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J Edu Health Promot 2020,  9:246

Exploring the process of turning back to professional nursing practice in Iran: A grounded theory

1 Department of Medical Surgical Nursing, Nursing Care Research Center, Iran University of Medical Science, Tehran, Iran
2 Department of Medical Surgical Nursing, School of Nursing and Midwifery, Tehran University of Medical Science, Tehran, Iran
3 Department of Medical Surgical Nursing, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran

Date of Submission18-Apr-2020
Date of Acceptance27-Apr-2020
Date of Web Publication28-Sep-2020

Correspondence Address:
Mr. Mokhtar Mahmoudi
School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jehp.jehp_379_20

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BACKGROUND: The current nursing shortage is complicated because of turnover intention among nurses. Most of the inactive nurses returned to professional nursing practice. Returned to professional nursing practice program was low attrition rates and a more cost-effective strategy that prepared inactive nurses returning to practice. This study aimed to explain the process of returned to professional nursing practice.
MATERIALS AND METHODS: This study was a grounded theory study, which lasted from about 2018 to 2020. Data were collected through semi-structured interviews and observations with participants after signing an informed consent form. The average interview duration was 45 min. The study participants were selected through purposeful sampling from both public and private hospitals affiliated to Iran University of Medical Sciences. Interviews were verbatim transcribed and analyzed using a constant comparative analysis method.
RESULTS: In this study, 16 participants were selected, including ten nurses, two educational supervisors, two head nurses, and two matrons. The “transformed competence” as the core concept and the four main concepts of “feeling alienated with the new environment,” “getting prepared for restart,” “gradual maturity in clinical practice,” and “components of organizational culture” were extracted from the data analysis process.
CONCLUSION: The process of returned to professional nursing practice in the context of the organizational culture of incentive learning leading to a high level of competence, and in the context of the organizational culture of inhibiting learning, is leading to deficiency incompetence.

Keywords: Nurse, nursing programs, personnel turnovers, return to work

How to cite this article:
Mohammadi N, Seyedfatemi N, Nasrabadi AN, Mahmoudi M. Exploring the process of turning back to professional nursing practice in Iran: A grounded theory. J Edu Health Promot 2020;9:246

How to cite this URL:
Mohammadi N, Seyedfatemi N, Nasrabadi AN, Mahmoudi M. Exploring the process of turning back to professional nursing practice in Iran: A grounded theory. J Edu Health Promot [serial online] 2020 [cited 2021 Jan 24];9:246. Available from: https://www.jehp.net/text.asp?2020/9/1/246/296394

  Introduction Top

Nurses are the largest professional group in the global health-care system, with a total of 7.3 million nurses and midwives working in the world.[1] It is estimated that the nursing shortage will reach its highest level within the period from 2015 to 2020. There will be a shortage of about 590,000 nurses around the world by 2020.[2] Leaving the nursing profession for reasons such as childcare was one of the essential factors in the shortage of staff in the nursing profession in countries around the world.[3] Former active nurses who stopped professional nursing practice (PNP) for a long period and left their profession are called inactive nurses. According to Flinkman's study, 17% of registered nurses in the United States were inactive nurses due to caring for their children or other reasons.[3] In a study conducted by Hesam et al. reported 21.4% of Iranian nurses to tend to turn over their PNP, due to a decreased quality of work-life.[4] There is a direct relationship between nursing shortage and increased mortality rate of inpatients, increased hospital-acquired infection, increased medication error, and increased hospital days of care.[5] Liang et al. showed that having a sufficient and standard number of nurses in the hospital and providing appropriate conditions for returning nurses can play an essential role in reducing the workload of other nurses. A sufficient number of nurses directly improved patient safety and increased quality of care. Given that, an adequate number of nurses can play an essential role in patient-centered care. Hospitals should play a vital role in reintegrating inactive nurses to professional practice.[5] Moreover, returners could use their skills, insight, and judgment gained from previous practice situations in similar situations and enhance the quality of health care.[6]

There is no doubt that most of the inactive nurses returned to practice had valuable clinical, communication, and leadership skills, which played an essential role in their future PNP.[7] Mokoka believed that as experienced professionals, inactive nurses returning to practice can play an important role in compensating nursing shortage at hospitals.[8] However, the findings of a study which was conducted by Yu et al. revealed that 76.7% of nurse managers are reluctant to recruit inactive nurses in their organization. These groups of managers argue that there is no guaranty that inactive nurses could get benefit from their previous experience to advance their effectiveness in the organization.[9] Therefore, there are concerns about the practice competence of nurses to returned to professional nursing practice, and nursing managers and decision-makers always discuss the challenges of returners to provided nursing services competently.[10]

