When Ruth Terashima, RN, started going to job fairs a few months ago, she expected to be swamped with offers. She had about 12 years of nursing experience-first as a Navy nurse, then as a civilian in the emergency department and critical care units.

She'd left nursing for 13 years to raise a family, but kept her license active. She was recalled during Desert Storm and participated as a nurse in various volunteer activities. She worked in her children's schools and spent a lot of time with the public.

When she decided to return to nursing, she took a refresher course offered by the Hospital Consortium Education Network in the San Francisco Bay Area, where she lived. "I had been told now is a good time to come back and there's a shortage of nurses," she said. She was enthusiastic about the response from refresher course instructors, who told students they would be in great demand because of their experience.

But when Terashima tried to enter the workforce, she felt about as welcome as used scrubs.

At the first job fair she attended, she was handed a stack of applications and paperwork. After she filled out the forms, she was asked, "Where are you working now?" "I'm not," she replied. "I'm a re-entry nurse." "Thank you for coming," said the person she had handed the papers to. "I'll take these papers to personnel."

All around her, she said, new graduates were being called in for interviews. Signs were posted offering bonuses and special training programs. No one was offering anything for the re-entry nurse.

"I was doubting there really was a nursing shortage," Terashima said. "The recruiters gave the response that the glass was half empty instead of half full. I think they saw this big blank on my résumé."

It seems logical to think, as Terashima did, that when hospitals are scrambling for qualified staff, the returning nurse would be welcomed back with open arms. But because health care has changed so much in the last decade, say hospital administrators and recruiters, nurses who have been out for more than five years require extensive retraining.

Once they receive that training, most become invaluable assets, administrators and managers said. But some hospitals don't have the means to train re-entry nurses, or they lump them into new graduate programs. In some areas, refresher courses are almost impossible to find or have been discontinued because of lack of interest.

Some refresher courses include clinical training. Others do not.

Finally, although all administrators and recruiters interviewed agreed that each nurse should be judged individually, they added that some employers, especially in critical care, may prefer new graduates, who come from nursing schools with the latest information still fresh in their heads.

As a result, some re-entry nurses find they have to actively sell their own assets-life experience, maturity and finely honed nursing instincts-to land a job.

Carole Rogers, MPH, RN, attended the same refresher course with Terashima.

"The only reason I got hired was because I'm a little more assertive than a lot of people," said Rogers who, after exchanging many phone calls and voice mail with a number of hospitals, found a job as a staff nurse at San Leandro Hospital in Northern California. "Ninety-nine percent of nurses re-entering suffer from a lack of self-esteem and self-confidence," Rogers said. "You put any bureaucratic barriers in front of them and they just don't follow through."

Interest among nurses who want to return to the workforce varies from region to region but seems to be generally increasing, according to a spot survey of refresher courses around the country. Enrollment in the refresher course offered by the Hospital Consortium Education Network has remained steady at about 20 to 30 nurses in the two years the course has been offered, said Rebecca Petersen, MS, RN, director of the network, which is sponsored by 53 hospitals, mostly in Northern California.

But enrollment in a refresher course at Cleveland State University nearly doubled this fall, the largest number of students in several years, said Jane Mahowald, MA, RN, executive director of the Ohio League for Nursing and project director for Ohio Colleagues in Caring.

Austin Community College in Texas canceled its re-entry program last fall for lack of interest. But this fall's course is full with a waiting list. Other re-entry programs in Texas, Idaho, Missouri and Indiana all reported increased interest within the last six months.

According to studies and anecdotal evidence from refresher course instructors and students, most nurses leave nursing for family reasons, as Terashima did. Others have gone into health care administration, insurance or other related fields. Some have left for a variety of reasons, including dissatisfaction with the work environment.

Many now say they want to get back into acute care nursing partly because their children are grown or they need go back to work, but almost all feel a sense of duty in the face of the hospital nursing shortage.

"It's something that I love to do and I have the skills, plus there's a need," said Lois Ihrman, RN, of Mission Viejo, Calif.

Ihrman, who left hospital nursing in 1978 to raise a family and pursue other projects, said she has come full circle back to her early nursing days. "I feel I have more to offer," she said. "It's about being out there and helping people, like it was when I first started in nursing."

Back to school
Most hospital administrators and recruiters say that they are happy to hire re-entry nurses, but that they need proper training. Some states, including Idaho and Texas, require nurses to complete an approved refresher course if they've been away from nursing for more than a few years.

