This research will use a descriptive qualitative approach to describe the phenomenon studied in detail.The data used in the research comes from the results of previous research and studies which are still relevant to the focus of this research.After the research data is collected, the researcher will immediately carry out data analysis and processing to produce significant findings.In this way, the results of this research will be presented comprehensively, making an important contribution to the understanding of the topic under study.

RESULTS AND DISCUSSION
The Importance of Employee Development in the Health Care Context Nurses, as a key element in providing quality care, play a major role in providing effective health services.They are at the forefront of caring for patients, monitoring changes in patients' conditions, and providing emotional support to them and their families.The presence of competent and trained nurses is an important factor in ensuring patients receive safe and quality care.In this context, employee development, especially nurses, becomes crucial.The increasingly complex and rapid changes in the dynamics of health services make nurses' duties increasingly demanding.They must cope with advances in technology, the demands of increasingly discerning patients, and evolving treatment protocols.Nurses not only need to have solid medical knowledge but also good interpersonal skills to communicate with patients and the rest of the medical team.They are also faced with the need to consistently keep abreast of changes in evidence-based care practices, which demands ongoing learning abilities.
The importance of employee development, including nurses, is reflected in its relationship to improving the overall quality of health services.Employees who are competent and continue to develop themselves are more likely to provide high-quality care.They can quickly recognize signs of changes in a patient's condition, avoid medical errors, and contribute to the efficiency of the care process.Well-trained nurses can provide a more holistic approach to patients, better accommodate patient needs, and increase overall patient satisfaction.In an era where patient expectations of health care are increasingly high, and with the number of chronic diseases and complex health problems increasing, employee development, especially for nurses, is an invaluable investment.Well-designed development programs can help nurses continuously improve their knowledge, skills, and competencies to provide high-quality care, making them strong pillars in the provision of safe and effective health services.
Nurse involvement in employee development also creates a more dynamic environment in the hospital.They can participate in improving procedures and care protocols, provide input based on their field experience, and even engage in research projects to identify new solutions that can improve efficiency and quality of care.This creates a sustainable culture in the hospital where employee development is not just a routine task but also becomes an integral part of organizational praxis and expectations.In addition, the positive relationship between employee development and improving the quality of health care can also create a positive reputation for the hospital.Patients and their families tend to seek care in hospitals that are known to have qualified and well-trained nursing staff.This can improve the hospital's image, increase the number of patients referred, and help in maintaining retention rates and recruitment of quality nurses.Thus, employee development in the healthcare context not only directly influences the quality of care, but also has a positive impact on various other aspects of hospital operations.

Strategies and Methods for Employee Development in Hospitals
A case study of the implementation of an employee development program at Hospital X reveals various strategies and methods used to improve nurse competency and performance.One approach implemented is through formal training and education.Hospital X provides nurses with the opportunity to take part in courses and training relevant to their specialty, both organized by the hospital itself and external institutions.This approach helps nurses to deepen their knowledge and skills in patient care, in line with developments in medical science and changing care practices.
Certification is also an important part of the employee development strategy at Hospital X. Nurses are encouraged to obtain certifications that are relevant to their field, such as certification in critical care, infection management, or care for patients with cardiovascular disease.This certification confirms a nurse's competency and provides a strong foundation for providing quality care.In this context, the employee development program at Hospital X focuses on improving the qualifications of nurses in line with the latest developments in health care.
The employee development program at Hospital X also emphasizes the development of specific skills that suit the needs and latest developments in health care.Nurses are allowed to take courses or skills training aimed at improving their abilities in things such as patient communication, time management, the use of medical technology, and so on.By integrating this specialized skills training into its employee development program, Hospital X can ensure that nurses have skills relevant to patient needs and current care practices.
Through this approach, Hospital X succeeded in creating an environment that supports the growth and development of employees, especially nurses.A holistic development program and in line with the latest developments in health care is one of the main factors that enables Hospital X to achieve high service standards and meet patient expectations.Thus, the employee development strategies and methods implemented at Hospital X prove their success in improving the competency and performance of nurses.
Apart from the methods mentioned above, Hospital X has also implemented an employee development program through a competency-based approach.In this case, nurses are evaluated based on competency criteria that have been established for their role, and development programs are tailored to address gaps in those competencies.This approach provides a clear focus on improving the skills needed to provide safe, quality care.
Hospital X also promotes continuous learning and collaboration between nurses.They encourage nurses to attend professional conferences, seminars, and workshops to share knowledge and experiences with fellow nurses.Collaborations like these encourage the exchange of ideas and best practices, which can collectively improve the quality of care provided by the entire nursing team in a hospital.Thus, a comprehensive and diverse approach to employee development at Hospital X helps create an environment that supports the growth and improvement of nurse competency.

