Although return to practice has been underused as a strategy for recruiting nurses, many returners are highly experienced and likely to remain in practice until retirement
There are many benefits of nurses returning to practice: most are very experienced, likely to remain in practice until retirement, and return to practice (RTP) courses have low attrition rates and are more cost effective than pre-registration training. A review of RTP courses found differences in clinical placements, information on courses, funding and the availability of good mentorship. Health Education England has been working with stakeholders to improve the consistency and effectiveness of RTP courses to make it easier for nurses who want to come back to nursing.
Citation: Stevens J (2014) Support for nurses returning to practice. Nursing Times; 110: 48, 12-14.
Author: Janice Stevens is director for Midlands and East, Health Education England.
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In response to the Mid Staffordshire Foundation Trust public inquiry (Francis, 2013), the Berwick (2013) review into patient safety and Clwyd and Hart’s (2013) report on NHS complaints, workforce planners have identified an urgent need to increase the number of nurses to meet service, quality and safety needs in health settings. Increasing pre-registration training places will take at least four years to yield any benefit but nurses returning to practice could bolster staff numbers in a much shorter time.
Nurses leave the profession for various reasons, including:
- Caring for children or older relatives;
- No longer wishing to work in their current specialty;
- No longer wishing to work in the NHS at that point in their career.
After a break, however, many nurses would like to return to nursing. To stay on the Nursing and Midwifery Council’s register, nurses must have completed 450 hours’ registered practice and 35 hours’ continuing professional development over the preceding three years; if they have not, they must complete an NMC-approved return to practice (RTP) course.
RTP could form a key component of workforce strategies but is often poorly understood and receives comparatively little evaluation. Health Education England is taking action to help grow nursing numbers through RTP courses to try to reduce the current supply-demand gap. To determine the most effective approach, a review on RTP courses in England was undertaken (HEE, 2014a) to identify:
- Relevant research and evaluations;
- How many returners go through RTP courses and what the courses are like;
- What works well and the challenges;
- Opportunities for the future.
Information was gathered via:
- A literature review;
- Interviews with RTP nurses, education providers, NHS trusts and national organisations (n=30);
- A WeNurses chat event;
- Events attended by about 100 people involved in returning to practice and nurses who have already done so.
This article summarises the main findings from the RTP review and the actions HEE has taken to support local NHS organisations to increase the number of returning nurses (HEE, 2014b).
Number of returners
Since RTP became the responsibility of local NHS organisations in 2004, there has been no central data collection to provide numbers of returners, how long they remain in practice after re-registration or where they end up working after completing the course. More research is needed on this and to ascertain by which branches and trusts they end up being employed.
Data on the pool of lapsed nurses able and willing to return to practice is lacking but a large number of nurses have lapsed registrations. Up to 10% could leave the profession each year; this estimate is based on evidence that early signs of departure are strong predictors of actual behaviour (Murrells et al, 2008) and a European study found that 10% of UK nurses intended to leave the profession (Heinen et al, 2012). The proportion of nurses leaving is also likely to be higher in inner cities, particularly in London, where turnover rates have ranged from 11% to 38% (Finlayson et al, 2002).
Previous initiatives suggest the number of returners could increase if funding covered course fees and clinical placements, and there was a campaign to attract nurse returners. An unpublished evaluation of a recent campaign to recruit lapsed health visitors was found to encourage returners to apply for, and undertake, RTP courses.
The benefits of RTP
Low attrition, high retention
RTP courses have low attrition rates; studies have found that 70-80% of people who start RTP courses complete them and return to nursing (Hawley and Foley, 2004; Alden and Carrozza, 1997; Bellack, 1995). The HEE review found most RTP nurses complete the course, with only one or two per group of 20 either deferring completion due to exceptional circumstances or dropping out. According to Mike Eccles, quality services coordinator at the University of Chester, this is true of his organisation:
“On a University of Chester return-to-practice course run in 2013, 23 of 24 returners (95.8%) successfully completed the course. All found jobs, either working as bank nurses within their field of nursing or permanent positions; the majority are in full-time posts.”
RTP nurses are often employed by the provider that recruited them. NHS organisations that interview, select and support returning nurses through their RTP course are more likely to recruit those returners on completion of the course (HEE, 2014a).
Returners are often local, mature nurses with wider experiences, who are unlikely to take a career break and more likely to work until retirement. Usually, they can also quickly and effectively integrate into clinical teams (Hammer and Craig, 2008). Many are women aged 40-50 years with dependants who, after regaining their registration, work part time until they retire (Hammer and Craig, 2008). As they have dependants, they usually stay in the same area, thereby creating a stable, experienced workforce.
A small study in the US found returners were predominantly female, had been out of practice for an average of 13 years, were around 50 years old, and had previously been a nurse for an average of 25 years (Bernardo et al, 2009). Similarly, a study in Australia found that 94% of applicants to RTP courses were female and 37.7% were aged 51 years and older (McMurtrie, 2014).
