THE PROFESSIONAL EDUCATIONAL NEEDS OF NON-PRACTISING NURSES REGISTERED WITH THE SOUTH AFRICAN NURSING COUNCIL

Unless the nursing profession can manage to recruit and retain sufficient numbers of professional nurses, it might become impossible to render adequate health care to the citizens of South Africa. Many studies and much effort, have b een d ire c te d to w a rd s the recruitment of nurses. Much less has been done to retain these nurses once they have entered the nursing world or to recruit non-practising nurses to re-enter the profession.


Introduction
U nless th e n ursing p ro fessio n can manage to recruit and retain sufficient numbers of professional nurses, it might become impossible to render adequate health care to the citizens of South Africa.Many studies and much effort, have b e e n d ir e c te d to w a rd s th e recruitment of nurses.Much less has been done to retain these nurses once they have entered the nursing world or to recruit non-practising nurses to re-enter the profession.
This study aim ed to c o n trib u te to knowledge about non-practising nurses and their educational needs, as well as to provide a data base for future studies.

Objectives
The specific objectives of this research were to: • ascertain w hether non-practising nurses registered with the SANC (South A frican N ursing Council) w ould c o n s id e r re -e n te rin g the nursing profession; • compile a profile of the personal characteristics of the non-practising nurses registered with the SANC; • discover the m ajor factors which caused these nurses to abandon their profession; • estimate the importance of various issues which m ight influence the potential professional re-entry of such nurses; • identify the professional educational needs of non-practising nurses, as perceived by themselves as well as by nurse a d m in is tra to rs and n u rse educators; this involved -evaluations of previously attended nurse re-entry courses; d e te rm in in g r e s p o n d e n ts ' expectations of the nature of an effective nurse re-entry course; -identifying specific topics to be included in an effective nurse re-entry course; -utilising the data obtained to compile a workbook for potential re-entry candidates; and -suggesting clinical procedures which should be mastered during the clinical updating period(s).

Motivation
Nurses constitute the largest single group among all health professionals and health services cannot function adequately w ithout a w e ll-d e v e lo p e d n u rsin g profession.Research done by Miller and Stokes indicated that increases in nurses per capita had a greater im pact on reducing community death rates than e ith e r in c re a s e s in p h y sic ia n s or increases in hospitals (Aiken 1981: 326).
Recruitment of student nurses declined from 1985 until 1988 as the total number of student nurses registered with the SANC during this period declined from 14 601 in 1985 to 12 565 in 1988, representing a decline of 13,9% over this period (Ehlers 1990: 16 - The potential shortage of professional nurses becomes more serious when this slow growth rate is coupled with the high median age of registered nurses in the RSA -estimated as being 38 years in 1984 (Cilliers 1984: 74).Serious problems could arise for the nursing profession between the years 2005 and 2010 if it is asssumed that the m ajority of these nurses will retire between the ages of 60 and 65.
Large numbers of nurses do not practise their profession despite m aintaining th eir re g is tra tio n w ith th e SA NC.Statistics o b tain ed from the SANC records reflected the following numbers of non-practising nurses: 1988 -3 300 1989-4 806 (Ehlers 1990:13) However, the numbers of non-practising professional nurses in the RSA could be much larger than indicated by the above figures because not all nurses responded to the relevant question on their annual SANC m em bership renew al cards.A nnually large num bers of nurses request removal of their names from the SANC's registers as illustrated by the following figures: • a serious shortage of professional nurses may be anticipated in the RSA within the next two decades; • the number of school leavers recruited fo r th e n u rsin g p ro fe s s io n has declined; • th e r e a re la rg e n u m b e rs of non-practising nurses in the RSA; • enabling these non-practising nurses to re-enter the nursing profession m ight a lle v ia te th e a n tic ip a te d shortage of nurses in the RSA; • the success of such professional re-en try may be enhanced by an effective nurse re-entry programme; • such a re-entry programme can only be effective if it is based on the professional educational needs of the non-practising nurses.
The research problem concerned the d e te r m in a tio n o f p ro fe s s io n a l educational needs of non-practising nurses as perceived by these nurses themselves, by nurse educators who might have to offer and co-ordinate nurse r e -e n tr y c o u rs e s , a n d by n u rse adm inistrators who might be future em ployers of th e se n o n -p ra c tisin g nurses.