Challenges and Obstacles in Implementing Employee Development Programs
In the context of implementing the employee development program at Hospital X, several challenges emerged that could affect the success of the program.One of the main obstacles faced is related to the budget.Employee development programs require a significant investment of resources, including training, education, and certification costs.Hospital X must ensure that the allocated budget is sufficient to support this program on an ongoing basis.This budget constraint can be an obstacle, especially when hospitals have to allocate resources for various other needs in health operations.Apart from budget constraints, human resources are also an important factor influencing the implementation of employee development programs.Another challenge is in finding the right time to involve nurses in training and development.Nurses often have busy schedules, and asking them to participate in development programs may disrupt the continuity of patient care services.Nurses' resistance to change can also be an obstacle in implementing development programs.Some nurses may feel uncomfortable with change or think that they already have enough knowledge.Increasing nurses' awareness and motivation to participate in development programs is a challenge in itself.
To overcome this obstacle, Hospital X has taken several steps.First, they have conducted a careful budget assessment and allocated funds wisely for employee development programs.Additionally, the hospital has designed a flexible training schedule to allow nurses to participate without disrupting patient care.In addition, an inclusive and collaborative approach was used to overcome nurse resistance.They have involved nurses in the planning of development programs, enabling them to contribute to the determination of development needs and priorities.Thus, Hospital X has attempted to overcome various challenges and obstacles in implementing employee development programs to achieve greater success.
Apart from budget constraints, the implementation of the employee development program at Hospital X is also faced with challenges in ensuring the availability of adequate instructors and training facilities.To face this challenge, the hospital has invested in the training and development of internal teaching staff who can provide training that meets the needs of nurses.This helps in optimizing existing resources.In addition, the training facilities are comfortable and equipped with the latest medical equipment and have been updated to ensure nurses receive effective training.While these challenges exist, investments in human resources and facilities have helped in minimizing their negative impacts.
Another challenge that needs to be addressed is changes in organizational dynamics.Implementing an employee development program requires a culture change and an emphasis on continuous learning.Increasing awareness and commitment of all hospital staff to the value of employee development is a step that is not always easy.Hospital X has used an approach that focuses on communication and education, both through training, seminars, and open internal communication.By doing this, hospitals strive to create a culture that supports and encourages employee development as an investment in better patient care and improving the overall quality of health care.

Evaluation of the Impact of Employee Development Programs
Evaluation of the impact of the employee development program at Hospital X is a crucial step to understanding the extent to which the program is successful in improving the competency and performance of nurses.One of the main obstacles in evaluation is the selection of relevant indicators to measure impact.Identifying appropriate indicators requires careful planning and measurement.Additionally, nurses may need more time to achieve significant results in patient care, so measuring long-term impact may be more complicated than measuring short-term impact.In dealing with these obstacles, Hospital X has taken a holistic approach by considering various indicators, including reducing patient complication rates, increasing patient satisfaction, and increasing participation rates in development programs.
Other factors that influence impact evaluation are budget and resources.Comprehensive impact evaluation requires the allocation of adequate resources to conduct the necessary research and analysis.Hospital X has ensured that adequate funds and human resources have been allocated to evaluate the impact of the development program.They have also invested in efficient reporting and measurement systems to make data collection and analysis easier.
Nurse resistance to evaluation and change is also an obstacle that may arise during this process.Part of the effort to overcome this resistance is involving nurses in the evaluation process and facilitating open dialogue to discuss results and recommendations.With an inclusive approach, nurses feel more involved and have a better understanding of the benefits of impact evaluations, which in turn allows them to support improvements in employee development programs.Through this approach, Hospital X overcame various challenges and successfully measured the impact of employee development programs to ensure continuous improvement in the quality of patient care.
To challenges surrounding indicator selection and resource allocation, Hospital X is also faced with obstacles in measuring the long-term impact of employee development programs.Some changes in nursing practices and nurse performance may take longer to become visible in measurable outcomes.In facing these challenges, the hospital has taken a holistic approach that considers both short-term and long-term evaluations.They understand that the impact of employee development programs may involve cultural and practice changes that take time to develop fully.
Hospital X has also attempted to measure the impact of employee development programs by taking into account the patient perspective.Assessment of patient satisfaction and clinical outcomes is an integral part of the evaluation.This helps hospitals see the impact of the program in terms of improving patient care and the outcomes they experience.By including the patient perspective in the evaluation, Hospital X gained more comprehensive insight into the program's success and was able to measure its impact more holistically.In doing so, the hospital has succeeded in overcoming several obstacles in evaluating the impact of employee development programs and gaining a better understanding of the program's benefits.

