As the largest segment of health care professionals in the world, nurses have been tasked with providing care during pandemic outbreaks such as the global flu pandemic, Zika virus, swine flu (H1N1), and severe acute respiratory syndrome (SARS) (Aoyagi et al., 2015; Jacobson & Kennedy, 2009; Wilson & Nguyen, 2017). Most recently, U.S. nurses were asked to respond to national public health care needs associated with COVID-19, a disease caused by a novel (or new) coronavirus that has not previously been seen in humans. Coronavirus (SARS-CoV-2, or commonly called COVID-19) is characterized by severe acute respiratory syndrome. According to the Centers for Disease Control and Prevention (2020), this disease was first identified in Wuhan, Hubei, China, in December 2019. On March 11, 2020, the World Health Organization (2020) formally declared COVID-19 a pandemic. Ironically, prior to this, the World Health Organization designated 2020 as the International Year of the Nurse and the Midwife. It could not be more timely that nurses would be placed in a position to sustain the front lines of a public health emergency.
Since the onset of the pandemic, staffing health care facilities with professional nurses with the skills needed across various clinical areas has proven to be a challenge (Spetz, 2020). Health care systems and organizations across the country have worked diligently to make the most of existing nursing resources. To supplement their efforts, federal and state leaders enacted policies to address the unmet needs associated with the rapidly increasing number of COVID-19 cases. At the federal level, H.R. 748, the Coronavirus Aid, Relief, and Economic Security (CARES) Act, provided much-needed resources to assist the academic nursing community and the nursing workforce in advancing pandemic-related health care services (American Association of Colleges of Nurses, 2020). In response to the spread of COVID-19 across Texas, particularly in metro areas (i.e., Dallas/Fort Worth and Houston), Governor Greg Abbott signed executive orders waiving requirements for licenses reactivation, facilitating the process of nurses with inactive and retired licenses returning to practice in health care settings (Office of the Texas Governor, 2020). The surge of nurses seeking to reactivate or return to practice as a result of these policy authorizations made reentry programming a top priority among many nursing education professionals.
As the nursing education community continues to adjust to meet the health care–related needs of this pandemic and future public health crises, refresher programs play an essential role in providing continuing education opportunities needed to reactivate licensure. The purpose of this article is to show how one such program served to meet the needs of out-of-practice RNs during a time of crisis. Beginning with a background on nurse reentry to the care settings, the remainder of this article provides an overview of the university RN Refresher Program, including an overview of the program structure and curriculum. This is followed by detailed information on the program's evaluation process and outcomes to date. The article ends with a discussion and conclusion relaying the importance of continuing education in meeting the needs of the health care community, particularly during the context of the global pandemic.
Background on Nursing Reentry and Refresher Programs
Before the COVID-19 pandemic, it was not uncommon for nurses to seek reentry to the workforce (Ferris & Brown, 1992). As nursing scholarship shows, practicing nurses often leave or take a break from practice for a variety of personal and professional reasons, and such breaks often result in the lapse of licensure and deficiencies in contemporary knowledge needed to deliver nursing care (Hayes et al., 2006; Skillman et al., 2010). Refresher or reentry programs are designed to address the needs that result from such lapses in credentials and knowledge, thus providing nurses with access to courses focused on nursing theory and opportunities to participate in a preceptorship to prepare for advanced clinical practice.
The refresher concept has been around since at least the 1980s as a means to address nursing shortages amid declines in nursing school enrollment (Ferris & Brown, 1992). Since then, refresher programs have served as a successful means to facilitate workforce reentry (Blankenship et al., 2003). Such programs have been effectively delivered through university-based, junior college-based, and hospital-based formats (Morrison et al., 2005), expanding opportunities for nurses to reorient themselves prior to returning to work in clinical settings.
Heeding the Call of COVID-19
Prior to the pandemic, a university outside of Houston, Texas, in conjunction with geofencing, conducted a local needs assessment to examine the need for refresher or reentry options in the metropolitan area. The assessment revealed minimal access to refresher courses within the 150-mile area surrounding the university. Additionally, the results revealed how a significant number of potential program candidates were either waitlisted or lacked access to the clinical rotation slots needed to complete their required hours.
To address the disparities in refresher course access within the region, the university launched a pilot RN Refresher Program in June 2019. The program aimed to provide nurses with the resources needed to reactivate licensure and return to clinical practice by offering a didactic component and clinical practice component delivered in a blended hybrid format. In August 2019, the two students who enrolled in the pilot completed the program requirements and immediately secured employment. The successful launch of this pilot helped the university procure external grant support needed to move the program forward, and the first full class of nurses was enrolled in January 2020.
By late March 2020, the COVID-19 pandemic raised concerns across Texas area hospitals regarding possible shortages in nursing staff, as well as the quality of care provided to incoming patients. During this time, the first cohort of students in the full program was completing the required clinical rotations at local area health care facilities.
