Struggle Turning Back to Professional Nursing Practice in Iran: A Qualitative Study.

BACKGROUND: Current nursing shortage is becoming more complicated because of turnover intention among nurses. Most of the inactive nurses in Iran after a long time for various rations Returned To Professional Nursing Practice (RTPNP). Because the RTPNP program does not exist in Iran to prepare inactive nurses returning to practice, this study aimed to explore the strategies that contribute to preparing nurses for RTPNP.
MATERIALS AND METHODS: The present study was a part of the findings of a larger grounded theory study that lasted about 9 months from April 2019 to December 2019. The data were collected through semi-structured interviews with participants after signing an informed consent form. The average interview duration was 40 minutes. The study participants were selected through purposeful sampling from both public and private hospitals affiliated to Iran University of Medical Sciences. Participants included eight nurses, two education supervisors, two matrons, and two head nurses. Interviews were verbatim transcribed and analyzed using a constant comparative analysis method.
RESULTS: Struggle turning back to PNP was the main category that emerged from four categories of "seeking learning resources," "return to practice support," "getting used to a practice," and "building a new family life" from the data analysis process.
CONCLUSIONS: Returners struggle to get prepared for providing PNP to clients if there is no definite process of RTPNP. Organizational support and RTPNP programs are efficient strategies and could help these returners get prepared for PNP. Copyright:

Introduction

Although nurses are the largest health professional group and there are 7.3 million active nurses and midwives worldwide, the health workforce shortage is estimated to be 7 million and is expected to reach 12.9 million by 2035.[1] In Iran, currently, the shortage of nurses is about 130 000. There are about 1.3 nurses per 1000 population, and it is anticipated that in 2020, there will be a shortage of 200,000 nurses.[2] There is a direct relationship between the nursing shortage and the increased mortality rate of inpatients.[3] Today, nurses' turnover intention continues to be one of the most crucial challenges for the nursing profession in both developing and developed countries.[4] Former active nurses who stop Professional Nursing Practice (PNP) for a long period of time and leave their profession, are called “inactive nurses.” According to Flinkman's study, 17% of Registered Nurses (RNs) in the United States are inactive nurses due to caring for their children or other reasons.[5] In a study conducted in Iran, Hesam et al. reported that 21.4% of Iranian nurses have a tendency to turn over their PNP as primarily due to a decreased quality of work-life.[6]

Most of the inactive nurses are willing to Return to Professional Nursing Practice (RTPNP) after a relatively long period.[4] There is no doubt that most of the inactive nurses returning to practice have valuable clinical, communication, and leadership skills, which play an essential role in their future PNP.[7] Moreover, inactive nurses returning to practice could use their skills, insight, and judgment gained from previous practice situations in similar situations and enhance the quality of health care.[89] Although RTPNP has been underused as a strategy for recruiting inactive nurses, the majority of the returners are highly experienced and likely to remain in practice until retirement.[4] Recruiting returners is a cost-effective and efficient use of human resource management.[10] However, the findings of a study which was conducted by Yu revealed that the majority of nurse managers (76.7%) are reluctant to recruit inactive nurses in their organization[11] and these group of managers argue that there is no guaranty that inactive nurses could get benefit from their previous experience in order to advance their effectiveness in the organization.[7] Therefore, there are concerns about the practice competence of nurses to RTPNP, and nursing managers and decision-makers always discuss the challenges of returners to provide nursing services competently.[5]

The needs of returners are unique, and they should not be treated as pre-registered graduated nurses.[1213] It has also been reported that returners have low self-esteem and high anxiety and are concerned about new working conditions and changes in organizational demands due to advances in technology and new responsibilities.[14] Although some studies discuss the returners' knowledge, clinical skill needs, and training programs, there is little information available on developing appropriate strategies for RTPNP. Given the diversity of health systems in different countries, the issue of RTPNP strategy has always been one of the challenges for policymakers in the nursing profession.[15] Some countries had been developed programs for RTPNP to prepare inactive nurses returning to practice.[16] However, the strategy for RTPNP was unclear in the significant number of countries, and there were no RTPNP programs in those countries. Although numerous studies focus on nursing shortage and turnover intention among Iranian active nurses, there was not much information on the process of RTPNP in Iran.[1718] It seemed that developing appropriate strategies for RTPNP, which tailored according to the health care system, is needed in Iran. The purpose of this article was to explore the strategies that contribute to preparing nurses for RTPNP.