Health care has changed tremendously since many re-entry nurses were last at the bedside, said Jeanette Tuttle, RN, clinical educator at Community Hospitals Indianapolis, who teaches a refresher course there. Patients are sicker, turnover is higher, technology and medicines have changed and paperwork has reached overwhelming levels. "It's a much faster pace," Tuttle said. "I tell them they can't handle the same amount of patients that they used to be able to years ago."

Re-entry nurses themselves are usually the first to admit they can't jump back in where they started. When Rogers went to an open house at a local hospital, she thought telemetry was something used to track missiles. "That's how much out of nursing I was," she said.

But finding a refresher course can be difficult. Ihrman said she called all over Southern California, looking for something to bring her up to speed.

When Bonnie Carl, MBA, RN, started researching her return to nursing in the Bay Area two years ago, she could find nothing.

Hospitals in Boise, Idaho, only recently have started to offer what used to be a self-directed study through the Robert Wood Johnson Foundation Colleagues In Caring program and the Idaho Commission on Nursing and Nursing Education, said Julia Robinson, DPA, the project coordinator.

Instructors of several refresher courses in the Midwest and Texas said that based on the response they have received in recent months, they expect more hospitals and colleges will start to offer them.

But Virginia Mulligan, RN, nurse recruiter for Torrance Memorial Medical Center in Southern California, said that a refresher program at a local college had recently been discontinued and that her hospital was looking for ways to accommodate re-entry nurses.

Refresher courses may be offered through hospitals, community colleges, state universities and sometimes by private groups.

Courses vary from an intensive program at Memorial Hermann Healthcare System in the Houston area, which includes 10 days of clinicals and usually takes three to four months to complete, to the 12-day classroom course offered by Hospital Consortium Education Network.

Some hospitals offer to pay for the programs. Others offer them for a fee-usually between $300 and $1,000-with no guarantee of a job, but often will hire at least some of those who complete the program.

Barbara Maxwell, RN, a peritoneal dialysis coordinator for Community Hospitals Indianapolis, said she and most of her classmates had no problems finding work 10 years ago after completing a six-week refresher course offered by the hospital.

Maxwell, who had worked in cardiac care before leaving nursing for 19 years to raise her children, said the course gave her a chance to explore new aspects of nursing. Eventually, she decided to work in renal care.

Re-entry nurses who complete a refresher course should not expect to go straight into a hospital job, refresher course instructors said. They still need orientation and preceptoring.

The refresher course "brings them back to the new graduate level," said Jean Stow, MSN, RN, administrator of the nursing refresher course at Memorial Hermann. Her institution has hired about 60 percent to 70 percent of those who have completed the course, she said. "Refresher nurses are a gold mine," she said, "because they know all the basics. So if you can bring them up to snuff, they can play."

But even if all the nurses who left hospital nursing decided to return, it probably would not solve the nursing shortage in the long run.

According to the National Sample Survey of Registered Nurses, compiled by the U.S. Health Resources and Services Administration, 18.3 percent of RNs reported not working in nursing.

Although some instructors report seeing younger faces in their classes, many returning nurses are in their 40s and 50s and, like many of their working counterparts, will reach retirement age within the next 20 years.

If nurses out of the workforce begin returning in high numbers, "it would probably help, but it wouldn't take care of the full deficit," said Susan Brank, assistant executive officer at the California Board of Registered Nursing.

Experience counts
Those who train and hire re-entry nurses say returning nurses have special qualities that make them invaluable to the hospital.

Judy Heinemann, RN, nursing director for transitional and intensive care units at San Leandro Hospital, said the life experience that Rogers has brought to the unit already has made Heinemann's job easier.

Rogers, who worked in hospital administration, set up a Web page for the unit and offered to work extra time so she could perfect her IV skills. By helping her learn new skills, staff members gain a perspective on the difference between the nursing Rogers did years ago and what they do now, Heinemann said.

"If we invest in the re-entry nurse, we're probably going to have a more mature, a more settled nurse," she said.

Carl, who works in the emergency department at an East Bay hospital in Northern California, said she has become a sort of surrogate mother to new graduates who see her as someone both experienced and sympathetic to the difficulties of just starting. She thinks hospitals could better use re-entry nurses as preceptors and mentors, pairing them with new grads but recognizing that the two groups are not the same.

"They would both have something to teach the other," she said.

