Being Refreshed: Evaluation of a Nurse Refresher Course

Being Refreshed: Evaluation of a Nurse Refresher Course Jennifer M. Hawley, MSN, RN, and Barbara Jo Foley, PhD, RN, FAAN ABSTRACT In light of the current nursing shortage, registered nurses who have been away from clinical practice are a valuable resource. This article examines the effectiveness of a structured nurse refresher course to return nurses to employment and to prepare them for effective clinical practice. This course was successful in returning 78% (n = 37) of the survey respondents to nursing employment and was found to be highly effective in preparing these nurses in the six areas included in the course. This refresher course may serve as a model for the development of more structured refresher courses for inactive nurses. The number of licensed registered nurses not employed in nursing is on the rise. There are currently 500,000 licensed nurses not working in nursing in this country and the number grew by 52,000 nurses between 1996 and 2000. The majority (69%) of these unemployed nurses are 50 years or older and only 7% are actively seeking employment in nursing (Health Resources and Services Administration, 2002). In light of today s severe nursing shortage, the nursing profession could look at this source of nurses as a means to lessen the shortage. Recent experience with refresher courses offered by the Continuing Education Department at the University of North Carolina at Chapel Hill (UNC-Chapel Hill) School of Nursing indicates that more nurses are inquiring about refresher course options due to the depressed economy. Also, enrollment in the Continuing Education Department s nurse refresher course has increased. During the 2002 calendar year, two refresher courses were conducted with a total enrollment of 30 nurses. Previously, annual enrollment was 10 to 12 nurses in a single course. Because of the current nursing shortage, registered nurses who have been away from clinical practice for many years are a valuable resource. When they return to nursing practice, they bring maturity and many life Ms. Hawley is Clinical Assistant Professor, and Dr. Foley is Director, Continuing Education Department, UNC-Chapel Hill School of Nursing, Chapel Hill, North Carolina. Address correspondence to Jennifer M. Hawley, MSN, RN, Continuing Education Department, UNC-Chapel Hill School of Nursing, CB #7460, Carrington Hall, Chapel Hill, NC 27599-7460. experiences. Well-structured refresher courses for nurses provide the knowledge, skills, and confidence that nurses need to return to practice. In some states, nurses who have been out of practice for 5 or more years are required to complete a nurse refresher course approved by the state s board of nursing. Since 1980, the UNC-Chapel Hill School of Nursing has conducted the Nursing Update refresher course for registered nurses on an annual basis. This structured refresher course consists of 124 didactic hours in the review and update of medical surgical nursing care and professional issues and 128 clinical hours in the provision of patient care under the direct supervision of a faculty clinical instructor. A student-to-faculty ratio of 8:1 is maintained. Prior to this structured clinical experience, a variety of clinical skills are practiced in a skills laboratory setting with instructor supervision as part of the didactic hours. A careful examination of the employment rates and practice settings for these graduates of the refresher course is critical to assess the effectiveness of such a course in returning these nurses to active nursing practice. This article describes the results of a survey of the graduates of this nurse refresher course from 1990 to 2000 that was designed to learn about employment following the course and the effectiveness of the course in preparing the graduates for nursing practice. BACKGROUND The UNC-Chapel Hill School of Nursing s Nursing Update refresher course for registered nurses was pre- 84 Volume 35, Number 2, March/April 2004

HAWLEY & FOLEY viously examined at the 5- and 10-year intervals using participant surveys. In the 5-year follow-up survey, Brown and Waddell (1988) reported that 78% (n = 36) of the course graduates who completed the survey were practicing nursing either full-time or part-time. Of the 56 questionnaires received from participants, 36 (64%) were completed. Results showed that 48% (n = 17) were employed in acute care settings, 33% (n = 12) in primary care, 11% (n = 4) in nursing homes, and 4% (n = 3) in nursing education and nursing administration. The 10-year follow-up survey conducted by Ferris and Brown (1992) revealed that 91% (n = 65) of the respondents who completed the survey successfully reentered and remained employed in nursing. Of the 126 surveys mailed, 71 (56%) of the course graduates responded. Of