The Role of Nurses in Improving the Quality of Care
In the context of the employee development program at Hospital X, nurses have a very important role in improving the quality of care.Employee development programs provide nurses with the tools and knowledge necessary to become leaders in implementing best practices in patient care.They are not only implementers of care but also planners and managers of care.This program provides nurses with deeper insight into quality improvement, including how to identify opportunities for improvement in their practice and how to implement them.By being a leader in implementing best practices, nurses can play a central role in maintaining patient safety and quality of care.
Employee development programs also encourage nurse involvement in innovation and research.Nurses are often on the front lines of patient care and have a unique understanding of patient needs.With the training and knowledge gained through the development program, nurses at Hospital X are encouraged to create innovations in their nursing practices.They can propose more efficient, safe, and high-quality changes in patient care.Additionally, this program provides a stronger foundation for nurses to engage in scientific research, which can provide a deeper understanding of evidencebased nursing practices.Thus, nurses at Hospital X play a major role in ensuring that patient care remains aligned with the latest developments in medical science and best care practices.Hospital X's employee development program also creates opportunities for nurses to develop strong communication skills and the ability to collaborate.This is critical in improving the quality of care, especially in multidisciplinary situations where nurses work together with a variety of health professionals.With the training provided in the program, nurses can learn how to communicate effectively with the rest of the medical team, manage conflict, and facilitate harmonious collaboration.This capability supports better coordination of patient care and reduces the risk of errors in care.
Nurses also have an important role in monitoring and reporting changes in patient conditions and contributing to care planning.Employee development programs strengthen nurses' evaluation skills in identifying signs of change that need immediate attention and sharing this information with the medical team.This helps reduce the risk of undetected complications.This program also provides nurses with knowledge about selecting and implementing appropriate interventions, which can improve patient care outcomes.
Nurses also play an important role in providing emotional support to patients and their families.Employee development programs not only improve nurses' clinical skills but also help them develop empathy, caring, and the ability to communicate with patients who may be experiencing difficult situations.In many cases, these emotional aspects are as important as the clinical aspects in improving the quality of patient care.Thus, nurses have a holistic role in improving the quality of care at Hospital X through a comprehensive employee development program that focuses on the development of clinical aspects, communication, and empathy.

Implementation of Employee Development Programs as a Sustainability Strategy
To maintain the sustainability of the employee development program at Hospital X, the first important step is to integrate this program into the organizational culture and hospital management system.This creates a strong foundation for the development program so that it is not just considered a temporary initiative.The integrity of this program within the organizational culture creates an expectation that employee development is a priority that all team members must pay attention to.It also creates an incentive for leaders and managers to continue to support, promote, and oversee the program.The next step is to ensure continuity in employee development as an integral part of quality care efforts.This includes providing ongoing support in the form of training, resources, and recognition of achievements.Hospital X has designed a long-term plan that considers employee development as a long-term investment.This includes the development of clear career pathways for nurses who have completed development programs, incentives to encourage participation and recognition for significant contributions to improving the quality of care.With this approach, hospitals create strong incentives and motivation for nurses and other staff to continue participating in employee development programs, making them an integral part of the organization's ongoing culture.
Hospital X also took steps to continue monitoring and evaluating the impact of employee development programs.They have regularly scheduled evaluation procedures to ensure that the program is effective in achieving its goals.The evaluation results are used to improve the program and make changes necessary to maintain the program's sustainability and conformity with developments in health care.With this approach, Hospital X remains committed to ensuring employee development programs as a sustainable strategy for improving the quality of care they offer to patients.Apart from that, the employee development program at Hospital X also includes efforts to build a strong network between nurses and various stakeholders in the world of health care.This includes collaboration with educational institutions, nursing professional associations, and other hospitals.Through partnerships with these institutions, hospitals can access additional resources, the latest knowledge, and training opportunities that can help nurses continue to grow.By integrating into a wider network, employee development programs become more sustainable because they receive the necessary external support and resources.
Hospital X also encourages nurses to become mentees and mentors in employee development programs.This creates a positive cycle where nurses who have benefited from the program share their knowledge and experience with other nurses.This mentoring process allows knowledge and skills to develop more quickly and creates a culture of continuous learning.It also helps nurses feel more involved in development programs and feel recognized for their contributions to improving patient care.Lastly, Hospital X is committed to continuing to innovate in employee development programs.They recognize that developments in the world of healthcare continue, and development programs must always be updated to reflect these changes.By focusing on innovation, hospitals ensure that development programs remain relevant, effective, and sustainable in the long term.With this approach, Hospital X maintains employee development programs as a vital sustainability strategy for improving the quality of patient care.

CONCLUSIONS AND SUGGESTIONS
The employee development program at Hospital X has proven its important role in improving the quality of patient care.In the discussion above, we see how this program has enabled nurses to become leaders in implementing best practices, contribute to innovation, and play a key role in improving the quality of health care.This program has also created an organizational culture that supports employee growth and development.To ensure the sustainability of the employee development program, Hospital X has integrated the program into the organizational culture and management system.They have created strong incentives and motivation for staff to continue participating in the program.Continuous evaluation efforts and efforts to build networks with wider stakeholders are also a commitment to maintaining program sustainability.Thus, the employee development program at Hospital X is one of the key strategies in improving the quality of care and serves as an important element in ongoing efforts to provide quality health care to patients.