Recruiting returners was an easy, affordable, and accessible way.[11] 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 demand due to advances in technology and new responsibilities.[12] As a consequence, returners mostly preferred to work in medical or surgical wards because advances less influence these wards in technology instead of working in critical care units, which are highly occupied by advanced technology.[12] The most common challenge of returners is concerned about changes in and complexity of patient care, which can be mainly due to a lack of proper training at the beginning period of RTP.[13] Inactive nurses faced many difficulties in returning to their professional activities. Although the needs of this group of nurses are unique, they should not be included as new graduates.[14]

If returned to professional nursing practice succeeds, they can serve as a professional model of patient care for novice nurses who only care about upgrading skills.[15] Kirpal stated that if we see the patient as the heart of professional nursing care, experience-based care can play a crucial role in improving patients' health. An inactive nurse with a high level of intellectual maturity gained from life experiences can focus exclusively on the needs of patients and their families.[15]

However, the strategy for returned to professional nursing practice is unclear in the significant number of countries, and there are no returned to professional nursing practice programs in those countries. Although numerous studies focused on nursing shortage and turnover intention among active Iranian nurses, there was not much information on the process of returned to professional nursing practice in Iran.[16],[17] It seemed that developing appropriate strategies for returned to professional nursing practice, which tailored according to the health-care system, is needed in Iran. This article was a grounded theory study that aimed to develop the returned to professional nursing practice process in Iran. The purpose of this article was to present the process of turning back to PNP.

  Materials and Methods Top

The present study was qualitative, carried out with the grounded theory approach, which lasted from about 2018–2020. The reasons for choosing this approach were that the phenomenon of returned to professional nursing practice in terms of the interactive nature of individuals and environments is consistent with what has been proposed in symbolic interaction theory.[18] Inclusion criteria included having a bachelor's degree or higher degree in nursing, being inactive in PNP for at least 2 years, returned to professional nursing practice for <1 year, and willingness to participate in the study.

Research participants were returners with a history of inactivity for at least 2 years and nurse managers in the categories of matrons, educational supervisors, and head nurse. Ethical considerations included coordinating and obtained permission to enter the research setting. So explained to the participant about the purpose of the research, interviewing method, and the right of them to study participants.also assured participants of the confidentiality their names and information at any time in the study. Data were collected simultaneously with constant comparative analysis after the first interview. Data were collected using open and semi-structured interviews and observations (attending the practice) with field notes and until reaching the saturation point by exchanging data with codes, categories, and themes formed, and the research process continued. The duration of interviews ranged from 30 to 60 min and lasted for 45 min on average. The researcher used formal observations and observational notes, field notes during interviews, informal and daily conversations between participants, and used memo when analyzing data. The data collection led to the analysis, the analysis led to the emergence of questions and concepts, and the questions led to more data collection and more understanding of the concepts. This process continued until the researcher reached saturation, to the point that the concepts were well defined and explained.

After selected the first participant, the emergence of the initial concepts, and the analysis of the resulting data, the subsequent participants selected through theoretical sampling to reach saturation, including do not emergence of new data, clarification of the relationship between concepts and sub concepts, and do not development of new categories. The evolution of the core concepts and the gradual emergence of the theory continued. Constant comparative analyses and comparison of events and differences and similarities of data provided the opportunity to collect data later. Repetition this process led to emergence categories, data diversification, an introduction to the concepts and sub-concepts, and design the theory. Interview sessions were held after organizing an appropriate time with participants. Participants were informed about the study purpose and signed an informed consent form before conducting the interview session. Interviews were held in a quiet and comfortable room, which was suitable for conducting interview sessions. A voice recorder machine audiotaped recorded interviews. The interviews often started with the question “please tell me a bit about the 1st day 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. Then, the observation started, indirect observation of returners regarding their clinical activity in practice, observation of their interaction with the patient, other nurses and nursing managers, how to complete documents, and their participation in educational and managerial activities were performed. In this study, two observation and field notes were performed.

