Munro, Marilyn
Marilyn Munro 8638561
PUBLISHED SEPT 2001
DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO
BETWEEN
COLLEGE OF NURSES OF ONTARIO Counsel for College of Nurses of Ontario
- and -
Marilyn Munro #86-3856-1
REASONS FOR DECISION
Counsel for Marilyn Munro, RN
Heard:
October 14-16, 1997
February 2-6, 1998
June 1-5, 1998
September 21-23, 1998
November 3, 1999
A panel of the Discipline Committee convened to hear allegations against Marilyn Munro. The allegations set out in the Notice of Hearing are as follows:
You have committed an act of professional misconduct as provided by subsection 85(3)(c) of the Health Disciplines Act, R.S.O. 1990, c. H.4, as amended, and subsection 21(n) of Ontario Regulation 459,
R.R.O. 1990 in that during August, 1993, and subsequently, while acting in the capacity of owner and director of Elite Specialty Nursing Services Inc., the nursing agency providing nursing services in Sudbury to the Client, you engaged in conduct or an act relevant to the performance of nursing services that, having regard to all the circumstances, would reasonably be regarded by members as disgraceful, dishonourable or unprofessional and that you fostered and maintained a close personal relationship with the Client's mother.
You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c.32, as amended, and defined in subsection 1(37) of Ontario Regulation 799/93, in that during 1994 and 1995, while acting in the capacity of owner and director of Elite Specialty Nursing Services Inc., the nursing agency providing nursing services in Sudbury to the Client, you engaged in conduct or performed an act, relevant to the practice of nursing, that, having regard to all the circumstances, would reasonably be regarded by members as disgraceful, dishonourable or unprofessional in that you fostered and maintained a close personal relationship with the Client's mother.
PLEA
Ms. Munro denied both Allegation #1 and Allegation #2.
BACKGROUND
A child with severe brain damage resulting from an accident was totally dependent for his daily care. Following hospitalization, the child was able to go home for weekend visits through Home Care and insurance company coverage, with 24-hour R.N. nursing care. Elite Speciality Nursing Services Inc. was the care provider. At all material times, Ms. Munro was the owner and chief executive officer of Elite Speciality Nursing Services Inc. (also referred to below as “Elite”). At the beginning the child was home full-time 7 days per week, 24 hours per day with Elite Specialty Nursing Services Inc. continuing as the care provider.
A year later, the child was readmitted to hospital due to a decrease in funding by the insurance company. However, several months after that the child was allowed to be taken home on weekends with Elite Specialty Nursing Services Inc. again as the care provider. Funding for this was provided by the trust fund monies. Eight months later the child was readmitted to hospital due to his deteriorating health condition. Elite Specialty Nursing Services Inc. was terminated four months later by the child’s mother. Throughout the relevant period, Ms. Munro was involved with the family and acted as an advocate for the child. Ms. Munro continued in this role even during the child’s numerous readmissions to the hospital.
Witness #1
The first witness called by the College of Nurses of Ontario (“CNO” or “the College”) was the mother of the child. She identified herself as married and mother of the client and another child. At the time of the incident, she was employed as a (Profession). Following the accident, she was on an unpaid leave of absence, returning to work just prior to the hearing. After describing the accident and resulting hospitalizations, she identified her son as brain-damaged, with constant risk of aspiration, having an indwelling gastrostomy tube and uncontrollable seizures.(The witness commented on her emotional vulnerability).
The witness described her attempts to secure a nursing agency for her son’s care at home. After several unsuccessful contacts with other agencies, she was relieved that she was able to secure the last local nursing agency, namely, Elite Specialty Nursing Services Inc.
The witness described the initial meeting with Ms. Munro in her son’s hospital room, which included an embrace of the witness, a kiss to the child and a promise to take care of her son. The witness confirmed that Ms. Munro agreed to accept the child’s care through Home Care and the insurance company Blue Cross, even though the insurance company coverage was lower than Ms. Munro’s usual agency rate.