Materials and Methods

This qualitative study was a part of a larger study that aimed to explore the process of RTPNP using a grounded theory approach[19] the study participants were returners with a history of inactivity for at least 2 years, and they were currently working in different parts of the hospital. The study participants were eight nurses, two educated supervisors, two matrons, and two head nurses who were selected through a purposeful sampling method while considering maximum variation in participants. In this method of sampling, according to the main purpose of the research, that was a strategy for RTPNP, nurses, and managers who had sufficient criteria and experience in this field were selected and interviewed. Inclusion criteria included having a bachelor's degree or higher in nursing, being inactive in PNP for at least 2 years, RTPNP for less than 1 year, and willingness to participate in the study.

Data were collected using an open and semi-structured interview method, which lasted about 9 months from April to December 2019. Interview sessions were held after organizing an appropriate time with participants. Participants were informed about the study purpose and signed an informed consent form prior to conducting the interview session. Interviews were held by the principal researcher in a quiet and comfortable room which, was suitable for conducting interview sessions. Interviews were audio-taped, recorded by a voice recorder machine. The interviews often started with the question “please tell me a bit about the first days of returning to PNP?” from the nurses and “how do the nurses return to their PNP?” from nursing managers and the follow-up questions were raised during the process of interview. The duration of interviews ranged from 30 to 50 min and lasted for 40 min on average. Participants' interviews continued until saturation of collected data was achieved.

To analyze the data, after each interview was listened to several times by the principal researcher, it was transcribed verbatim using Microsoft Word Software version 16 in a short time after the interview. The principal researcher checked transcripts word by word while he was listening to audiotapes to make sure that there was no mistake in the transcripts. A constant comparative analysis method was used to conduct the data analysis process. First, open coding was done throughout the transcripts. Afterward, the classification of codes into sub-categories and categories was done based on constant comparison of characteristics, dimensions, similarities, and differences of codes and categories.[20]

The following steps were used to achieve credibility, dependability, transferability, and conformability.[21] To achieve credibility, the analysis process double-checked by two other members of the research team. Afterward, the coded interviews were returned to three participants to confirm the findings. To gain reliability, the researchers put aside their previous knowledge of the research topic and wrote them down during the research and finally compared them with final analysis to see whether their prior knowledge had affected their analyses or not. In order to achieve conformability, the findings of the study were given to three people out of the research team for investigation. Finally, the maximum diversity was considered in the selection of the study participants to gain the transferability of the findings.

Ethical considerations

The study obtained the Ethics Code under No IR.IUMS.REC 1397.1260 from Iran University of Medical Sciences. In addition, the following ethical consideration was taken in the process of study. These considerations were signing an informed consent form by each participant before participating in the study, conducting interviews in place and time preferred by participants, obtaining consent for audio-taped interviews during the data collection process, explaining the purpose of the study to the study participants before they participate in the study, and ensuring participants about confidentiality and privacy.

Results

Table 1 presents the demographic characteristics of the participants [Table 1]. After data analysis, a total of 110 refined codes were extracted and classified into 12 concepts, 4 categories, and 1 main category. The results of the interviews showed that the most important strategy was Struggle turning back to PNP.