METHODOLOGY
Research approach A literature review was conducted to place the research problem, namely "the p r o fe s s io n a l e d u c a tio n a l needs o f non-practising nurses registered with the SAN C ' within a broader perspective.Nurse re-entry courses offered in the U nited S tates of A m erica, Canada, Australia and the United Kingdom were studied.Great diversities were identified with regard to admission criteria, course c o n te n t, c o u rs e o rg a n is a tio n and duration as well as evaluation procedures and criteria.No nationally co-ordinated nurse re-entry course appeared to exist in the RSA.
Descriptive surveys (using postal questionnaires) were employed to determine the professional educational n e e d s of n o n -p ra c tis in g n u rses as p erceiv ed by them selves, by nurse administrators and nurse educators.The population of non-practising nurses, for this research, consisted of the 3 300 non-practising nurses registered with the SANC on 31 January 1989.A 20% computerised random sample was drawn from this population and a total of 760 questionnaires were mailed.Only 380 (50% ) u sab le q u e stio n n a ires w ere returned.
In the three participating provinces (Transvaal, Natal and the Orange Free State) 34 hospitals and 16 colleges of nursing could be identified which offered the four year diploma and/or degree c o u rs e s fo r s tu d e n t n u rse s.Questionnaires were mailed to all 34 nurse ad m in istra to rs and 16 nurse educators.Despite personal phone calls, only 20 nurse administrators and 11 nurse educators returned their com pleted questionnaires.
The Statistical Package for the Social Sciences (SPSS) was utilised to obtain computerised analyses of the data.

The research instrument
T h e s e lf -a d m in is te r e d p o s ta l questionnaire was the selected research instrument for this study, necessitated by the large size of the sample and wide geographic distribution.

Description of the questionnaires
The questionnaire consisted of five major sections: Section 1, consisting of 14 questions, requested biographical information such as age, sex, marital status, educational qualifications, professional experience, and the number and ages of children.S e c tio n 2 trie d to d e te rm in e the expectations to be met by an effective nurse re-entry programme as perceived by the non-practising nurses themselves.This section comprised the largest part of the questionnaire and consisted of 54 questions.
Section 3 (24 questions) tried to establish w h eth er th e n o n -p ractisin g nurses in te n d e d to r e -e n te r th e n u rsin g profession and if so, at what stage and under what circumstances.
The seven questions of section 4 sought information concerning the reasons for abandoning the nursing profession.
Section 5 (four questions) requested information about previously attended nurse re-entry courses (to be completed only by respondents who had attended such a course).
The questionnaires directed at the nurse adm inistrators and nurse educators included questions identical to those c o n ta in e d in s e c tio n 2 of the non-practising nurses' questionrmau-es.F u r th e r q u e s tio n s a tte m p te d to determine whether any nurse re-entry courses had been offered during the preceding two years and the nature, scope, duration and financial costs of such courses.The nurse administrators were asked under what conditions they would employ non-practising nurses.

Biographic data
The most important research findings concerning the personal characteristics of the non-practising nurses registered with the SANC included: • T he h ig h est p e rc e n ta g e of the respondents (45,24%) resided in the T ra n sv a a l, 25,93% in th e C ape Province, 5,29% in the Orange Free State, 18,78% in Natal, 3,44% in S.W.A./Namibia, and 1,32% in other areas.
• English was the preferred language of communication for 74,74% of the respondents.
• White respondents returned 92,61% of the usable questionnaires, but comprised 71% of the randomised sam ple.No explanation could be provided for this large percentage of white respondents.
• The largest number of respondents (113 or 29,97%) fell within the age group of 31-39 years.
• Although 82,01% of the respondents had children, the age of the youngest child was reported to be less than six years by 46,35% of the sample.
• The majority of non-practising nurse respondents (94,67%) reported then family income as falling within or above the average family income group.
• As many as 77.36% of the respondents h e ld tw o o r m o re p ro fe s s io n a l quahfications.
• A high percentage (78,86%) of the re s p o n d e n ts d id m a in ta in fully paid-up membership of SANA.
• Approximately half (50,94%) of the respondents indicated that they read the official nursing journal "Nursing RSA Verpleging" regularly.
Family commitments (40,3%) presented the single most im portant reason for abandoning the nursing profession; followed by dissatisfaction with the hours of work and/or remuneration (31,6%).
As many as 41,1% of the respondents worked in fields outside nursing.Of these 49% worked full time and 51% worked part time.