The witness further stated Ms. Munro performed the initial and all ongoing assessments, and forwarded reports to the insurance company.
The witness testified that the insurance company wanted the nursing agency to teach the family how to perform the deep suctioning procedure necessary for the child’s survival. She described how neither she nor her husband were emotionally able to perform the deep suctioning procedure.
The witness then described how Ms. Munro became more influential. Ms. Munro fought for the continuation of nursing coverage through the insurance company. Ms. Munro initially suggested and later insisted on a change in physician to one who was a personal friend of Ms. Munro’s and who would sign anything and make housecalls. Ms. Munro pressured the witness to bring in an associate of hers as client advocate for her son, despite the witness’s dislike for and lack of trust in him. The witness stated she trusted Ms. Munro implicitly and did not have the strength to resist.
Upon being questioned on Ms. Munro’s relationship with her, the witness described Ms. Munro as friendly, vocal, affectionate, demonstrative (i.e., hugging and kissing) and complimentary. Ms. Munro visited the family home 3 to 4 times a week bringing religious books and related items, as well as having frequent telephone contact. During the last year, contact was practically daily with the witness frequently having dinners out with Ms. Munro and the client advocate. The dinners were usually paid for by Ms. Munro.
The witness testified how stressful and difficult everything was at the time and how her relationship with (Family Member #1) was strained. She stated that Ms. Munro offered to take (family Member #1) to live at her home for as long as needed.
During the child’s hospitalization in (DATE) 1994, the witness testified that she stayed with her son from 7 p.m. to 11 a.m. and then went to Ms. Munro’s home to sleep until 3:00 p.m. Ms. Munro, the client advocate, and the witness would then go out for dinner.
The witness described Ms. Munro’s involvement in a trip to the (institute) in Philadelphia. Although the Institute’s policy restricted attendance to immediate family only, Ms. Munro persisted in attending and did so posing as her sister-in-law. The witness stated that this ruse by Ms. Munro caused her great stress.
There was evidence pertaining to another trip, this one to Los Angeles. The witness hoped that she could raise money for the child’s care at home. Ms. Munro offered to pay for the witness’ flight ticket and did so without seeking repayment. In cross-examination, the witness denied asking to borrow the money from Ms. Munro.
The witness explained that a legal counsel was introduced by Ms. Munro to the child’s family. He was to represent the child in an arbitration proceeding between the insurance company and the family. The retainer fee of $500.00 was paid by Ms. Munro, who made no request for repayment from the witness.
The witness described (marital dispute) which occurred in the child’s hospital room in the summer of 1995. (Description of dispute) . Subsequently, the witness moved into Ms. Munro’s home for one week until reconciliation occurred.
In (Date) 1995, the child was in the hospital with pneumonia. The witness was afraid the child was in danger of dying and believed the child would receive better care at home. Upon phoning Ms. Munro for help, Ms. Munro made a comment to the witness regarding the insignificance of the location of the child’s possible death. The witness stated she felt personally devastated by this and felt she had lost her best friend. The witness asked Ms. Munro to request her nurses to volunteer their services but Ms.
Munro refused to do so. The witness then contacted the nurses herself to request them to volunteer their services.
Throughout the witness’s testimony-in-chief and in cross-examination, she made numerous comments regarding her close relationship with Ms. Munro. The witness described Ms. Munro as being always there for her, a pillar of strength, kind, her closest friend and confidante, and champion for her child. The witness testified that, metaphorically, she placed Ms. Munro up on a pedestal, in her words, “she wasn’t a nurse to me, she was a friend or so I thought.” The witness indicated that Ms. Munro had presented herself as a friend for two and a half years and that this relationship was mutual. In cross- examination, she stated that Ms. Munro was caring, understanding, kind and would push for your rights. She also agreed that Ms. Munro maintained professionalism in the care of the child.
Witness #2
The second witness called by the College was the husband of the first witness and father of the brain- injured child. He is employed full-time in Sudbury.
