Return to general nursing: on the register but ‘out of practice’?
The programme designed for when the usual return-to-practice courses don’t apply
The usual return-to-practice courses don’t apply to registered nurses who want to re-route into clinical practice but lack the confidence or experience. Theresa Brennan explains how her Nottinghamshire hospital developed a programme designed to help them, and boost recruitment
- Many registered nurses have not undertaken clinical practice for a long time and need support to shift to a staff nurse role
- Lings Bar Hospital’s ‘out-of-practice’ programme for current NMC registrants sits alongside its return-to-practice course for those who have dropped off the register
- The programme is being rolled out more widely to help fill nursing vacancies
When NHS England published the interim NHS People Plan in June, encouraging nurses who have left the profession to return to practice was identified as a priority in tackling the nursing workforce crisis.
To help address the 40,000 nurse vacancies in hospital and community services in England identified in the plan, Health Education England (HEE) joined forces with parenting website Mumsnet to launch a return-to-practice campaign.
Supporting former nurses to return to the workforce was also the focus of a previous campaign from HEE – the national Come Back campaign, launched in September 2014.
Six months earlier, at Lings Bar Hospital in Nottinghamshire, we had started looking at widening our own approach to recruiting qualified nurses. Lings Bar, a community-based hospital offering rehabilitation, recovery or ongoing assessment to older people after a hospital stay, went on to develop a return-to-practice employment programme in November that year. Its focus was those who had left nursing and were no longer registered with the Nursing and Midwifery Council (NMC).
But while working on this programme, we were approached by nurses who were still registered with the NMC but had not practised in a general healthcare setting, or whose careers had developed into specialist areas, such as health visiting, school nursing, education or management.
Encouraging ‘out-of-practice’ nurses into general nursing
These nurses – who we refer to as ‘out-of-practice’ nurses – wanted to return to general nursing but felt they lacked the confidence and competence to make a direct move back to a staff nurse post.
They were aware of their professional responsibilities and were concerned that, by taking on a role they did not feel able to perform safely, they would be in breach of the NMC code.
With staff shortages and increasingly heavy workloads for NHS nurses, supporting new staff who need to update their skills and knowledge in crucial nursing areas can be difficult to manage safely and effectively.
As nurses who hold a current active registration with the NMC do not qualify to attend university-based return-to-practice courses, their safe route back into general nursing is limited.
We decided to develop a programme to help meet the needs of these nurses and support them back into practice. This also had the potential to increase nurse numbers at the hospital and further improve the quality of our nursing workforce.
Our out-of-practice programme was also launched in November 2014. Although different to our return-to-practice programme (see box), it runs alongside this and our usual recruitment strategies.
Comparing the return-to-practice and out-of-practice programmes
Return to practice
- Individual’s Nursing and Midwifery Council (NMC) registration is inactive
- A fixed-length programme, set by the university and NMC
- Academic assessment required
- Re-registration with the NMC required to complete programme
Out of practice
- Individual has an active NMC registration
- Flexible programme, dependent on competence and confidence
- Assessment based on competencies only
- Registration with NMC already in place
Structure of the out-of-practice programme
The programme is employment-based only and is offered on a 12-month fixed-term training contract.
This helps overcome any financial barriers to nurses undertaking the programme, and although they may not need the full year to complete the programme, it gives them a generous timescale and a target date for completion.
Embedding returnees into the nursing team also enables staff to support them more fully and offers a better retention rate. This is particularly important given the investment required by the ward team.
Nursing staff in the placement area have to put significant time and effort into the returnee’s development. They are essentially agreeing to be a staff nurse short until the person reaches the required level to undertake the role, so commitment from the whole team is crucial.
When the out-of-practice programme began, educating the rest of the team about what these individuals could and could not do, and how they could contribute to their learning and development, was vital. Once this was established, ward staff were incredibly supportive.
Funding for the post comes from a vacant band 5 staff nurse position. As the returnee is not taking on the full role and responsibilities of a band 5 staff nurse, the salary is at the top of band 3. Those on the programme are not counted as registered nurses in the staffing establishment, enabling them to develop their leadership, patient care and management skills in a supported way.
Competencies gained on the out-of-practice programme
The return-to-practice programme has a clear aim – successful re-registration with the NMC – whereas the out-of-practice programme is more fluid and intuitive and is based on the achievement of competencies. When the nurse is ready to take on the full staff nurse role, we liaise with the human resources department to formalise the post and agree where on the band 5 scale they should sit.
The competency programme structure and content are the same as on our clinical preceptorship programme. But while the preceptorship programme is structured around a three-month period, the out-of-practice programme is much more individual and flexible.
Recruitment to the programme runs alongside our regular recruitment plans. Adverts for registered nurses and out-of-practice and return-to-practice nurses run alongside each other, enabling people to select the route to employment with which they feel most comfortable.