To analyzed data, after each interview was listened several times by the principal researcher and then verbatim transcribed using Microsoft Word Software version 16 in a short time after the interview. A principal researcher was checked transcripts word by word while he was listening audiotapes to make sure that there is no mistake in the transcripts. A constant comparative analysis method was used to conduct the data analysis process. To conduct a data analysis process, first, open coding was done throughout transcripts. Then, the classification of codes into subcategories and categories was done based on the constant comparison of characteristics, dimensions, similarities, and differences of codes and categories [Figure 1].
Figure 1: Flowchart study

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The following steps were used to achieve credibility, dependability, transferability, and conformability.[19] To achieve credibility, the analysis process double-checked by two other members of the research team. Further, 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 if their prior knowledge has affected their analyses or not. 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.

  Results Top

The study participants were ten nurses, two nursing directors, two head nurses, and two educational supervisors from public and private hospitals. The age distribution ranged from 30 to 55 years. They had a history of leaving from 4 to 21 years with a history of RTP from 15 days to 2 years. All participants were men and women and working in a variety of hospital wards [Table 1].
Table 1: Demographic characteristics of research participants

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Transformed competence was the main categories of returned to professional nursing practice process, which included four main concepts, “the sense of alienation with the new environment,” “the getting prepared for restart,” “the gradual maturation of clinical activity,” and “the components of organizational culture.” There were numerous subcategories that, based on a paradigmatic pattern, these categories defined the structure of the process of turning back to PNP [Table 2].
Table 2: Development and extraction of key research concepts

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Transformed competence (core concept)

Transformed competence was the main categories of this study. Returners who start their works face changes in their abilities and interests. On the other hand, they face organizational changes, all of them leading to surprises. Hence, returners are forced to make maximum effort, and these efforts change their ability to care for the patient. Therefore, these nurses achieve another model of competence that leads to the promotion of their motivation and ability. In this regard, one of the educational supervisors stated:...a nurse who worked in the intensive care unit, and she left the nursing for six years and returned, she pass-fail in professional competence exam in the first days, the head nurse said that I don't want this nurse, she doesn't know more, and she is very weak in skills. Still, after six months to RTP, she can overcome her disabilities, and she was becoming the best nurse in this ward, responsible for the shift, and after being reinstated as a model nurse and has a very high motivation right now. Returner says I'm not ready to drop out of practice again unless I retire. She said I would not change my nursing activity with anything. Returners are more motivated than before. They feel better about their colleagues and react to new experiences (Education Supervisor 2).

Or one of the nurse's states:...after returned, I have a good feeling after six months of working in this ward, I was creative, and I can learn and use it. Like my colleagues, use abbreviations and learned the antibiotics and new drugs, I feel more motivated and empowered, so I am thrilled to be able to work well now. Especially now, I can use my education maybe I didn't have this skill at before. (Nurse 3).

The sense of alienation with the new environment

Research participants reported a return to PNP with a sense of alienation from the new environment. This sense is a set of invades of concern, turmoil in the returned to professional nursing practice, and clinical change. In this regard, one of the participants stated after returning to professional practice related to invading of concerns. (… Well, I was extremely stressed out, it was a new environment, new people, did they accept me among themselves? Or not? It was a kind of collaboration between my colleague and me. Another aspect of the patients was: Can I take care of my patient? Can I deal with doctors? Can I cover my shift without stress? Easy to finish? Especially my working conditions, when the moment I arrived, I had to learn from the first days to be in charge of the shift. I stay alone in the evenings.) (Nurse 3).

Another contributor to the turmoil in return to professional practice stated:

When I went on the first day I said no, I couldn't, and it was challenging for me. The hospital is not a company or office that you can commit to minor mistakes. I take responsibility for patients' lives, and I shouldn't do these jeopardies (Nurse 2).

Another contributor about clinical change stated:

...I didn't feel good in the first days, the enormous amount of equipment we saw, even the abbreviations I used, such as CPR, CBR, that forgotten entirely. I didn't even know the abbreviations. Also, the warnings were unclear for me, what the CBR means. Or, for example, I had also forgotten NPO. The Revival Trolley always reminds me of a particular horror, especially when I opened the first and second drawer and saw so many medications that I have forgotten) (Nurse 5).

Getting prepared for restart

Participants state their experiences of seeking learning resources, return to practice supports, getting used to practice, and building a new family life as nurse skills to getting prepared for restart.

One participant spoke about return to practice supports. (...”I 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 tried, you could quickly reach others.”) (Nurse 8).

Another participant expressed getting used to practicing. (“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 4).

Another participant mentioned the effort of building a new family life. (...”I did not 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 was not very difficult for me.”) (Nurse 6).

Another participant also mentioned seeking learning resources. (... 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 5).