The witness described the initial meeting with Ms. Munro in his child’s hospital room. He confirmed his wife had telephoned Elite Specialty Nursing Service Inc. He described Ms. Munro as flamboyant, hugging his wife, kissing the child and telling them she would take care of everything. He stated he was taken aback by Ms. Munro’s behaviour as it implied familiarity. The witness testified that Ms. Munro came to the home each weekend and later more frequently. When questioned about social activities, the witness testified that these occurred at least four times a month, involving restaurant meals and going to a bar for drinks. He indicated that there was no discussion of his child’s nursing care on these occasions. He verified that he was not often present but when he was, he paid his own way.
The witness explained that there were two trips to (the institute) in Philadelphia. The first trip in the Spring of 1994 was attended by his wife, Ms. Munro and himself. The second trip in the Fall of 1994 did not involve Ms. Munro. The witness stated that it was Ms. Munro’s idea to go as his sister and that she subsequently went as his sister. His wife was very paranoid about this arrangement. The witness was not sure whose idea it was for Ms. Munro to go. He stated Ms. Munro wanted to go to check things out.
When questioned about the (marital dispute) of July 1995 he explained that he (was) concern(ed) that his wife was not home for their other child; “she was always at (Ms. Munro’s) home to get away from it all.” (Description of dispute) He confirmed his wife stayed at Ms. Munro’s home for one week.
(Description of wife’s emotional vulnerability)
The witness testified he had no knowledge of any payment by Elite Specialty Nursing Services Inc. to a lawyer. The witness testified that he felt it was useless for his wife to go to Los Angeles. He did not want her to go, nor did he want her to borrow money for the airfare. But she was desperate to get money for their child’s care. He further testified that he did not know if the money was repaid to Elite Specialty Nursing Service Inc. as he wanted nothing to do with it.
The witness stated he was upset about leaving their existing family physician to transfer to the physician suggested by Ms. Munro. The transfer occurred because of Ms. Munro’s suggestion. The witness described his feelings about the child’s accident and resulting family situation. He was relieved when Elite Specialty Nursing Services Inc. took over his child’s care at the family home. He blamed his wife for his child’s accident. He was bitter and expressed grief, “My child is dead to me.” He further explained the family was (description). The witness described his wife as emotional, honest, and desperate for money for their child’s care.
The witness described Ms. Munro as being flamboyant, demonstrative of emotions, a fighter who fought for their interest and agreed if Ms. Munro had not been there to support his wife, she (description). The witness described feeling left out, as he had no input. His wife relied on Ms. Munro, the client advocate and the family physician.
Witness #3 Expert Witness
The third witness called by the College was presented as an expert witness.Her curriculum vitae identified her as a Registered Nurse employed full-time by a nursing service as Corporate Quality Management Director.
The panel accepted her as an expert witness. It was her evidence that the nurse-client relationship is to be therapeutic to enable the plan of care to be accomplished for the well-being of the client. This relationship can involve the family which in a “Home Care” setting includes the child and his or her decision-makers i.e. father, mother, grand-parents and siblings. In the home environment, the boundaries of the nurse-client relationship must be more securely demarcated by the nurse. It is the responsibility of the nurse to establish and maintain boundaries.
When asked about the issue of the balance of power in the nurse-client relationship, the expert witness pointed out that the nurse has the knowledge and the client is vulnerable. A personal relationship can compromise the objectivity of the nurse. The client may perceive information given by the nurse as a friend, to be professional in nature. If the client perceives a personal as well as professional relationship, expectations would be heightened and the client would not be able to tell if decisions were being made by the friend or nurse.
The expert witness confirmed that the issue of “boundaries” is covered in nurses’ training and that blurring of the boundaries would constitute professional misconduct.
It was the expert witness' evidence that if the nurse recognizes that a close personal relationship is perceived by the client, the nurse should withdraw from the nurse-client relationship once an appropriate replacement has been established.