Selecting and monitoring nurses on the programme
A critical part of the initial process is having a face-to-face meeting with the individual before application or interview. This enables the potential applicant to ask questions and allows the manager or lead person to get to know the individual and see how they would fit in with the nursing team.
The value of this meeting cannot be overstated. It can turn someone who is uncertain into a committed applicant or be a reality check for those who realise it is not for them. It has also encouraged some people, once they see the clinical preceptorship programme and are aware of the support available, to apply not as an out-of-practice nurse but for a regular staff nurse post.
As with all learning and development, progress and problems need to be monitored. The returnee completes a self-assessment form before the start of the course so we can credit them with the skills and knowledge they bring and focus on any areas of concern.
Informal reviews involving the returnee and their mentor are carried out at the start of the programme, with more formal assessments carried out after six and 12 weeks.
Any concerns regarding progress or competencies are identified, and targeted support is put in place by the practice development nurse. This could be study sessions, more formal learning plans, additional supervision or clinical guidance.
If returning nurses struggle to work effectively in the current healthcare environment, we set clear goals. If they are unable to achieve these, we discuss their future with us and help them consider other areas of nursing.
Many programme participants have stayed with the team
It is made clear at the beginning of the programme that if we do not think we can support the nurse to make a successful return to practice in our area, their programme may be ended.
Since the out-of-practice and return-to-practice programmes began, we have supported 15 nurses back into practice. Most of the returnees have stayed with us for at least another year and many are now established team members. We have employed people with a variety of experience and skills, including health visitors and school nurses, who have enriched our clinical area.
This approach is now an established thread of our recruitment strategy. Following its success, we shared it with other healthcare organisations and it is now being adopted in NHS trusts across England.
‘When you’ve been out of practice for a while, you lose the confidence’
Emma Robinson explains how the out-of-practice programme has enabled her to choose a new career path:
After qualifying in 1995 as a registered general nurse, I worked in general medicine and neurological rehabilitation before moving out of clinical practice in 2003 to be a case manager for patients with brain injuries.
In January 2008, I began working on retrospective assessments for Continuing Healthcare, working from home for 11 years. I used my clinical experience and knowledge, maintaining my NMC registration but in a non-clinical environment.
After being made redundant earlier this year, I started looking at how I could return to a staff nurse post in general nursing. But it soon became clear that I did not have the up-to-date clinical skills necessary to take up these roles safely.
I needed to refresh my skills and knowledge but the only route I could find was a return-to-practice course. As I still had a ‘live’ NMC PIN, I was ineligible to apply for one of these.
When I contacted Health Education England (HEE) to see what my options were, I was surprised at the lack of support available. Although those who did respond to my request were welcoming, they did not have a clear plan of support, and there was no guarantee that after two weeks’ induction I would not be dropped in at the deep end. I knew I needed more support to be able to return to practice safely.
‘Other team members understood the “grey area” I was in as a registered nurse unable to take on the full staff nurse role’
After being told by HEE that Lings Bar Hospital had experience in this area, I was contacted by the hospital’s practice development facilitator, Theresa Brennan, who explained how the out-of-practice programme was structured, how it could be paced to match my progress and that I would not have to fulfil the role of a registered staff nurse until I was ready.
A drop in wage, but still earning
As nurses on the programme are paid a band 3 wage, the initial drop in salary would have been difficult without my redundancy pay – but I would still be earning while returning.
It was clear that a lot of thought and planning had gone into the programme, and it was reassuring that being part of a team was recognised. Other team members understood the ‘grey area’ I was in as a registered nurse unable to take on the full staff nurse role, and it was structured so that I could go at my own pace. As the skills I was confident and competent in were credited, I was able to spend more time on different areas.
When you have been out of clinical practice for a while, you lose the confidence you once had and that needs building back up. But you still retain the sense of professional responsibility that keeps everyone safe.
‘It seems bizarre that it is easier to return to a clinical role if you have let your NMC registration lapse’
One of the biggest changes for me is the increase in patient acuity. The role of healthcare assistants has also expanded, and staff nurses now have more of a focus on case management, overseeing and coordinating the patient journey and maintaining and monitoring standards of care.
After starting my course in March, it took me 11 weeks to feel ready to take up the full band 5 staff nurse role. Although this is roughly the same length of time as the hospital’s preceptorship programme, the structure of the out-of-practice course meant I could pace myself, with support, and build up to taking on the full responsibilities of a band 5 nurse.
I love working within a nursing team again, I like the ward atmosphere and the different mix of patients.
It seems bizarre that it is easier to return to a clinical role if you have let your NMC registration lapse. Considering the current staffing crisis in nursing, it needs to be much easier for registered nurses to re-route back into clinical practice.
Theresa Brennan is practice development facilitator at Lings Bar Hospital in Nottinghamshire