Bringing back nurses who have already completed a funded three-year programme is economically sensible. Estimates indicate it can cost up to £100,000 (BBC News, 2006) to train a nurse on an undergraduate programme, compared with £2,000 to enable a nurse to return to practice. Successful initiatives also impact on nurse shortages more quickly: it can take as little as six months to advertise, recruit and train returning nurses.
RTP course review
RTP courses are mainly self-funded and comprise a 12-week academic course taught face-to-face, through web tutorials or distance learning, and clinical placements with mentors. Assessment usually occurs via reflective essays, case studies, numeracy tests; clinical competency is assessed through placements. The review found a great deal of variation however (Table 1) and showed that mentors had limited internal support and struggled to mentor and fulfil their own clinical responsibilities.
Areas of practice
Although most returners go into adult hospital nursing there is a growing need to increase the scope of RTP to:
- Target specific areas of persistent vacancies in hospitals, for example, intensive care and theatre nursing;
- Address the growing need for primary care, mental health and community nurses.
In some areas of England NHS providers, higher education providers and commissioners have shown a commitment to returning nurses to practice and have developed creative clinical placements.
HEE has been working with local education commissioners to refresh existing RTP courses, address the variation and set up support for returners. In 2014, it sent an RTP toolkit (learning.wm.hee.nhs.uk/resource/about-toolkit) to all education commissioners so they could self-assess where they were in terms of RTP and be supported in developing an action plan to meet core expectations around funding, support and good practice. This aimed to put in place support before a national campaign was launched in September 2014.
The review found that cost and having to do an unpaid 150-hour clinical placement deterred lapsed nurses from returning to practice. A UK study also found some non-returners reported being unable to afford to return because of childcare costs (Durand and Randhawa, 2002). In response to this, HEE has worked with commissioners to standardise course fees and as part of its Come Back campaign has funded course fees, offered additional financial support (such as for travel or childcare costs) and enables trusts to claim placement tariff.
The need for flexibility
A UK study involving interviews with 24 nurses who had recently returned to practice and 28 on a career break found those who returned did so when their own circumstances allowed; half returned as bank nurses to work flexible, family friendly hours (Durand and Randhawa, 2002).
One study of nurses on an RTP scheme in the US found course flexibility was key to their ability to return to practice (McLean and Anema, 2004). This reflected the composition of participants on the RTP programmes - female and with children. HEE has identified good practice around developing flexible, part- and full-time courses (as well as online theory courses) and has shared this across England.
Supernumerary status and access to mentorship
The expectation is that returners on placement are supernumerary and have access to a mentor during the course as well as preceptorship support once they get work. Mentorship quality is central to nurses’ ability and confidence to return to practice. Professional commitment is stronger than organisational commitment in determining turnover (Lu et al, 2002). Having a good clinical mentor and access to ongoing personal development opportunities is likely to improve nurse retention, not just for returners. Effective professional support and mentorship should be considered for all nurses to reduce turnover.
A joined-up approach
A joint approach between the NHS and education providers in course design, management, evaluation and interviewing and selecting candidates was found to be the most successful approach to return nurses; it is promoted in the RTP toolkit. The interview process is vital in ensuring the right returners are offered places. It should involve a joint trust/education provider interview and an orientation session on what it is currently like to work within the NHS. Linked to this, applicants should be encouraged to gain recent experience in health or social care so they are aware of the changes in the NHS and how they have affected nursing practice; this could also help manage their expectations.
Courses are expected to feature theory and clinically based training, and provide access to simulation techniques that can be used to practise skills. The toolkit has collated the expected course content, which should be reflected in course design.
HEE’s toolkit promotes placement development in areas that previously had very few returners, such as GP practices, nursing homes and community nursing. Some areas want to develop community placements by primary care providers coming together and forming an educational collaborative or linking practice with other community service providers such as care homes. There are also some hospitals offering placements where 20% of the course is based in an alternative setting so returners looking to move to a different specialty can gain relevant experience.
Implications for research
There is relatively little data on nurses who leave and/or return to the NHS. More research is needed about both aspects, but identifying why nurses leave is particularly important as it will enable policy makers and employers to take steps to prevent more nurses doing so and lapsing their registration.
Nurses returning to the NHS are a relatively untapped potential workforce; there is a real opportunity to use these more mature nurses to grow the workforce more quickly and manage growing demand. Nurses who have been out of practice for several years may lack confidence but, if supported through a short course and preceptorship, they have the potential to step into more senior roles fairly quickly; they also offer the NHS a wider set of skills and a different perspective due to the time they have spent away from practice. The expectation is that the recent work of HEE and local areas to support RTP and standardise good practice will enable more nurses to return to the profession year on year.
- Return to practice (RTP) programmes are the only way nurses with a lapsed registration can come back to clinical practice
- Returners are often local, experienced nurses who are likely to practise until retirement
- RTP courses have low attrition rates and are more cost effective than undergraduate training or overseas recruitment
- A significant pool of nurses have lapsed registrations - estimates suggest at least 10% of nurses leave the profession per year
- A positive approach and standardising RTP practice, would help more nurses to return to the profession
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