In a situation where the client’s vulnerability was increased, the expert witness opined that the nurse should have increased concern about relationships due to the power imbalance.
In her evidence, she confirmed that it was not acceptable for a professional to say that a close personal relationship would be therapeutic for the client, as the personal relationship blurs the objectivity of the nurse.
The expert witness was asked to comment about a number of hypothetical situations. In commenting on the second hypothetical situation put to her, which involved facts similar to those in this case, the expert witness testified that a nurse-client relationship existed between the nurse and the parents of the handicapped son. She confirmed that the nurse has the responsibility to maintain a therapeutic relationship with all members of the family unit and that this relationship continues while the child is cared for in hospital.
In commenting on the hypothetical situation, the expert witness indicated that the “emotionally vulnerable state” would increase her concern that the boundaries should be clearly outlined. She expressed concern that family would “latch onto the nurse.”
The expert witness testified that the facts in the hypothetical situation reflected the presence of a close personal relationship. The activities listed would be perceived by the child’s mother as indicative of the development of a close personal relationship.
The regular occurrence of meals attended by the member “raises a flag” in the expert witness' mind, especially if the mother’s perception was that these meals were more of a social outing. The payment of the mother’s airfare was inappropriate, as generosity blurs the boundaries of expectations. The client’s mother staying at Ms. Munro’s home for approximately one week following a marital dispute was inappropriate and could be perceived by either spouse as taking sides. Boundaries would be blurred whether the mother asked to stay at Ms. Munro’s home or if Ms. Munro extended the invitation to her.
The expert witness confirmed that Ms. Munro supporting the mother regarding her inability to deep suction her son was appropriate. Ms. Munro advocating for the family with regard to securing a physician, lawyer and spokesperson was appropriate. However, a list of alternative names should have been provided. The word “introduced” concerned the expert witness. A possible conflict of interest situation may exist as the physician, lawyer and spokesperson were all personal friends of Ms. Munro.
Regarding the lawyer’s being paid for by Ms. Munro, the expert witness clearly identified this as a conflict of interest situation resulting in heightened expectations. The expert witness stated this is not a role a nurse would play in a therapeutic relationship.
The word “betrayed” in the hypothetical situation reinforces her opinion that expectations were
heightened. One would not expect an agency to provide volunteer service.
In commenting on the College’s Guidelines for Professional Behaviour, the expert witness agreed with the first paragraph, under 4.2 re “Interpersonal Relationships” (pg. 28) and also agreed with the information under 4.2.2 re “Friendship/Platonic Relationship” (pg. 28 & 29). In commenting on a nurse’s use of a social activity as part of a treatment plan, the expert witness explained that the social activity has to be documented as to intent and outcomes.
In the expert witness' opinion the behaviour of the nurse in the hypothetical situation fell under the category of “failing to maintain the acceptable boundaries of a relationship with a client” as outlined in the Guidelines for Professional Behaviour, XI, Disgraceful, Dishonourable, and Unprofessional Conduct (page 46). Specific reference was made to the airline ticket, social activities, and the client’s mother staying in Ms. Munro’s home. Her view was that this behaviour would be regarded by the profession as disgraceful, dishonourable and unprofessional.
In cross-examination, the expert witness testified that if a client perceives harm, whether it was intended or not, it is harm. She also expressed concern regarding Ms. Munro’s objectivity in advocating regarding the deep-suctioning issue.
The expert witness was recalled on September 23, 1998, to respond to Ms. Munro’s allegations that at another hearing held in July, 1997, she committed perjury by denying her nursing service's expansion into the Sudbury area. It was also alleged that the expert witness was in a conflict of interest situation in the present hearing due to her employment with her nursing service. When recalled, the expert witness denied having any knowledge of expansion plans by her nursing service into the Sudbury area when testifying before this panel in February, 1998.