those nurses employed, 48% (n = 34) practiced in hospitals, 27% (n = 19) in nontraditional settings (e.g., surgicenters, alcohol rehabilitation centers, and institutions for people with mental disabilities), 11% (n = 8) in community health, and 6% (n = 4) in long-term care. These results are similar to those obtained by Kalnins (1986), who showed a return to employment rate of 71% for respondents of a telephone interview after completion of a Return to Nursing course in Fairfield, Connecticut. Of these 64 nurses, 49 completed the interview for a response rate of 77%. O Connor (1991) reported a return to employment rate of 72% (n = 52) for respondents who completed a survey after completion of a return-to-practice course at the University of Southampton. Of the 130 questionnaires mailed, 74 (56%) were returned. Alden and Carrozza (1997) examined the effectiveness of a self-paced registered nurse refresher program to promote reentry into practice and reported that 69% (n = 68) of respondents who completed that program had returned to nursing practice. In this study, 187 questionnaires were mailed with 99 returned (53%). There are limited current publications addressing the issue of reentry to practice following a nurse refresher course. Concerns frequently encountered by nurses who enroll in refresher courses have also been examined. Quant (2001) stressed that uncertainty, pessimism, and lack of confidence are seen in adults making changes in their work lives. They may view themselves as being out of date and out of practice, doubting their ability to cope with new information and practice (p. 40). Recommendations are made to keep courses small to benefit learners and help them to feel more secure and take a more active role in the course. Bensing (2001) stressed that life experiences the experiences and the skills learned while away from nursing are helpful for nurses in their transition back to practice. Kalnins (1986) examined the employment settings for refresher course graduates. Of the 35 nurses who were employed, the majority (40%, n = 14) were employed in hospital settings and 26% (n = 9) in longterm care settings. Other work settings included private duty (14%, n = 5), offices (11%, n = 4), and other settings (9%, n = 3). METHOD Data collected from the 1990 2000 graduates of the Nursing Update registered nurse refresher course offered through the Continuing Education Department at the UNC-Chapel Hill School of Nursing included: demographics, nursing employment since completion of the course, effectiveness of the course in preparing graduates for nursing employment, positive factors of the course, and continuing education activities attended since completion of the course. The survey tool was similar to the one used for the 5- and 10-year follow-up studies conducted by Brown and Waddell (1988) and Ferris and Brown (1992), with new questions added to examine the effectiveness of the course in preparing graduates to return to clinical practice. The survey was mailed to 125 (100%) graduates of the Nursing Update course for the 10-year period. FINDINGS Of the 125 surveys mailed, 37 were completed and returned for a 30% return rate. Twenty-four (19%) were returned with no forwarding address, and six (5%) were returned with new forwarding addresses and were re-mailed to these six graduates. As listed in Table 1, the sample was primarily between the ages of 41 and 60 years when they completed the course. All resided in North Carolina. The time away from nursing practice ranged from 1 to 36 years. There were more nurses with either a diploma or a baccalaureate degree in nursing than with associate s or master s degrees and 25 of the 37 had maintained an active license to practice nursing prior to the course. Reasons for taking the refresher course were identified. Most of the respondents were motivated to take the course by their desire to return to the nursing profession. Other reasons included having children who were older, which allowed them to return to nursing practice, and a change in marital status that presumably affected their income. Current employment status after the refresher course was addressed with 78% (n = 29) of the respon- The Journal of Continuing Education in Nursing 85