Table 1

Demographic characteristics of research participants

Number	Participants	Sex	Age	Education level	Education level	Experience	Duration of leave activity (year)	Reentry to practice time	Scheduling	Wards
1	Nurse A	Woman	30	Bachelor	Bachelor	5	4	4 months	Shift in circulation	Surgical
2	Nurse B	Woman	40	Bachelor	Bachelor	10	4	6 months	Shift in circulation	Surgical
3	Nurse C	Woman	60	Bachelor	Bachelor	11	21	1 year	Shift in circulation	Internal
4	Nurse D	Woman	41	Bachelor	Bachelor	3	17	8 months	Shift in circulation	Internal
5	Nurse E	Man	50	Bachelor	Bachelor	12	14	1 month	Shift in circulation	ICU*
6	Nurse F	Woman	36	Bachelor	Bachelor	4	12	15 days	Shift in circulation	Internal
7	Nurse G	Woman	38	Bachelor	Bachelor	12	4	1 month	Shift in circulation	Internal
8	Nurse H	Woman	39	Bachelor	Bachelor	11	6	6 months	Shift in circulation	ICU
9	Head nurse A	Woman	55	Bachelor	Bachelor	35	….	….	Morning	Nursing management
10	Head nurse B	Woman	36	Bachelor	Bachelor	19	….	….	Morning	Nursing management
11	Education supervisor A	Woman	50	Bachelor	Bachelor	21	….	….	Morning	Nursing management
12	Education supervisor B	Man	35	PHD** student	PHD student	4	….	….	Morning	Nursing management
13	Matron A	Man	55	Bachelor	Bachelor	35	….	….	Morning	Nursing management
14	Matron B	Woman	58	Bachelor	Bachelor	30	….	….	Morning	Nursing management

*ICU=intensive care unit; **PHD=doctor of philosophy

Struggle turning back to professional nursing practice

Struggle turning back to PNP was the main category, which refers to the participants' challenges and efforts in both family life and working life to RTPNP. In fact, it was challenging for the study of participants to achieve their clinical competence regardless they had clinical experience in the past. Returners, who work in hospital recently, always use the strategy of Struggle turning back to PNP to be able to work professionally similar to their other colleagues. To achieve this capability, first, they used the strategy of returning to practice support, with the support of managers and colleague, the strategy of struggle to turn back started, after receiving support, with the help of various learning and educational resources and along with the support of family members, the concept of getting used to practice has occurred. Finally, the strategy of turning back to PNP was completed [Figure 1].

Figure 1

Flowchart of main categories

Struggle to turn back to PNP, which was extracted from four categories of “seeking learning resources,” “return to practice supports,” “getting used to the practice,” and “building a new family life.” [Table 2].

Table 2

The process of reaching the main category “struggle turning back to professional nursing practice”

Main category	Categories	Concepts
Struggle turning back to professional nursing practice	Seeking learning resources	Preceptorship learning resources
		Peer-based learning resources
		Observational learning resources
		Self-directed learning resources
	Return to practice supports	Respectful organizational culture
		Encouraging organizational culture
		Flexible working atmosphere
	Getting used to a practice	Making sense of being a team member
		Making sense of being responsible
		Making sense of being accountable
	Building a new family life	Participatory family structure
		Expanded family roles

Seeking learning resources

Seeking learning resources refers to the participant's effort to access information in order to improve their knowledge and skills after RTPNP since the nursing profession is changing every day, and returners may not have competence when they return. Participants revealed that they sought a wide range of learning resources in order to improve their knowledge and skills and choosing the learning resource was based on the accessibility of the resource. The study participants stated that they had continually challenging effort to access to appropriate learning resources in the first days of RTPNP in order to achieve and improve their clinical competence back and to become ready for providing PNP. One of the study participants pointed out: “The first week when I turned back work, I wasn't confident and needed learning support to RTPNP” (Nurse N.4).

These resources included preceptor ship learning resources, peer-based learning resources, observational learning resources, and self-directed learning resources. In some participants' perspectives, preceptors played a crucial role to support and provide learning resources. This quotation was taken from one of the participants. ”My preceptor helped me more than others by handing me pamphlets and holding some classes. Whenever the preceptor had time, I tried to approach her and ask my questions” (Nurse N.7).

