In a climate of growing nurse shortages nationally and internationally (Buchan et al, 2017) it is vital that we attract and retain as many registered nurses (RNs) as possible and support them as they adjust to contemporary practice. To practise as an RN in the UK, nurses must revalidate every 3 years from the date of initial registration. This involves providing evidence of professional competence, including a minimal level of working hours and continuing professional development.
Failure to fulfil revalidation requirements results in a lapse in registration. To return to work as an RN thereafter it is necessary to complete a return to practice (RtP) programme, the standards for which are set by the Nursing and Midwifery Council (NMC). Following an extensive consultation process, the 2011 standards have been updated and published this month (NMC, 2019a). What did the consultation process reveal and how have the standards changed?
The consultation process included a literature review followed by engagement with stakeholders across the UK over 3 months: nurses and midwives on the register and lapsed, students, including those on RtP programmes; educators; regulators; care commissioners and employers. The reviewers were interested in the extent of loss of skills and competence in non-practising professionals, views on the use of computer-based testing and/or objective structured clinical examinations (OSCEs) to assess clinical competence. They also considered processes and procedures used by overseas regulatory bodies for nursing and midwifery and by other UK health profession regulators.
The views on the use of Tests of Competence (ToC) for the purpose of RtP were mixed. NHS Employers (2018) expressed reservations about this approach without a stronger evidence base. It noted that OSCEs are currently used with nurses from outside the European Economic Area seeking to work in the UK, but this is presumably time-consuming and costly. Instead, they advocated an employer-led approach to facilitating a return to practice.
An investigation of how return to practice is handled by other professions revealed that the NMC was unusual in its requirement for lapsed registrants to complete an RtP programme. The General Medical and General Dental Councils operates a faster process, whereby the medical deaneries provide more flexible plans to support individual needs. The Healthcare Professions Council is also less prescriptive and advocates self-study courses where required and supervised practice. However, in six countries overseas the nursing regulatory bodies were found to have parallels with the NMC, with prescribed refresher courses or competency tests.
Data from the NMC (2019b) register showed that between 2012 and 2017 6380 nurses/midwives rejoined the register after completing an RtP programme. The four top reasons that those who had lapsed gave were retirement, relocation, pressure of work and ill health, although some did not provide a reason. Interestingly, the proportion of people on the register is increasing in two groups: those aged 21–30 years and those aged 56 years and over. This indicates that more people are returning to work towards the latter stages of their careers.
The NMC (2019b) found that more flexibility in the design and delivery of RtP programmes was required, with some support for self-declaration together with a portfolio for assessment, particularly for those approaching revalidation. Some also supported an NMC ToC as an alternative to RtP programme completion. The consultation also revealed a desire to take a more stringent approach towards those who had left the register following a fitness for practice panel. However, legal advice indicated this would be unfair as these individuals would have already faced sanctions and that this group must be treated like any other.
Following the consultation and review, the new RtP standards (NMC 2019c) were altered to introduce additional flexibility. The readmission standards remain the same in terms of evidence of 450 hours of work as a nurse in the past 3 years. An applicant can then complete the RtP programme as before (although the curriculum has been updated), or from January 2020 they can pass an NMC two-part ToC for the relevant part of the register. This is the same test as that taken by overseas applicants. One further change is that those with insufficient hours to meet revalidation requirements will be able to apply for a short extension to complete revalidation, thus hopefully preventing some avoidable lapses from the register.
This consultation process has been thorough and offers further flexibility to practitioners and employers and is to be welcomed. However, to retain experienced practitioners means having ongoing support from colleagues and nurse leaders. Nurse retention is a significant problem worldwide. Work pressures are made worse by nurse shortages, with 1 in 9 RN posts reported vacant (NMC, 2017). Returning RNs are therefore a precious resource and one that we must cherish.