As a result of the conditions surrounding the pandemic, the refresher students quickly became a vital asset to the health care community. In the face of the pandemic, students who were already RNs were even more eager to heed the call to return to the frontline as the Texas outbreak was projected to escalate. The refresher students felt compelled to complete the program and gain additional guidance before returning to practice. The RN refresher students' responses during this pandemic underscored an urgent need for experienced health care professionals across our state. For nurse educators at the university, it was a true call to action to help nurses to relaunch their careers and serve the Houston area in the fight against COVID-19.
Assessing Competency Upon Reentry
Assessing the competence of nurses seeking reentry is essential for continuing education efforts. Beginning with the pilot program enrollees, university faculty administered a survey adapted from the Nurse Competence Scale in the first class meeting. The survey uses a Likert scale, as well as an open-ended response section, to collect qualitative data regarding their nurse education background, current nursing education level, the length of time spent out of practice, the area of nursing worked, and perceptions of managing basic adult acute care patient situations as it relates to common disease process examples. In addition to the clinical assessment piece, the survey gauged students' level of confidence and anxieties related to didactic course-work and medical–surgical-focused clinical requirements.
Results from the survey exhibited education levels ranging from diploma in nursing to associate degree or bachelor's degree in nursing as the credential obtained. The length of time spent in nursing practice ranged from 4 to 25 years. A strong majority of the students (95%) expressed mild to moderate anxiety. Although the length of a student's hiatus was not overwhelmingly associated with feelings of anxiousness or confidence, those who worked in specialized areas of nursing before their departure expressed a higher level of anxiety and confidence in the ability to be able to perform in the acute care clinical setting.
The university-based RN Refresher Program is designed to serve RNs applying for license reinstatement through the Texas Board of Nursing (TBON), currently licensed RNs seeking to reenter the clinical setting after an extended absence and RNs who were licensed in another state and seeking to apply for Texas licensure. The 120-hour concept-based program is delivered at the competence level of a medical–surgical nurse who has completed a basic prelicensure generic capstone course and was successfully licensed as an RN. The course content and percentage of time assigned to both the didactic and clinical areas were guided by the rules set forth by the TBON and is delivered in a hybrid, or blended, learning format that includes online and in-person modes of instruction. The didactic component features 40 hours of coursework divided across 8 weeks. This is followed by an 80-hour evidence-based clinical practice component, which includes 12 hours of simulation.
Concerning marketing and promotion, the program was promoted on the university's main website, and Vendini, an external marketing company, was also hired to advertise more broadly across the metro area. Health care facilities, community colleges, and area universities served as vital points of contact to support the recruitment of program participants. In addition, nurse educators and faculty from the program shared information at required nursing advisory meetings and distributed informational flyers at various nursing state and local convenings. These efforts resulted in the successful recruitment of 12 qualified enrollees, which was the target number for each cohort in the full program.
With regard to course curriculum, all students receive the same instruction and are required to meet the same objectives, whether or not they have an active license. The didactic portion of the program is designed for students to develop knowledge of—or be reintroduced to—multiple areas, including scope of practice, medical–surgical concepts, pharmacology, medication administration, and documentation, as well as clinical preparation. The didactic course of the program is delivered by doctorate (PhD) and master's credentialed faculty who guide and mentor program participants to successfully return to practice in health care settings.
The evaluation of didactic course deliverables is directly aligned with TBON requirements, which are intended to advance practitioner knowledge, nursing skill, and confidence in practice abilities. The didactic curriculum meets this criterion through weekly modules focused on the scope of practice as it relates to the Texas Nurse Practice Act, TBON rules related to documentation, quality assurance, and legal implications. Additionally, students review the Nursing Process and Basic Adult Medical–Surgical principles, as well as Pharmacology and Medication Administration content, as it relates to current technology, equipment, nursing trends and practices, and current legalities. After participating in a variety of face-to-face and online lectures, readings, and collaborative activities, students complete learning assessments such as quizzes, case studies, content presentations, and skills laboratory demonstrations to determine competency across the learning objectives. Based on the results of these assessments, remediation is conducted for all areas of deficiency.
The acute care clinical experience serves to support the nurse to gain confidence and skill to deliver safe and effective care to adult medical–surgical clients under the supervision of a nurse preceptor. This component of the program comprises 80 mandatory contact hours aimed at facilitating the application of theory. To achieve this objective, the clinical experience provides opportunities for practical hands-on experience of patient care delivery (i.e., dressings, medications, health, and physical assessments) in an acute care setting with a focus on adult medical–surgical skills. To enhance the clinical experience, students are asked to keep an ongoing journal of reflections related to the clinical rotation.
The clinical experience is supplemented with simulation requirements at the university's campus site, where two 6-hour high-fidelity, culturally diverse simulation scenarios are conducted with debriefing. One simulation is conducted during the first week of the clinical course prior to the start of the hospital rotation, and the second simulation experience occurs at the midpoint of the clinical course to assess and evaluate skills and competence. Upon completion of the program, participants receive a certificate of completion from the university and the required paperwork is validated and submitted to the TBON.