DEFENCE
Witness #4 Marilyn Munro
Ms Munro has been in nursing for 21 years, in both hospital and home settings. She is the Chief Executive Officer of a small, private, for profit agency providing home care services. At the time of her involvement with the client's family, the agency had a staff of 50, with a mix of RNs, RPNs, Personal Care Workers and Health Care Aides.
Ms. Munro testified that her understanding of a therapeutic relationship is “to promote the well being of the individual and do no harm”.
Ms. Munro testified that she had been contacted by phone by the client's mother, who was crying and distraught. The client's mother explained that she had previously contacted three other agencies, none of which would accept the Blue Cross rate. After discussion with her nursing staff, it was agreed that Elite Specialty Nursing Service Inc. would accept the child as a client. Ms. Munro explained that by accepting the client, both the nursing staff and the agency were accepting a reduced rate.
Ms. Munro described the initial meeting with the client's family at the hospital. She found the client's mother to be anxious and upset while the client's father gave no demonstration of consoling the client's mother. Because of this, Ms. Munro hugged the client's mother and attempted to reassure her that she would do all that she could to bring their son home. Ms. Munro requested permission to examine the child and stroked his head and arm, and kissed his hand in order not to frighten him.
Ms. Munro went on to explain her actions involved in bringing the child home. This included an assessment, speaking with the parents, physicians and nurses at the hospital, reviewing the client’s chart. Her actions also included compiling a nursing care plan with her Director of Nursing Care and forwarding necessary forms to the Insurance Company. She confirmed her ongoing weekly negotiations
with the insurance company, in addition to preparing the monthly summaries. When everything was in place for bringing the child home on weekends, Ms. Munro made supervisory weekend visits to the client's family home. Following the initial meeting and implementation of the care plan, Ms. Munro did not have a great deal of contact with the client's family.
After the trip to (the institute) in Philadelphia, Ms. Munro returned to the role of CEO of Elite, and had little contact with the client's family between April and August of 1994. ( )
Ms. Munro gave the following account of her trip (to Philadelphia) and attendance with the client's family. The father of another brain injured child, who was also the client's family advocate, recommended that Ms. Munro attend the program with the client's family in Philadelphia. This recommendation was made despite the Institute’s policy that only family members attend. Ms. Munro stated that the client's mother suggested Ms. Munro attend as her husband's brother’s ex-wife. Ms.
Munro explained she did not like the idea but agreed to go along if it would help the child. Ms. Munro testified that she went on this trip not to foster friendship but in the interests of the child, the client's family and the RNs employed by Elite Specialty Nursing Services Inc.
Ms. Munro introduced the client advocate to the client's family for the purpose of the client advocate becoming the client's family advocate. Ms. Munro recommended the client advocate because he was assisting other clients of Elite, had experience with insurance company coverage, and Ms. Munro needed assistance in dealing with insurance company complexities.
In her assessment, the client's family were unable to perform the deep suctioning procedure. The physicians supported her assessment. Ms. Munro continued to negotiate and advocate for the client's family regarding their inability to perform the procedure.
Ms. Munro’s nursing role was to ensure proper competent care of the client in the setting of their choice. She believed her first role as a nurse was to advocate for clients.
Ms. Munro denied participating in various social activities as she was busy with other clients between September 1993 to April 1994. She further denied the client's mother had called her to participate in social activities. The member testified that following the receipt of a letter by the client's mother from the insurance company in August, 1994, indicating a reduction in future coverage , there were frequent lunches. Often, these lunches with the client's mother occurred daily, but this was dependent on the client's mother’s frame of mind. Most of the lunches occurred in 1995. They were always on “neutral ground” and most of them were paid for by Ms. Munro.
Ms. Munro admitted recommending to the client's father that her friend become the child’s physician, but she denied any coercion.
Ms. Munro further testified that she referred the client's family to a lawyer. Ms. Munro paid the lawyer’s expenses in coming to Sudbury.
It was Ms. Munro’s evidence that the client's mother asked to borrow money from her for the trip to Los Angeles. Ultimately, the money was loaned by Elite Specialty Nursing Services Inc. and not repaid by the client's mother.