F actors w hich m ight in flu en ce non-practising nurses to re-enter the nursing profession
Eighteen such factors were identified (See Table 2).(Please note: although 380 usable questionnaires were analysed, the data presented in Table 2 reveal that all 380 respondents did not necessarily c o m p le te all th e ite m s on the questionnaire.Consequently, no total (N) can be provided for the table as a whole.The total number of respondents for each item is provided in the final column of each row which implies that N differs for each row).
The ability to work the hours of choice was regarded as an important aspect influencing their decision to re-enter the profession by 90,15% of the respondents.The assurance that they could work in the departm ent of their choice was perceived as important by 88,46% of the non-practising nurses registered with the SANC.O f the p a rticip a tin g nurse administrators, 68,18% would allow the re-entering nurses to work the hours of choice; and 13,64% would allow this p ro v id e d th o s e h o u rs s u ite d th e h o sp ita l's needs.Sim ilarly, of the p a rtic ip a tin g n u rse a d m in istra to rs 31,02% w o u ld not p ro m is e th e re-entering nurse that she could work in the department of her choice; 36,36% were prepared to make such a promise; and a n o th e r 13,64% w ould do so provided a need existed in the nurse's chosen department.
M ore than h alf of the respondents an tic ip a ted w orking until reaching pensionable age subsequent to their professional re-entry.Thus the services of large num bers of non-practising nurses might be obtained for many years.

Expectations of an effective nurse re-entry course
The majority of non-practising nurses, as well as nurse administrators and nurse educators, would expect an effective nurse re-entry course to: • last five weeks; • not to cost more than RlOO; • provide an update of kowledge and sk ills as w e ll as b u ild in g th e re-entering candidate's confidence; • be offered by hospitals; and • be listed by the SANC (although only 50% of nurse administrators held this view).
A total of 47 topics, to be included in an effective nurse re-entry course were identified from the literature study.T hese to p ic s w ere ra n g e d as very im p o rta n t, fairly im p o rta n t or not important at all, by the non-practising nurse respondents, as well as by the participating nurse administrators and nurse educators.These findings are summarised in Table 3.
A spects considered m ost im portant included: • cardio-pulmoncuy resuscitation; • the nursing process; • com m unication and interpersonal skills; • legal aspects of nursing practice; • the scope of practice of the registered nurse; • nursing care plans; The nurse educators seemed to regard each of the above topics as being more im p o r ta n t th a n e ith e r th e n u rse adm inistrators or the non-practising nurse respondents.However, the only significant difference among the three groups concerned the importance of an explanation of the four-year diploma course for student nurses in association w ith u n iv e rsitie s.T his to p ic was portrayed as being most important by 100% n u rse e d u c a to rs, 50% nurse administrators and 40% non-practising nurse respondents.The reason for this ap p a re n t discrepancy could not be ascertained from this survey's fmdiogs.
Only one topic was regarded as not at all im p o rta n t by th e m a jo rity of the respondents (non-practising nurses, n u rse e d u c a to r s a n d n u rse administrators).This concerned basic nursing care such as feeding and bathing patients.
Prior to attending a nurse re-entry course, the majority of the non-practising nurse respondents (331 or 91,69%) would prefer to revise the theoretical aspects of nursing with the help of predetermined assignments and /or by completing a workbook.