Some managers and instructors say they would not consider hiring or placing re-entry nurses into fast-paced areas like critical care.

Gloria Tobin, MA, MBA, RN, chief nursing officer at Memorial Hermann Hospital, helped establish the first refresher course at Memorial Hermann Southwest Hospital. She said that although no re-entry nurses have applied for jobs in the level one trauma center where she works, she doesn't think it would be something they could handle.

"I think our directors would be reluctant to hire them," she said. "When we have to make a choice, we go with the new grads."

Sometimes, hospitals that don't have programs in place may be unsure how to train a re-entry nurse, Mulligan said. "The last thing I want to do is hire a nurse who has been away from the bedside and not support them and they run away for good," she said. But as the nursing shortage continues, she said, hospitals will have to find ways to attract re-entry nurses rather than scare them away.

In the meantime, successful re-entry nurses are discovering that persistence pays off.

At her first job fair, Terashima insisted on talking to a manager. After an interview, the manager said he'd be interested in hiring Terashima for a night shift. When she explained she wanted to work days, he promised to forward her information to the day manager at his hospital.

Eventually, she received a call from the day manager. "I can't really imagine being gone that long and coming back," the manager said, "but your résumé looks good." Then the manager told Terashima she already had saved her a spot in an upcoming critical care course. After she brushed up on her skills, the manager thought Terashima would be a good match for a job in critical care.

"I got a really negative response from the recruiters," Terashima said, "but the managers know what they're looking for. The managers know they've got a more mature person."

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Re-entry game plan

Re-entry nurses, refresher course instructors, hospital administrators and recruiters offer these suggestions for nurses returning to the workforce:

• Check with the state board of nursing to find out the requirements for re-entry in your state and for a list of refresher courses offered by hospitals, community colleges and other organizations.
  
• If you can't obtain re-entry information from the state board, call around to community colleges and hospitals to see if they offer refresher programs. Your state or local nursing association also may have information. Finally, try the Web site of your regional Robert Wood Johnson Foundation Colleagues In Caring organization or your local nursing association. A number of these have information for re-entry nurses, or at least can tell you where to look.
  
• Take classes to show you are up-to-date and also to bolster your confidence in areas you feel unsure of, including computer skills, medications and physical assessment.
  
• Polish your job-hunting, résumé-writing and interviewing skills. Emphasize to employers how your life experience will help you to be a better nurse. For instance, if you worked in an insurance office, you can talk about your ability to read and understand complex medical records. If you worked in a library, talk about your research skills. If you owned a business or ran a household, talk about your organizational skills.
  
• Use your time in a refresher course to explore different areas of nursing and decide where you would like to go in your career.
  
• Be assertive. Find out who at the hospital is responsible for hiring for the department you want to work for. Then try to set up an interview with that person.
  
• Ask about hospital programs that can help bring you up to speed. No one expects you to start where you left off and you shouldn't expect it of yourself either.
  
• Network with other re-entry nurses who are looking for jobs.
  
• Be nice to yourself. One of the greatest challenges for re-entry nurses, say refresher course instructors, is overcoming a lack of self-confidence.

Refreshment menu

Based on her own experiences and those of her classmates in a nursing refresher program, Carole Rogers, MPH, RN, offers these suggestions for hospitals that want to attract re-entry nurses. Rogers has worked in health care administration and is a former CEO of a health management organization in San Diego. She is now a staff nurse at San Leandro Hospital in California.

• Have one person designated to handle RN refresher applicants. That person should be available during the day to take phone calls and speak in person to applicants. The person should be able to answer questions about available shifts, salary and details of the hospital's preceptorship or training program.
  
• Offer a training program for returning nurses. The program can be similar to new grad programs, but should recognize that returning nurses have had previous acute care experience and most just need instructions for new computerized equipment, such as PCA pumps, IV pumps, ventilators, online hospital computers, etc. Eight weeks full time seems to be the norm, but the program may need to be adjusted for part-time employees.
  
• Allow returning RNs a graduated level of responsibility. Include written goals and objectives in the preceptorship or training program. Some nurses will need more hand-holding than others. Hospitals need to be flexible; many returning nurses have families or other responsibilities and may be available only for one shift or part-time work.
  
• Have a different level of expectation for the nurse returning after more than 10 years out of the acute care setting. The home health department may be a great place to start.
  
• There seems to be some ancient belief that nursing peers are not friendly or supportive of each other. Show us wrong.
  

~Cathryn Domrose