EVALUATION OF A NURSE REFRESHER COURSE TABLE 1 CHARACTERISTICS OF NURSE REFRESHER COURSE GRADUATES (N = 37) Characteristic No. Years away from nursing < 5 4 5 10 7 11 15 10 16 20 7 > 20 9 Range 1 36 Educational preparation Diploma 13 ADN 8 BSN 15 MSN 1 Age on completion of course (y) 20 30 1 31 40 3 41 50 17 51 60 16 Licensure status prior to course Active RN in North Carolina 21 Active RN in other states 4 Inactive 9 Lapsed or expired 2 Revoked or surrendered 1 ADN = associate degree in nursing; BSN = bachelor degree in nursing; MSN = master of science in nursing; RN = registered nurse. dents reporting that they were currently working in nursing. Two nurses responded that they did return to nursing but were no longer working because of family demands. Reasons identified for not currently working in nursing included illness of self or family, no financial need to work, different job opportunity, and family or church commitments. Nursing positions and places of employment varied widely, as shown in the figure. Nine of the nurses (32%) were employed in hospital settings and seven (24%) in outpatient settings. FIGURE. Employment settings of registered nurses following completion of the refresher course. *Includes nurse consultant, health educator, parish nurse, and correctional facility nurse. **Includes clinics, physician offices, and health departments. Course graduates were asked to rate how well prepared they felt in six areas after completion of the refresher course. The rating scale ranged from 5 (very well prepared) to 1 (not at all prepared). The scale used 4, 3, and 2 as the range of somewhat prepared. Overall, the respondents felt well prepared for reentering nursing practice when they completed the Nursing Update course. As listed in Table 2, a high percentage rated each area as either 4 or 5 (n = 37): Nursing theory (core classroom content) 94%. Professional issues (e.g., legal issues or ethics) 92%. Clinical knowledge (theory to care for patients) 92%. Clinical skills (nursing procedures) 84%. Self-confidence 87%. Overall competence 89%. When asked the value of the Nursing Update course in helping them to gain confidence and competence to return to nursing, 92% (n = 33) answered very valuable and three responded somewhat valuable. None responded no value. Only 36 of 37 individuals completed this page of the survey. TABLE 2 EFFECTIVENESS OF PREPARATION OF REFRESHER COURSE GRADUATES (N = 37) Not at All Very Prepared Somewhat Prepared Prepared Average Items 5 4 3 2 1 Score Nursing theory 70% (26) 24% (9) 5% (2) 0 0 4.61 Professional issues 65% (24) 27% (10) 8% (3) 0 0 4.57 Clinical knowledge 65% (24) 27% (10) 5% (2) 3% (1) 0 4.54 Clinical skills 41% (15) 43% (16) 11% (4) 5% (2) 0 4.20 Self-confidence 57% (21) 30% (11) 11% (4) 3% (1) 0 4.44 Overall competence 46% (17) 43% (16) 11% (4) 0 0 4.35 86 Volume 35, Number 2, March/April 2004

HAWLEY & FOLEY Survey participants were asked to indicate the most positive factors in the Nursing Update refresher course. Table 3 reveals that 100% (n = 36) of the respondents felt supported by the course coordinator and clinical instructor and 86% (n = 31) felt support from their fellow students. All graduates responded that they would recommend this refresher course to others who wish to return to nursing. Attendance at nursing continuing education courses after the refresher course and attainment of additional degrees or certification were also solicited. A majority of graduates (81%, n = 29) indicated that they had attended at least one continuing education program since completing the refresher course. Half (n = 18) had attended more than three programs, whereas 11 had attended one to three programs. Eight (22%) had earned additional degrees or certification since completing the refresher course. These included master of science in nursing, certified diabetes educator, parish nursing education, bachelor of science in nursing, and clinical trials research education. DISCUSSION Seventy-eight percent (29 of 37) of the respondents to this survey returned to nursing employment. This rate is comparable to those found in studies by Alden and Carrozza (1997), Brown and Waddell (1998), Ferris and Brown (1992), Kalnins (1986), and O Connor (1991). Employment settings for the graduates have shifted in the past 10 years, with more nurses practicing in outpatient settings and fewer practicing in the traditional hospital setting. This may result from the increased number of outpatient nursing positions available in recent years and the down-sizing of hospital nursing positions in the 1990s. Survey results indicate that this nurse refresher course has been successful in preparing its graduates to return to nursing. The majority of participants reported being very prepared in the six areas included in the course. The surveys reflected the value of this course, with 92% (n = 33) of respondents rating it as very valuable in helping them to gain the confidence and competence needed to return to nursing practice. An examination of the most positive factors that encouraged reentry into practice reflected the importance of support from the course coordinator and clinical instructor, as well as support from fellow students. The benefits of this structured refresher course include the supportive and nurturing environment that builds confidence and fosters camaraderie among its participants. The variety of