CONCLUSIONS
Based on the foregoing summary and discussion of the research findings, the following conclusions could be drawn (relevant to the assumptions underlying and the objectives guiding this study).
Non-practising nurses registered with the SANG c o u ld c o n tr ib u te to w a rd s a lle v ia tin g th e p e rc e iv e d n u rsin g m anpow er sh ortage in the RSA, if recruited successfully.Only 19,9% of the n o n -p ra c tis in g n u rse re s p o n d e n ts indicated that they definitely did not contemplate re-entering the profession therefore as many as 80,1% of these non-practising nurses might be recruited back to nursing.
T he s u c c e s s fu l re c r u itm e n t of non-practising nurses should consider that the majority of the non-practising nurses registered wdth the SANG were married women younger than 39 years of age, w ith p re sc h o o l ch ild ren .The re s p o n d e n ts in d ic a te d "family commitments" as being the major reason for abandoning the nursing profession.
Two m ajor c o n d itio n s, (excluding effective niu-se re-entry courses) which m ight fa v o u ra b ly in flu e n c e n o n p ra c tis in g n u rse s to r e -e n te r the profession were identified empirically.These included the ability to work the hours of one's choice in the department of one's choice.It seemed possible that the ability to work the hours of choice might be important in enabling the nurse to fulfil both her domestic and professional obligations.
Unless nurses could be enabled to work when and where preferred, the perceived shortage of nursing manpower might persist.
An effective nurse re-entry programme, based on the professional educational needs of non-practising nurses, has potential to facilitate the professional re-en try of these nurses.Such an e ffe c tiv e p ro g ra m m e s h o u ld also incorporate the professional educational n e e d s as p e rc e iv e d by th e n u rse administrators and nurse educators.The needs perceived by the non-practising respondents differed in some respects from those revealed by the other two groups of respondents as indicated in Table 2.
The theoretical professional educational needs of non-practising nurses registered with the SANC might best be met by completing a workbook and/or study guide with predetermined assignments prior to the actual professional re-entry.A guided clinical update would seem to be essential in the real hospital situation after the workbook had been completed.However, subsequent to employment, inservice education would be essential for the candidate to acquire confidence.
N on-practising n u rse s' professional educational needs, which should be accom m odated in an effective nurse re-entry course, might involve more than a mere update of nursing knowledge and skills.A spects such as role strain management and assertiveness training w ould seem to be e s s e n tia l for a successful professional re-entry.

IMPLICATIONS
The conclusions of this research holds various im plications for the nursing profession in the RSA.
Non-practising nurses registered with the SANC could contribute towards reducing the perceived shortage of nursing manpower in the RSA.More intensified recruitment efforts should be directed towards this potential pool of r e g is te r e d n u rs e s .
S u c c e ssfu l re c ru itm e n t of th ese n u rses m ight encom pass several advantages over recruiting student nurses only.Although student recruitment will always remain essential for the growth, development and very ex iste n ce of th e n ursing pro fessio n , th e se e ffo rts could be augmented by recruiting non-practising nurses to re-enter the profession.The latter group might be able to render professional services within a few months (subsequent to completing a re-entry p ro g ra m m e , c lin ic a l u p d a te a n d inservice education), compared to the minimum of four years required to educate a student nurse.Non-practising nurses who re-enter the profession would be likely to render uninterrupted service for up to 25 years compared with an expected three years of newly registered nurses (Nursing News, August 1989: 1).Nurses who re-en ter the profession during their early forties would be unlikely to require m aternity leave, hospital creche facilities, special leave to tend to sick babies, and their husbands might be less likely to be relocated than those of younger, newly reg istered nurses.The more mature re-entered registered nurse, with accumulated life experiences should be able to offer em otional support, not only to her p a tie n ts , b u t a lso to h e r n u rsin g colleagues.
The single most important reason for abandoning the profession concerns family commitments.This might imply that most non-practising nurses would not have abandoned the profession if they had perceived themselves as capable of combining family and professional commitments.Nurses should seriously seek ways of enabling nurses to work part tim e during the hours which each individual nurse would prefer to workenabling her to fulfil both family and professional commitments.This might indeed be the case because as many as 41,1% of the n o n -p ractisin g nurse respondents to this survey w'orked in fields outside nursing, and 49% of these worked full time.Thus they perceived th em se lv e s as b e in g c a p a b le of combining family commitments with their present jobs, but not with nursing.Unless nurses could enable nurses to work hours accommodating their family commitments, nurses might continue to abandon their profession in pursuit of other jobs offering such possibilities.
As many as 90,15% of the respondents regarded the ability to work the hours of choice, and 88.46% the ability to work in the department preferred, as important aspects influencing their decision to re-enter the profession.The majority of participating nurse administrators would not allow the re-entering candidates to work the hours of their choice; and m erely 36,36% of th e n u rse a d m in is tra to rs w ould g ra n t th ese candidates the assurance of working in the p re fe rre d d e p a rtm e n t.T hese serendipitous research findings could have far reaching implications for the nursing profession and its manpower situation.Unless nurses would enable nurses to work when and where each individual nurse would prefer to do so, the perceived shortage of registered nurses in the RSA might continue to exist, if not increase.Conversely, if nurses could work when and where p r e f e r r e d , up to 90% o f th e non-practising nurses registered with the SANC might consider re-entering the profession.Even if the majority should re-enter the profession on a part time basis, an im m ediate and su stain ed improvement in the nursing manpower situation might be effected.If nurse administrators and plaimers are unable to implement duty schedules allowing individual nurses to work when and where preferred, whilst m eeting the insitution's needs for nursing services, serious consideration should be given towards the institution of nurses' bank schemes in the RSA.Such nurses bank schem es m ight offer a so lu tio n to providing the required nursing services to the insitutions concerned, whilst enabling the "bank nurses" to work when and where desired.
H owever, all no n -p ractisin g nurses re-entering the profession -via a nurses bank scheme or not -should, prior to such re-entry, complete a nurse re-entry programme based on their professional educational needs.The needs identified by this research, and incorporated into a workbook (available from the author) might provide a point of d e p artu re towards meeting the professional needs of these candidates.The workbook includes the following aspects:-General in tr o d u c tio n ; P r e p a r a tio n fo r professional re-entry: personal aspects; Revision of basic nursing knowledge; A list of procedures to be revised during the 2-week clinical update.This approach would, however, imply regular updating of the workbook, based on feedback from the candidates themselves, as well as from the nurse administrators and nurse educators concerned.The completion of a s ta n d a rd is e d w ork b o o k an d the inspection of the re-entry candidates' documents by the SANC, would imply an im provem ent in the nurse re-en try courses offered throughout the RSA.