The gradual maturation of clinical activity

This concept was highly abstract, which included concepts such as: promoting professional competence, achieving self-confidence over time, overcoming challenging situations, embracing communication, and taking advantage of resources in retraining and novitiate.

One of the nurses mentioned the promotion of professional competence (I used to try my trick to learn. When written on 1/3 2/3 of my serum card, I would go to the patient and look at the side of the patient to find out what the serum was. Later I would choose the right serum) (Nurse 1).

One participant said about achieving self-confidence over time (... The first month I RTP. Although it was a little time, I was able to expand my knowledge and enhance practical work. I am now satisfied and happy to do some work) (Nurse 10).

Another contributor stated about concepts of overcoming challenging situations. (... I was trying to behave and show that doing all of the responsibilities correctly. I did my work without any discussion and I could do my work right...) (Nurse 3).

Another of the nurses expressed the concept of embracing communication. (... My attitude towards each colleague was different, I was trying to test their personality and connect with a colleague with strong characters, and I was trying to communicate with and get more information from colleagues who were more kind and flexible.) (Nurse 1).

Finally, regarding the concept of taking advantage of resources in retraining and novitiate, one of the nurses said:... I had a notebook, and I wrote all the things in it. When I was working on a case method, I would ask my colleague what would happen to the patient from start to finish. From learning the HIS system to routine medications, or teaching the patient, or what treatment physician has, and what kind of diet? I wrote all this in my notebook. (Nurse 2).

The components of organizational culture

Participants stated that the phenomenon of returned to professional nursing practice occurs in contexts such as management arrangements in the organization, receiving organizational support, the organizational culture of incentive learning, and organizational culture of inhibiting learning.

Regarding the management arrangements in the organization, one participant stated:... During this time, I felt that my college was not helping me, but the educational supervisor has helped me so far with the holding classes and gave pamphlets (Nurse 5).

One of the nurses also said about the concept of receiving organizational support:... the head nurse was protecting me. She would not allow me to send me elsewhere. Sometimes my colleague was naughty, and they didn't want to work with me, but my head nurse responded very well and supported me… (Nurse 3).

Another nurse state about the organizational culture of incentive learning:... The atmosphere of the ward was like that I was not afraid of asking questions. I could easily ask the smallest question, they will leave me or help me. (Nurse 4).

Finally, another nurse described the concept of the organizational culture of inhibiting learning. (... as I was older than my colleagues, I had to endure the behavior of some colleagues at times. It may not be a good idea for them to ask an older and inexperienced nurse, and they will have to answer the question.) (Nurse 9).

Structure of Returned To Professional Nursing Practice

In describing the participants' experiences and reviewing all the diagrams and memos regularly, the researcher concluded that the core concept of this research had been transformed Competence. Returner had previous patient care experience and had different levels of Competence, they returned to professional nursing practice after many years of quitting. Returner who turned back to the profession with concern, for example, fear and anxiety, If the organizational culture of incentive learning over the organizational culture of inhibiting learning, they used getting prepared for the restart as a strategy. The gradual maturation of clinical activity acquires a different level of professional competence that leads to more motivation and experience. However, if the organizational culture of inhibiting learning over the organizational culture of incentive learning, it will lead to a decrease in motivation and competence and ultimately lead to a failure in professional competence [Figure 2].
Figure 2: Diagram of how the concept of transformed competence was formed

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  Discussion Top

This study showed that the organization's plans for the successful return of this group of nurses play an essential role in enhancing their professional performance. Similarly, Davidhizar's study (2006) showed that inactive nurses who returned to professional nursing practice have low self-esteem and high anxiety, concerned about new working conditions and changes in organizational demand due to advances in technology and new responsibilities. Therefore, the strategies that lead to their improvement in clinical and patient care should be designed by the hospital's organization and management.[13] A professional re-entry act was also approved in 1996 by the British Nursing and Midwifery Council (2005), which states that, given the community's need for the nurse, midwife, and health-care providers, nurses who resign after a long period of time can RTP after undergoing training and requalifying.[20]

In the present study, regarding the context of returned to professional nursing practice, the concept of the components of organizational culture was mentioned as the research context, emphasizing the underlying factors in many studies. In this regard, Yu et al. Have shown that management and organizational planning programs designed to prepare inactive nurses to return to professional nursing practice should be an essential motivation for this group of nurses. These programs must be capable of responding to changes in the clinical environment, increasing self-esteem, motivating, and adapting to the organization.[7] Although Kent believed that organization programs are not useful in understanding the concept of patient care, because these nurses understand the essence of patient care, and it doesn't change over time.[11] However, Yu et al. Also showed the high tendency of most nursing managers (89%) to recruit inactive nurses. Moreover, in their study, they stated most nursing managers the reason for their willingness to recruit these nurses was the lack of nurses. But over time, nursing managers with organizational platforms have used several methods to encourage inactive nurses to restart and continue their activities.[7] On the other hand, by conducting extensive and planned training courses, they were able to enhance their professional commitment, practical competence, and suitability with the organization and play an effective role in providing nursing staff.

