Facilitators and Barriers to Reengaging Healthcare Workers Through Refresher Programs: Lessons Learned from a Systematic Literature Review

By Brooke Lombardi, Catherine Moore, Erin P. Fraher

Sep 18, 2025

Introduction

With rising concerns about the number of health care workers exiting the workforce and health workforce shortages emerging across the United States,¹^,² efforts to reengage individuals who have left the workforce are needed to facilitate re-entry and increase clinician supply to meet patient demand.³^,⁴^,⁵ Healthcare professionals exit the workforce for a variety of reasons (e.g., family or medical leave, career change and burnout)⁶^,⁷ and these breaks can result in a lapse of their licensure and deficiencies in the theoretical and clinical knowledge necessary to deliver high quality clinical care if they choose to return to the workforce.

While North Carolina (NC) specific data on the proportion of the healthcare workforce that has exited and subsequently reentered the workforce are not currently available, recent data on employer vacancy rates and workforce exit are available for nurses. The statewide Health Talent Alliance report found a 15% vacancy rate for RNs across North Carolina employers in 2024.⁸ A recent analysis from Sheps Health Workforce NC found an increase in the number of RNs who exited the workforce from 2016 (13.9% exit rate) to 2023 (15.1% exit rate).⁹ Taken together, these data on RNs suggest that re-engaging healthcare workers who have exited the workforce may be an effective strategy for reducing healthcare workforce vacancy rates, and this approach may have relevance for other healthcare professions facing similar workforce challenges. Specific programs are available for healthcare workers who wish to reenter the workforce (i.e., reenter after a period of extended leave, typically resulting in a lapse in license). Refresher programs serve as ways to facilitate workforce reentry into clinical practice. The process of reentering the workforce through a refresher program may include the following: 1) a clinical skills assessment; 2) updating knowledge and skills to meet current licensure and clinical requirements (may include preceptorship, didactics, case reviews, EHR training, or simulation-based skills training); 3) documentation of continuing education requirements; 4) the professional licensure board reinstatement process; 5) reentry into practice with a practice and supervision plan. The success of refresher programs is typically measured by program completion, the reinstatement of the clinician’s license, and reentry back into the workforce. This report aims to assist workforce stakeholders in NC to better understand how to reengage healthcare workers who have exited the workforce. We conducted a systematic literature review on strategies to reengage healthcare workers. In this report we summarize: 1) the identified barriers and facilitators to reengaging healthcare workers who have left the workforce; 2) key elements of existing reengagement programs; 3) high-level barriers and facilitators to healthcare workers reengaging in the workforce and in current refresher programs; 4) key elements of refresher programs to consider; and, 5) how this report’s findings could be applied to NC-specific policy interventions.

Methods

We searched CINAHL Plus with Full Text (EBSCOhost), Cochrane Database of Systematic Reviews, PubMed, and Scopus (Elsevier) databases using subject headings (e.g., “healthcare worker reentry” and “refresher programs” and key words “re-enter,” “return-to-work,” AND “physician,” “nurse”). The final sample of our systematic literature review included 39 articles, and Table 1 describes the article extraction process. Of the 39 articles, 26 examined reengagement practices internationally and 13 were based in the United States. Sixteen (16) articles described reengagement practices (Table 3) while the other 23 studies described the facilitators and barriers to reengaging various professions of the health workforce. Overarching facilitators and barriers to workforce reengagement at various levels (clinician-level, organizational-level and systemic/policy-level) identified in this review are outlined in Table 2.

Table 1. Article extraction process

Article extraction category	Article extraction process
Study type	Quantitative, qualitative, mixed-methods, or case studies that either quantitatively measure the outcome of reengaging healthcare workers who are reentering the workforce or describe a reengagement program or strategy employed
Population	Previously licensed physicians, dentists and dental hygienists, nurses, pharmacists, allied health professionals, and mental health professionals (e.g., social workers, licensed practical counselors, etc.) who exited the workforce (i.e., due to an inactive, expired, or revoked license, or those returning from an extended parental or health-related leave).
Date range	Published between 2014 to 2024
Databases systematically searched	PubMed, CINHAL Plus with Full Text (EBSCOhost), and Scopus
Key search terms	“inactive” OR “refresher” OR “return” OR “re-enter” AND “return to work” OR “return to practice” OR “reentered work” OR “reintegrate”
Article assessment	2,194 articles identified in search and included in title and abstract screen -> 105 articles included in full-text review -> 39 articles included in final literature review

Table 2. Facilitators and barriers to healthcare workers reentering clinical practice

Level of Reengagement	Facilitators to Reengagement	Barriers to Reengagement
Clinicial-Level	Personal motivation and sense of purpose Moral obligation to contribute Positive past experiences	Lack of respect from peers Lack of confidence Feelings of being perceived as less competent Ongoing health issues Family concerns (childcare costs, scheduling) Difficulties gaining employment Inability to meet physical demands of job
Organizational	Positive and supportive leadership Understanding of family needs (e.g., gradual reentry after parental leave, flexible scheduling, accommodations for breastfeeding) Continuing education and training Mentorship and preceptorship programs Career pathways for advancement Accommodation for physical needs (e.g., lactation breaks and spaces, sit-to-stand workstations, gradual return to work schedule or modified hours)	Poor leadership with lack of support and mentorship Poor communication between the department/administration about reentry and job-related expectations Limited access to training and continuing education Skills required by the employer to return to practice do not meet the required standards for clinical care (e.g., evidence-based decision making at the bedside, inefficient or incorrect charting, delayed decision making in high-pressure situations) High workload and understaffing
Systemic and Policy-Level	Support of the licensing body (e.g., clear pathway to relicense after program completion, Nurse Licensure Compacts) National or regional return-to-practice programs	Licensure and regulatory challenges Insufficient financial support for return-to-practice programs

Table 3 summarizes the interventions for reengagement (N=16); these interventions covered reentry into both clinical practice in hospital settings and outpatient/community-based settings. Of the 16 articles, 12 articles outlined refresher programs for different clinician types including certified nurse midwives (n=1), registered nurses (n=3), physicians (n=5), and a variety of clinicians (n=3); one article outlined a physician reentry preceptorship program; two articles outlined programs specific to reengagement following parental leave; and one article outlined established policies in the workplace for clinician reentry. Overall, the refresher programs included both didactic and clinical skills components, with the majority of time spent on clinical skills. Some programs included simulation labs, both during the course or at the completion of the course to assess overall skill development. In the case of participants who needed additional clinical skills training before reentering practice, one program offered simulation labs for further training. Some courses offered a general curriculum for all enrolled participants, while other programs tailored the clinical skills component of the program to the learning needs of participants.

Table 3. Reengagement Article References by Type of Reengagement Intervention (N=16)

Type of Reengagement Practice	Number of Studies	Key Elements	References
Refresher programs by clinician type
Midwifery	1	This refresher program is split into 25% of the course covering theory and 75% skills and concepts required for clinical practice. Overall, the program covered clinical skills; communication and patient interaction; decision-making and critical thinking skills; team collaboration; updating clinical knowledge.	Cowman et al., 2020¹⁰
Nursing	3	These nursing refresher programs included the following components: 1) didactic (i.e., in the classroom or in a lab), clinical practice and direct patient care, and simulation experiences to evaluate skills; 2) comprehensive nursing preparation encompassing scope of practice, professional standards, and patient care delivery; 3) Emphasis is placed on medical-surgical nursing concepts, pharmacology, medication administration, and intravenous therapy; 4) core nursing competencies are reinforced through clinical preparation, skills review, and effective communication.	Alexander, 2021⁴; Borgfeld, 2014¹¹; Garside et al., 2021¹²
Physician	5	One program integrated simulation-based clinical training focused on enhancing medical documentation, critical appraisal, and patient advocacy. Another program related to critical care, resuscitation, and airway skills. Other programs include review of clinical knowledge and practical assessments in both inpatient and outpatient settings through rounds, case logs, and chart reviews, supporting the development of real-world skills and professional competency.	Allen et al., 2024¹³; Goldberg et al., 2015¹⁴; Green et al., 2019¹⁵; Rayburn et al., 2016³; Varjavand et al., 2015¹⁶
Variety of clinicians	3	Comprehensive programs combining technical and non-technical skill development through five standardized clinical scenarios, including delirium management, sepsis assessment, complex discharge planning, end-of-life care, and acute management. Emphasis is placed on professional and medication safety, orientation to clinical environments, and both specialized and supervised clinical practice. The program also supports team building, effective communication, self-care, and action planning for a successful return to work.	MacCuish et al., 2021¹⁷; McMurtrie et al., 2014¹⁸; Saunders et al., 2020¹⁹
Physician reentry preceptorship program	1	A tailored reentry preceptorship program designed to meet physician training needs through an individualized mentorship model. It features a comprehensive, self-paced didactic curriculum and structured clinical preceptorship, customized based on self-assessment, future practice goals, input from the referring body, and pre-assessment exams. Physician progress is formally reassessed every three months to guide ongoing development.	Varjavand et al., 2019¹⁵
Departmental guidelines and policy for reentry	2	One study included guidelines for retired nurses returning to practice and these included: 1) flexible work schedules; 2) a minimum of 4 hours of work per pay period; 3) role development based on prior work with minimal physical constraint; and, 4) Pay is based on years/hours of prior experience and pay is per-diem with no other benefits. Two other studies included guidelines and policy recommendations for physicians and residents preparing for and returning from parental leave. This included pre-planning with the supervisor/chief resident, antepartum and postpartum shift scheduling, specified lactation space and storage, and flexibility in return/training timeline.	Allen et al., 2024¹³; Boerger et al., 2019²⁰; Gordon et al., 2019²¹

Of the 12 articles that outlined refresher programs, reoccurring facilitators and barriers to program administration were identified and are summarized in Table 4.

Table 4. Refresher program administration facilitators and barriers

Program Facilitators	Program Barriers
High-Fidelity Simulation: Provides a realistic and safe environment to assess and improve skills without risking patient safety.	Heterogeneity of Programs: Lack of standardized curricula across different refresher programs.
Tailored Curriculum: Flexibility to address individual needs and knowledge gaps.	Patient Safety Concerns: Challenges in assessing competency through real patient interactions.
Comprehensive Assessment: Detailed evaluations to identify specific deficiencies and areas for improvement.	Resource Intensive: High costs and logistical challenges associated with high-fidelity simulation.
Supportive Environment: Orientation and familiarization with the refresher program, clinical assessment, and any simulation activity to reduce anxiety and improve performance.	Variable Skill Levels: Differences in the needs and abilities of clinicians based on their reasons for leaving practice and duration of absence.

The review of these 12 articles yielded several key considerations for the planning, implementation, and evaluation of a refresher program (Figure 1). Important factors include the overall cost of the program to both the administering organization and the participant, as well as the duration and any mitigating circumstances that may affect its length. The findings also highlight the importance of considering wrap-around support to facilitate successful reintegration into the workforce. Finally, robust evaluation strategies should be considered, including metrics such as program completion rates, employment outcomes, changes in licensure status, and long-term retention in the healthcare workforce following reentry.

Flow diagram showing the 4 key considerations of refresher programs, cost, time, support, and results, and their corresponding descriptions.

This report provides an overview of the barriers and facilitators to reengaging healthcare workers into the workforce through refresher programs. Key elements of reengagement programs, and the barriers, facilitators, and factors affecting reengagement program success. North Carolina faces growing health workforce shortages, exacerbated by high vacancy rates and burnout.⁸^,⁹ This presents an important opportunity for NC Workforce Stakeholders (e.g., employers, educators, licensure bodies and other partners) to collaborate to develop mechanisms to reengage healthcare workers who have left the workforce. NC AHEC, for example, already plays a key role in supporting the infrastructure and facilitating the partnerships needed to support reentry education, clinical training, and career pathways for registered nurses. Table 5 outlines potential policy interventions to support the recruitment and reengagement of former healthcare workers back into the workforce.

Table 5. Potential policy interventions to recruit and reengage healthcare workers back into the workforce

Intervention 1	Funded Reentry Pathways—Subsidies could be offered for clinicians, employers, and/or educators to assist in covering the cost of refresher courses (direct and indirect costs), clinical placements, and re-licensure fees.
Intervention 2	Accessible Hybrid Learning—Expand hybrid online/in-person reentry courses, with the opportunity to target rural and underserved areas.
Intervention 3	Supportive Incentivization—Incentivize supportive resources such as childcare, transportation stipends, and temporary lodging during clinical rotations to remove non-academic barriers.
Intervention 4	Public Awareness—Collaborating with workforce stakeholders to increase awareness among inactive healthcare workers about reentry opportunities.
Intervention 5	Streamlined Licensing Opportunities May Exist to Simplify Relicensure Pathways—Assess opportunities to simplify re-licensure pathways for inactive healthcare workers. This could include recently retired or inactive clinicians with minimal time away whose reentry and refresher needs are more regulatory than clinical, veterans returning to civilian practice, regulatory waivers during public health emergencies or urgent workforce shortages.
Intervention 6	Partnership with Employers—Expand collaboration with hospitals, outpatient clinics, community health centers, and long-term care facilities and other employers to provide job interviews and job placement opportunities for those completing reentry programs, offer sign-on bonuses, and return-to-workforce stipends.
Intervention 7	Mentorship and Clinical Coaching—Establish a peer support program that pairs reentering healthcare workers with experienced mentors to guide clinical reintegration and promote retention. This would allow a more personalized process for all clinicians (e.g., RNs, LPNs, and physicians) who are reentering the workforce to target specific specialties and settings.
Intervention 8	Measure Outcomes—In addition to measuring refresher program completion rates and reengagement in the workforce, ensure the retention rates of clinicians who reenter the workforce are measured at multiple timepoints (i.e., yearly).

References

Arredondo K, Hughes AM, Lester HF, Pham TND, Petersen LA, Woodard L, et al. Churning the tides of care: when nurse turnover makes waves in patient access to primary care. BMC Nurs [Internet]. 2024 Oct 10 [cited 2025 Jul 18];23(1). Available from: https://bmcnurs.biomedcentral.com/articles/10.1186/s12912-024-02389-8 ↩︎
Adashi EY, O’Mahony DP, Gruppuso PA. The National Physician Shortage: Disconcerting HRSA and AAMC Reports. J Gen Intern Med [Internet]. 2025 May 6 [cited 2025 Jul 18]; Available from: https://link.springer.com/10.1007/s11606-025-09575-7 ↩︎
Rayburn WF, Quintana A, Cosgrove E, La Farge G. Facilitating Physician relicensure and reentry into clinical practice: Collaboration between a state medical board and a medical school. J Med Regul. 2016;102(3):18–23. ↩︎
Alexander KE. Relaunching Nurses to the Forefront of the COVID-19 Pandemic: Heeding the Call Through an RN Refresher Program. J Contin Educ Nurs. 2021;52(2):67–71. ↩︎
Varjavand N, Johnson C, Greco MJ, Duke P. Physician Reentry: Results of a Post-Program Survey. J Med Regul. 2019;105(3):14–9. ↩︎
Muir KJ, Porat-Dahlerbruch J, Nikpour J, Leep-Lazar K, Lasater KB. Top Factors in Nurses Ending Health Care Employment Between 2018 and 2021. JAMA Netw Open. 2024 Apr 9;7(4):e244121. ↩︎
Mohr DC, Elnahal S, Marks ML, Derickson R, Osatuke K. Burnout Trends Among US Health Care Workers. JAMA Netw Open. 2025 Apr 21;8(4):e255954. ↩︎
NC Center on the Workforce for Health [Internet]. [cited 2025 Jul 18]. Health Talent Alliance. Available from: https://workforceforhealth.org/hta ↩︎
NC Health Workforce - How has RN Retention in North Carolina Changed over Time? [Internet]. [cited 2025 Jul 18]. Available from: https://nchealthworkforce.unc.edu/blog/rn-retention/ ↩︎

Funding & Acknowledgements

The HPDS is maintained by the Program on Health Workforce Research and Policy at the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill, in collaboration with the North Carolina Area Health Education Centers Program (AHEC), and the state’s independent health professional licensing boards. Ongoing financial support is provided by the NC AHEC Program Office. Although the NC HPDS maintains the data system, the data remain the property of their respective licensing board. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by NC AHEC. To learn more about NC AHEC please visit: https://www.ncahec.net.

Facilitators and Barriers to Reengaging Healthcare Workers Through Refresher Programs: Lessons Learned from a Systematic Literature Review

Introduction

Methods

References

Recent Posts