At the initial start of the clinical rotations in March 2020, the number of COVID-19 positive patients in the Houston and surrounding areas and those hospitalized did not pose a problem with access to clinical rotations. However, the evolving pandemic resulted in an increased number of inpatients, and the shortage or lack of access to personal protective equipment became an increasing concern. By week 3 of the students' clinical rotations, the possibility of health care facilities canceling student rotations prompted the need to increase the number of shifts to help students complete the required hours. Additionally, in preparation for students' rotations being canceled, an alternate plan was instituted. Students experiencing difficulties completing their clinical requirements in a hospital setting were offered the option to complete the remaining hours at the university simulation laboratory under the instructor's supervision. The canceling of student rotations did occur and the alternative plan was enacted. Although most of the students were able to complete their required clinical hours in their assigned hospital, four students completed their remaining hours (ranging from 15 to 20) via the campus' faculty-supervised simulation.
Throughout the program, observations and assessments of students revealed concerns around safety and fluctuating levels of confidence concerning the delivery of care, and such concerns were exacerbated by the ongoing pandemic. To address this area, program faculty serve as mentors to the students to provide support and guidance aimed to increase self-efficacy. In addition to support from faculty, University Mental Health Services presents to students during the second week of the didactic course-work to share resources, services, and contacts to support mental and emotional wellness. During the clinical rotations, faculty continuously provide ongoing formal and informal check-ins via telephone and Zoom videoconferencing to discuss successes, concerns, and personal clinical reflections.
This second cohort completed the program in May 2020. After completing the program, each student submitted a program evaluation survey that assesses confidence for returning to practice and program satisfaction. These evaluations will be used to inform and guide program improvements. To support participants' workforce reentry goals, all students are offered assistance with resume development and provided suggestions for updating their job search materials. During the program, and up to 90 days after program completion, job advertisements and notices for new opportunities are emailed to assist with the process of seeking employment. Students were also provided with information on additional opportunities for continuing education at the university. This continued communication also allows nursing instructors to foster an ongoing relationship and continue to serve as external mentors. As of August 2020, 85% of the students from this cohort are actively working as RNs in local health care facilities. Completers are primarily employed in acute care, pediatric intensive care unit, and direct COVID-19 care units.
Discussion and Conclusion
The COVID-19 pandemic has increased the need for experienced health care professionals across our state, catapulting staffing to the forefront of concerns regarding the nursing workforce and delivery of quality of care. The staffing issues brought on by COVID-19 raises concerns about the number of nurses in the workforce, forcing nurse educators to consider ways to help strengthen the nursing pipeline. The program development experience described in this article demonstrates how nurse educators can heed this call to serve communities during critical times by providing educational resources needed to prepare nurses to return to practice. As demonstrated throughout this article, the RN Refresher Program is a useful mechanism to minimize gaps in access on the pathway back to the workforce by providing accessible options for license renewal. For the nurses desiring to return to nursing during a crisis such as COVID-19, refreshers may prove beneficial in terms of enhancing skills for relaunching their career.
Although refresher programs are instrumental in providing the educational opportunities needed to improve the nursing shortage, such initiatives are also affected by changes in the health care setting resulting from the pandemic. This work highlights the challenges many nurse education programs are facing regarding students' clinical experiences given that COVID-19 forces practice facilities to limit or halt clinical practicum opportunities. For refresher programs to be successful, it is imperative to ensure the quality of the clinical learning experience with qualified and willing preceptors, which, in the context of COVID-19, may mean that nurse educators will need to seek alternatives (i.e., completing clinical hours in a simulation laboratory under the instructor's supervision) to traditional clinical rotations. In addition to providing flexible course delivery modes and clinical practice alternatives, these programs should also be affordable, adaptable to the needs of nontraditional students, and provide support securing employment at the conclusion of the refresher experience.
Also noteworthy in the context of COVID-19 is the grit, motivation, and resiliency displayed by the nursing students in the university refresher program. Students were willing to step up to meet the needs of the community without hesitation, and eagerness to heed the call during this pandemic is a testimony to their dedication to the profession. Refresher program staff should leverage this and counter by providing support for experiences that help nurses who have been out of practice to see their worth and the necessity to pursue the journey back to practice.
Based on the success of this program, the university is committed to continuing this fast-track program and finding ways to make it more accessible to nurses desiring to come back to practice. A key takeaway from this experience is that refresher programs increase the supply of nurses across the state who are available to deliver patient care and serve on the front lines of the fight against coronavirus. Furthermore, universities and grant-funding entities searching for ways to support frontline health care workers should know that refresher programs need financial support to thrive and that investments in this area support the return of experienced nurses to the workforce.
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