RECOMMENDATIONS
Future research efforts should improve upon the limitations encountered in this survey, or explore relevant issues in greater depth.These should include: • A ttem pts to study non-practising nurses not registered with the SANC in order to comptu-e and contrast such knowledge with the data obtained by this survey.It would prove difficult to identify such a population because of a total lack of information (including addresses) of these nurses.
• Registered nurses who request the rem oval of their nam es from the SANC's registers could be studied in an attempt to obtain information from non-practising nurses registered with the SANC.
• This survey's data could be augmented by data obtained from interviews conducted with non-practising nurses registered with the SANC.Two issues could be pursued in greater depth by means of this approach; the conditions under which a professional re-entry w o u ld b e c o n s id e r e d and determination of specific reasons for pursuing jobs other than nursing.
• Interviews should be conducted with n u rs e s w ho h a d su c c e ssfu lly re-entered the profession after an absence of m ore than two years.R e-entry problem s could thus be identified retrospectively.
• Non-practising nurses belonging to all racial groups should be studied.
• C andidates who might utilise the workbook, based on the results of this survey, should be requested to furnish feedback concerning improvements to the workbook.
• More intensified research should be done to establish the perceptions of n u rse a d m in is tra to rs a n d nurse educators concerning the importance of including various topics in a nurse r e -e n tr y p ro g ra m m e .S im ilar research efforts could be extended to include registered nurses practising as ward sisters.
• The implications of obtaining and maintaining SANC listing of a nurse r e -e n tr y c o u rs e , s h o u ld be investigated.
• Urgent research should be conducted into the feasibility of enabling nurses to work when and where preferred, whilst meeting the institutions' needs for nursing services.This could involve investigating the feasibility of instituting nurses' bank schemes in the RSA.
"The shortage of professional nurses is the problem that needs the most urgent a tte n tio n from n u rse le a d e rs world-wide...it can determine the future of nursing in the next two decades" (Searle 1987: 288).This research has demonstrated that the RSA could reduce its shortage of registered nurses by en ab lin g n o n -p ra c tis in g n u rses to re-enter the profession.

Table 1 Number of professional nurses who requested removal of their names from the SANC's registers
(Ehlers 1990: 14 -obtainedfrom SANC s ta tis tic s C 2 /M 8 5 (H ); C 2M 87(H ); C2/M98(H) and C2.M90(H).STATEMENT OF THE PROBLEM Such statistics indicate t h a t: