Phoenix Nurses: A Path to Renewal

Sometimes being on the front lines involves caring for our colleagues. “Assisting nurses to nurture and heal themselves” is a defined role of holistic nursing practice (AHNA & ANA, 2013, p. 8). Nothing can be more catastrophic for a nurse’s career than the loss of her/his license to practice. In this dark hour, a nurse will often need extra support and someone to walk alongside her/him in the healing process. This article describes a holistic nurse in North Carolina who is helping nurses in her region find the courage to rise up from the ashes and start anew.

Nurses can sometimes make catastrophic mistakes when the personal stress in their lives intersects with an extremely stressful healthcare employment. Nurses who have lost their employment and licenses after making life-changing mistakes, and come back from these traumatic choices, are known as Phoenix Nurses. A phoenix is a mythical bird that burns itself to ashes and comes back with a new life. The rising of the phoenix after death symbolizes renewal, resurrection and overcoming catastrophic changes in our lives (Garry & El-Shamy, 2005).

Phoenix Nurses

Phoenix Nurses have made poor clinical or non-clinical decisions which result in disciplinary actions, probation, suspension or revocation of their nursing licenses. In North Carolina, when a nurse is reported to the North Carolina Board of Nursing (NCBON) for a violation of the Nurse Practice Act, she or he may be required to successfully complete a 24-contact hour Ethical/Legal Decision Making course in order to regain their licensure. In 2012, approximately 167 nurses had their licenses placed on probation, suspension or revoked (National Council of State Boards of Nursing, 2013). During the time of suspension, these nurses are often unemployed and are not allowed to work as Certified Nursing Assistants (Lewallen & McMullen, 2001). Even though these nurses have many years of nursing experience, they may not be knowledgeable in all aspects of nursing practice. Profiles of nurses disciplined in North Carolina demonstrate that the typical nurse has more than 10 years of nursing experience (Lewallen & McMullen, 2001). The ordeal of going through a Board of Nursing hearing can have significant and devastating personal and professional effects on a nurse. The “Phoenix Process” is a transformational process of the personal and professional self in which licensees “engage in and go through” in response to disciplinary action (Pugh, 2009, p. 2027).

The results of suspending a nursing license can have cataclysmic financial, emotional and professional impacts on a nurse’s life. As an Ethical/Legal Decision Making Instructor for the NCBON, I have worked with and coached 27 nurses in North Carolina who have experienced disciplinary action, job loss and/or licensure loss. Many of these nurses have feelings of failure, extreme loss, and loss of identity as a nurse in addition to related personal experiences of shame, fear, anger, sadness, financial devastation, social isolation, depression and embarrassment. Two of the nurses with whom I have worked, were living in a local campground in a camper, and one was living in a car. These mental and spiritual stressors also manifest with physical symptoms such as hypertension, weight loss and gain, headaches, back pain and insomnia.

Effect of Stress on Decision-Making

Many disciplined nurses state that stress played a major role in their violation of the Nurse Practice Act. My initial meeting with a disciplined nurse is always very intense. I ask to hear the nurses’ stories, which are always highly emotional and tearful. The stories share a common theme: the presence of very stressful events in their personal lives (see box below) which then intersect with stressful work environments, leading to catastrophic nursing decisions such as diversion of narcotics, medication errors, delegation errors, or failure to obtain a documented narcotic waste observation. These nurses carry their personal stressors to the work setting, and at critical decision-making junctures, they are unable to clearly and analytically make good, grounded decisions.

On the job, they face short staffing, high patient census and acuity issues, multiple patient care priorities, complex medication and treatment plans, and always ethical dilemmas. “An ethical dilemma is a situation that requires an individual to make a choice between two equally unfavorable alternatives” (Aiken, 2004). In nursing, ethical dilemmas are often connected with refusing treatment, informed consent, clinical competency, paternalism, allocation of health resources, truth telling, confidentiality, and experimentation (Thobaben, 1992). When faced with an ethical dilemma, competence in judgment can be compromised by stress. Significant reasons for job stress include “inadequate time to complete job responsibilities, inability to voice concerns, and too much to do with too few resources” (Seaward, 2013, p.41). As Kearney (2010) describes, “for many nurses, getting through the day can be a painful struggle. An artful blend of experience and intuition, knowledge, and expert skill can easily become a task-oriented relay race where there is little time spent with patients and seemingly less time to think about the actions being performed.” Overwhelmed and exhausted from stress, even the most skilled nurses can make critical mistakes.

A Course to Renewal

As part of the Ethical/Legal Decision Making course for disciplined nurses, each licensee is required to submit a paper on how they plan to strengthen their ethical/legal decision making and stress management skills. In each paper, we work together to identify stress management, coping and prevention strategies that can help them find their way to a path of healing. Included in the course are assignments defining coping skills and relaxation techniques for stress management (see box on p. 12). The word coping is defined as “the process of managing demands that are appraised as taxing or exceeding the individual’s resources” (Seaward, 2012). The purpose of coping strategies is to increase self-awareness of one’s issues and work toward a peaceful resolution. Successful implementation of coping strategies can minimize the negative impacts of stress as well as enhance decision-making abilities under stress.

Licensees are also required to submit a final paper entitled, “How I Violated the North Carolina Nurse Practice Act and my Plans for Strengthening My Legal/Ethical Decision Making Skills.” This final paper is used by the board and board staff during deliberations of the nurse’s relicensure (Lewallen & McMullen, 2001). Board staff examine the final paper carefully for evidence of self-care strategies to prevent further career- ending mistakes. This is consistent with the philosophical principles of holistic nursing to continually examine and improve one’s self: “The nurse’s self-reflection, self-assessment, self-care, healing, and personal development are necessary for service to others, growth/ change in the nurse’s own well- being, and understanding of the nurse’s own personal journey” (AHNA & ANA, 2013, p. 8).

I also apply coaching skills to my work with Phoenix Nurses. For example, I ask powerful questions such as “Where do you feel that in your body?” to connect mind-body-spirit and help the nurses explore their experience and feelings from a holistic perspective. Specifically, I use this when we are discussing issues related to re-entering the work force, which requires job interviews. Many of these nurses have great anxiety about telling future employers the story of how they came to lose their licenses, and then explaining the lessons they have learned from their experience. I ask powerful questions to help nurses identify where the pain and anxiety lives within their bodies so that they can then take small “under promising” steps to move through this discomfort and make a plan for facing the job search (Bark, 2011, p. 78).

Rising from the Ashes

Most nurses do return to practice after discipline and they perceive the Ethical/Legal Decision Making course experience as contributing positively to their growth as professionals (Lewallen & McMullen, 2001). Of the 27 nurses that I have instructed and coached in the last seven years, 23 returned to practice.

How do we help nursing staff members in multiple healthcare settings manage work stress and personal stress to prevent career-ending mistakes? At the hospital where I work, we address this issue in an Annual Skills Lab by teaching nursing staff to “Take a Pause” when they are feeling overwhelmed. We encourage our nurses to stop what they are doing momentarily, go to a quiet place (restroom, break room, empty patient room), and take several deep breaths in an effort to decrease their heart rates, respiratory rates, and blood pressures. We ask each nurse to talk to a colleague or a supervisor to help them process these tasks or decisions they are about to make and to discuss creative and positive strategies when faced with ethical dilemmas. If there are more severe, personal stressors, employees are referred to our Employee Assistance Network for additional resources and personal or financial counseling. Other coping strategies include encouraging staff to make use of essential oils, massage therapy, reflexology, healing music, and Healing Touch. We have also provided a four-hour course on “Letting Go of Stress: Strategies for Self- Care” and we conduct an annual Staff Healing Arts Fair for our employees which showcases other coping and relaxation stress management techniques. In multiple staff meetings, we review different aspects of nursing practice such as documentation, medication administration, and importance of documenting narcotic dosage and waste.

The stories of Phoenix Nurses convey a very important message: We must pay attention to both the job-related stress and personal stress that nursing staff experience every day, regardless of healthcare setting. We need to be more proactive in creating programs in healthcare environments where strategies for “self-awareness, self-care, self-healing, and self- responsibility” are incorporated into orientation, continuing education, and mandatory competencies for nursing staff (AHNA & ANA, 2013, p. 20) Poor choices at work when facing ethical or legal dilemmas can result in loss of career, financial security and professional identity. There are multiple stories of Phoenix Nurses who have lost everything and then find their way back to themselves. Their lives have been transformed by their mistakes, they have learned great lessons about their nursing practice, and when re-employed in the work setting, they serve as exemplary performers after walking through and emerging from the fire. There are great lessons to learn from Phoenix Nurses when we give these nurses a second chance.