In regard to peer-based learning resources, one of the managers said: “Colleagues could play an important role in helping returners to put them on the track again. Although the organization had an orientation program for pre-registered nurses, there was not orientation for returners. So, they were asking for support and help from colleagues to be able to get knowledge and skills to get back on the track sooner” (Head Nurse N. 1).

Return to practice supports

Return to practice support refers to the workplace measures, which helped participants to cope better with the organizations' culture. For the study participants, the return to practice supports would be accomplished with respectful organizational culture, encouraging organizational culture, and a flexible working atmosphere. For some of the participants, respect was playing a significant role in retaining them in their new PNP. One of the participants stated: “I'd like to work in a place that people speak respectfully to each other. It makes me be motivated to do my best and keep going through a challenging situation in my PNP. I had a preceptor who always encouraged me by keep saying, we were all the same on the first days, and if you try, you can quickly reach others” (Nurse N. 2).

In addition, participants believed that returners liked to be more involved in the workplace and improve their knowledge and skills more when they were encouraged by colleagues and managers. In relation to encouraging organizational culture, one of the participants stated: “I became very happy when I did good work, for example, when I did venipuncture well because I realized that I had the ability; for example, when I could recognize the IVs, or when I learned antidotes” (Nurse N. 8).

Getting used to a practice

Getting used to practice refers to the participant's feeling about practicing the profession of nursing. Although participants had a challenging experience when turned back to PNP, they gradually felt confident about their independent practice and being attached to the team. Some of the participants explained how they were getting used to their PNP when they had a sense of being a team member. The following excerpt was taken from a participant in the study. “I was working efficiently without anxiety when I felt I was attached to the team” (Nurse N. 1).

Participants believed that they developed a sense of responsibility and accountability with the progression in their PNP and advancing their knowledge and skills. In this regard, one of the participants states: “I was happy to accept the responsibility to look after patients independently when I was confident about my clinical competence. To be honest, I was frightened to have the responsibility of patients in the first days because I was not confident enough” (Nurse N.3). Another study participant added: “As a returner, it just took a few days that I became accountable for my PNP, and my preceptor agreed that I could be fully responsible for providing care for patients” (Nurse N.1).

Building a new family life

Building a new family life refers to the need for changes in the participants' family life due to RTPNP. Participants discussed building a new family life through participatory family structure and expanded family roles as an appropriate solution providing returners to be better prepared to RTPNP successfully. For participants, these issues in family life were considered as the main barriers to RTPNP. “I turned back to work after staying home with my kid for almost 20 months to look after her” (Nurse N.7). They also believed that building a new family life was the most important factor for becoming prepared for RTPNP. One of the participants' strategies to build a new family life was having a participatory family structure. One of the participants stated in this regard: “I didn't have the stress of leaving my child alone at home because my spouse cooperated with me and took care of the child, or I took the child to the kindergarten or my mother's. It wasn't very difficult for me” (Nurse N. 5).

For some participants, the expanded family roles was another strategy to build a new family life. One of the managers pointed out: “It's unfair not to point to the role of their family as main motivators and assistant for returning to practice. Their family encouraged them very much, and they told them to go back to work because they would help them in household affairs” (Matron N.1).

Discussion

The findings of this study showed that returners struggle to become prepared to turn back PNP, and they were seeking learning resources and organizational support in order to prepare themselves to get used to PNP. It also required changes in their family life in order to cope with the work-life. Although there was no definite program to prepare returners for PNP, the Nursing Council in the UK states that due to the community's need for nurses, midwives, and healthcare personnel, graduate nurses can return to work again after undergoing training and regaining professional qualifications after a long period of nonprofessional work.[4] Barriball et al. pointed out the importance of a three-stage training program for preparing returners to enhance their practical performance. In this way, it helps to develop the knowledge of inactive nurses and eliminates their negative views on reentry to practice.[22] Similarly, Burns emphasizes a rapid educational approach through the provision of up-to-date knowledge, the use of new technology, and the development of educational opportunities required to enhance the knowledge of inactive nurses in the least possible time.[23] Studies have shown that RTPNP requires a basic program. Unfortunately, there is no such program in Iran, and the development of this program requires understanding the strategy of nurses to return to practice. In this study, we introduced the strategy of struggle turning back to PNP used by nurses, and Organizations can use this strategy to help develop future training programs in Iran.