In this study, the sense of alienation with the new environment was identified by concepts such as invades of concern, turmoil in returned to professional nursing practice, and clinical change. In this regard, Davidhizar and Bartlett have shown that nurses' returned to professional nursing practice is associated with a high level of anxiety and worry that can affect their process of reactivation.[13] In their study, Burns et al. also state the return of inactive nurses to professional practice, along with levels of self-esteem and fear of rejection by other nurses. In the present study, concepts such as fear, anxiety, and worry were included as main concepts in this category, which were similar to the Studies reviewed.[21]

The concept of getting prepared for the restart was the emergence of the phenomenon of returned to professional nursing practice, which included concepts such as seeking learning resources, Return to practice supports, Getting used to practice, Building a new family life. In this regard, Barriball et al. noted the support of nurses by colleagues in practice and the need for inactive nurses to have a friendly environment. They perceived support in most of the focus groups they had with these nurses.[22] Yu et al. consider the most critical factor in nursing to requitting clinical practice, and reducing motivation to continue is family tensions and nurse confidence in child care by family as an essential strategy to enhance nurses' motivation to continue nursing practice.[7] Burns et al., whereas, emphasized the importance of innovative approaches to effective nursing learning and the use of fast-paced educational methods through the provision of up-to-date knowledge, the use of new technology, and the development of educational opportunities in the least time. Furthermore, it was trying to employ a returner with higher work experience as a preceptor in this training program so that these nurses could be reprepared as soon as possible.[21]

The concept of gradual maturation of clinical activity consists of promoting professional competence, achieving self-confidence over time, overcoming challenging situations, embracing communication, and taking advantage of resources in retraining and novitiate. In this regard, the Health Education England stated that the return of inactive nurses to PNP, if carried out by the nursing program, can improve the professional competence of nurses and play an essential role in enhancing their motivation to returned to professional nursing practice.[23] Lansiquot et al. also state that emphasizing the support of managers for nurses by designing useful training programs, promoting professional competence, and achieving self-confidence are some of the essential benefits of supporting a nursing group in achieving self-efficacy.[24] Yu et al. (2016) also pointed out meeting individual needs and utilizing flexible resources for the returner to balance work and promote PNP. They also emphasized on enhancing their communication skills with other nurses and mentioned it as a unique feature of these nurses.[9]


One of the most important limitations of this study was access to eligible participants for the study. Because there was no enough information about inactive nurses, and very difficult to access and select them to participate in the study. Therefore, it is suggested that in future studies, a returner in the group of students who graduated from university and returned to work in the hospital be selected and studied.

This article is an innovative study. Because it is the only study that surveys the process of turned back to PNP and has selected this group of nurses as the target population, exploring the process of returners to professional practice in the hospital can help the hospital managers to enhance professional competence of this group of nurses.

  Conclusion Top

Nurses are the essential care loop at hospitals, playing a vital role in enhancing patient-oriented health. Hence, the organizations should provide the condition for returners to be able to practice the best and have the competence for reaching their previous level of ability. Given that very few studies of inactive nurses have been published in prestigious journals around the world. This study specifically explored the process of turning back to PNP and explaining the four fundamental concepts: the sense of alienation with the new environment, getting prepared for restart, gradual maturation of clinical activity and components of organizational culture, and the central concept of transformed competence was explained as the main concept of research. The process of returned to professional nursing practice in the context of the organizational culture of incentive learning leads to a high level of competence. In the context of the organizational culture of inhibiting learning, it will lead to defective incompetence.


This article is a PhD project and financially is supported by Iran University of Medical Sciences. Researchers would like to acknowledge the study participants for their participation and sharing their experience. The Ethics Committee approved this study of Iran University of Medical Sciences with code IR.IUMS.REC.1397.1260.

Financials support and sponsorship

This study was financially supported by Iran University of Medical Science.

Conflicts of interest

There are no conflicts of interest.

  References Top

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