classroom instructors was identified by 61% of respondents and hands-on TABLE 3 MOST POSITIVE FACTORS OF THE REFRESHER COURSE a Support from course coordinator and/or clinical instructor (100%). Support from fellow students (86%). Variety of clinical experiences/observation days (75%). Variety of classroom instructors (61%). Hands-on practice in skills laboratory (56%). Exploration of nursing employment opportunities (36%). a Percentage identifying each factor is listed in parenthesis. practice in skills laboratory by only 56%. Because the survey asked for identification of the most positive factors, the survey tool may have limited the number of responses and, therefore, not reflected accurately the value of these elements of the course. The supervised clinical experience with a low student-to-faculty ratio and the group support and shared learning opportunities have been cited as most valuable by the refresher course nurse graduates. These key elements may be missing in other approaches to providing refresher courses, such as self-study formats and precepted clinical experiences. For this reason, the UNC- Chapel Hill School of Nursing Continuing Education Department is receiving an increasing number of inquiries and subsequent enrollments from nurses outside of the usual catchment area. Many nurses are searching for this type of supportive learning environment as they seek to return to nursing. Our experience in teaching this course for the past 15 years has provided insight into the learning needs of these nurses, their recruitment into practice, and their success in nursing practice. Many inactive nurses who seek to return to nursing desire a structured, interactive, and supportive learning environment as they search for their niche in nursing. Recognition of their own life experiences and their value for nursing is critical to this process. Nurse recruitment efforts for these refresher course graduates have intensified in this region. The variety of career opportunities and vacancies in nursing positions have led to many employment choices for these nurses. During periodic reunions, it is remarkable to note that numerous course graduates have gone on to successful nursing careers and expressed satisfaction in returning to the nursing profession. Limitations of the survey include the low response rate, which may have occurred due to some nurses being reluctant to admit that they were not employed. The Journal of Continuing Education in Nursing 87

EVALUATION OF A NURSE REFRESHER COURSE In retrospect, the investigators believe that 10 years is a long time between course graduation and this survey. In the future, the survey will be conducted every 5 years, which may increase the response rate. CONCLUSION The survey revealed that a structured refresher course is appealing to inactive nurses to encourage their return to the profession and to tap this valuable resource in an effort to ease today s nursing shortage. In North Carolina, there are few structured nurse refresher courses with a supervised clinical experience offered on a regular basis. Offering more such structured courses could be another strategy that employing agencies might use to increase their nurse pool. Also, marketing efforts to attract inactive nurses into practice need to be considered and implemented by hospitals and educational institutions with possible reimbursement of course fees in return for a promised period of employment. Through these efforts, this valuable pool of potential nurse employees can help to fill the nursing shortages in today s healthcare arena. REFERENCES Alden, K., & Carrozza, M. (1997). The North Carolina AHEC selfpaced RN refresher program: An evaluation of the first two years. Journal of Continuing Education in Nursing, 29, 14-19. Bensing, K. (2001, April 2). Refresher courses: Easing the transition for nurses returning to practice. Advance for Nurses, 3, 38. Brown, L., & Waddell, G. (1988). Professional outcomes of participants in a nursing refresher course: A five-year follow-up. Journal of Continuing Education in Nursing, 19, 134-136. Ferris, L., & Brown, L. (1992). A 10-year follow-up study: Nurse refresher program. Journal of Continuing Education in Nursing, 23, 220-223. Health Resources and Services Administration. (2002). Projected supply, demand, and shortages of registered nurses: 2000-2020. Rockville, MD: Bureau of Health Professions, U.S. Department of Health & Human Services. Kalnins, I. (1986). Outcomes of a nursing refresher course. Journal of Continuing Education in Nursing, 17, 12-15. O Connor, S. (1991). A chance to come back into the fold: Assessment of a return to nursing course. Professional Nurse, 7(1), 10-12, 14. Quant, T. (2001). Education for nurses returning to practice. Nursing Standard, 15(17), 39-41. 88 Volume 35, Number 2, March/April 2004