The result of this study showed that returners seek numerous learning resources, including preceptors, peers, observation, and self-directed, to improve their knowledge and skills and prepare themselves for PNP. Hsing reported that the programs planned for preparing inactive nurses to renter PNP should be able to create motivation in this group of nurses for reentry to PNP.[24] However, Kent believes that these programs do not help understand the concept of care since these nurses know the essence of patient care, and this understanding does not change over time.[10] Studies have shown that updating knowledge is critical to improving nurses' performance. Numerous methods for updating knowledge have been studied, and in the present study, the importance of updating knowledge is quite clear. Returners use a variety of information resources to update their knowledge, which is stated in most studies.

The result of this study showed that there is a variety of methods to encourage returners to turn back and continue their PNP as they return to practice supports. Hsing et al. outline that nursing managers use different methods to encourage returners to turn back to PNP.[24] Barriball et al. aimed at the support of nurses by a colleague in practice and the need for inactive nurses in a friendly environment.[22] On this basis, Yu also referred to the individual needs and the importance of a flexible plan for these nurses to make a balanced working environment as a strategy for being accepted by colleagues.[11] Organizational managers are considered as one of the most important sources of encouragement and support. Given that the position of nurses is in the organization, and one of the most important roles of the organization is to provide enough number of nurses. Therefore, all studies have emphasized the use of various strategies to encourage nurses to RTP. In the present study, one of the most important strategies for RTPNP was to provide suitable working conditions by organizational management.

The study results revealed that returners were not confident about practicing at the beginning days of turning back. Davidhizar also showed in his study that returners have low self-esteem and high anxiety and are concerned about new working conditions and changes in organizational demands. Therefore, strategies that lead to further development in practice and patient care, should be designed by the organizations and hospital managers.[14] Besides, most returners prefer to work in internal wards, as advances in technology less influence these wards. Accordingly, preparing returners for turning back to PNP is of high priority.[13] Getting used to practice is one of the important strategies that are used by nurses to turn back to PNP, and it has been mentioned in most studies. This strategy is used to overcome impotence and achieve confidence.

The results of this study revealed that the family life of returners has great influences on their work-life. Returners need to build a new family life in order to cope with workplace conditions. Hsing identified the nurses' assurance of the family taking care of children as an essential strategy to enhance nurses' motivation to advance the nursing practice.[24] Barriball also cites family responsibilities (49%) as the most important reason for leaving nursing practice in the UK and urges health organizations to provide facilities to support these nurses to relieve family tensions.[22] In the present study, family life has been shown to be one of the most important sources of support for RTP. Therefore, family life support is one of the most important strategies for returning to professional practice, while in most studies; the importance of the role of family life in the successful return of nurses has been shown. Therefore, the results of the present study are aligned with other studies.

One of the most important limitations of this study was access to eligible participants for the study. Because there was no regular information about inactive nurses, and it was very difficult to find and select nurses who had left the workplace for more than 2 years and had recently turned back to work. Therefore, it is suggested that in future studies, the returner in the group of students who graduated from university and returned to work in the hospital be selected and studied.

Conclusion

The organizations ought to provide the condition for returners to be able to practice the best and have the competence for reaching their previous level of ability and preparing the returners to use an essential strategy for RTPNP. Returners seek many learning resources to get used to PNP competently. However, they require organizational support to prepare them for turning back to PNP successfully. Besides, building a new family life is a necessity to continue PNP. The study results suggest that returners, when RTPNP, could greatly enhance and deal with nursing shortage in both developing and developed countries due to the quick pathway PNP and assure competence in returners.

Financial support and sponsorship

This article is financially supported by the Iran University of Medical Sciences.

Conflicts of interest

Nothing to declare.