Ms. Munro testified that ( ) the mother noted that Ms. Munro and (Family Member #1) had a good relationship. The mother asked Ms. Munro if (Family Member #1) could stay at Ms. Munro’s home. On one occasion when the client's father was unable to locate his wife, he phoned Ms. Munro to ask her to look for (Family Member #1).
In describing her contact with (Family Member #2), Ms. Munro stated that (Family Member #2) would phone her ( ). Ms. Munro also testified that (Family Member #2) asked Ms. Munro to visit her in (another city). Ms. Munro did so on one occasion for approximately one hour duration.
Ms. Munro gave the following account of her knowledge of (the marital dispute). The client's mother phoned Ms. Munro and informed her (description of dispute).
Ms. Munro testified that the client's mother asked her if she could spend a couple of hours in the afternoon to rest at her home. The client's mother wanted to stay in the office side of Ms. Munro’s duplex. Ms. Munro agreed to the request with the understanding that this was a temporary and not permanent arrangement. Subsequently, the client's mother asked if she could sleep in the other side of the building, which was Ms. Munro’s private residence as the office side was too noisy. Ms. Munro consented and allowed the client's mother to use a couch in the family room. This arrangement was terminated after Ms. Munro found the client's mother participating in a prayer meeting with other women in Ms. Munro’s home.
Throughout her testimony, Ms. Munro denied attempting to foster and maintain a close, personal relationship with the mother of the child. Ms. Munro denied being the client's mother’s best friend. Ms. Munro denied socializing with the client's family. Ms. Munro stated the loan of money for the client's mother’s trip to Los Angeles was for a therapeutic purpose and not as a gesture of friendship. Ms.
Munro stated her attendance with the client's family in Philadelphia was intended to be beneficial to the child and the agency’s nursing staff and was not based on friendship. The referral to the lawyer was for business reasons and not part of an attempt to befriend. Ms. Munro stated that (she developed a supportive role with Family Member #1) and denied this was done to foster a close personal relationship. Allowing the client's mother to stay in her home following the (marital dispute) was intended to be supportive rather than an attempt to befriend.
When Ms. Munro was questioned about aspects of the College’s Guidelines for Professional Behaviour, Ms. Munro disagreed with the definition provided for friendship/platonic relationships and disagreed that a power relationship existed between the nurse and client. Ms. Munro stated, “I am completely within these guidelines.” Ms. Munro saw no problem in a friendly relationship providing the nurse did not take the first step. She stated that she did not think nurses in general initiated friendships with clients and went on to say that it was acceptable for a client and nurse to have a friendship. Ms. Munro stated she did not understand why she was before the College at a disciplinary hearing. She had never attempted to promote friendship and if the client's mother made that assumption, there was nothing she could do about it.
Witness #5
Witness #5 informed the panel he was in private practice in the Sudbury area. He was the Medical Advisor to Elite Specialty Nursing Services Inc. He also provided medical services to those clients of Elite Specialty Nursing Services Inc. who were without a family doctor. He testified that he made house calls.
The witness stated he first met Ms. Munro while attending Ms. Munro’s mother, and subsequently became Ms. Munro’s physician. When asked in cross-examination about his relationship with Ms. Munro, he admitted a number of relationships. Ms. Munro was a friend, a business associate, and formerly a client. For slightly more than a year, he lived in a room at Ms. Munro’s agency office building. He also confirmed using a car leased by Elite Specialty Nursing Services Inc., reimbursing Ms. Munro for the cost of the lease.
When asked how he became involved with the client's family, he explained that the child’s family physician did not make house calls. A few months after becoming the child’s physician, he became the entire family’s physician and continued in this role until being fired by the child’s mother. This firing followed his refusal to alter an affidavit regarding the parent’s capability to perform the deep suctioning procedure. In cross-examination, he clarified that the mother did not like his wording.
The witness confirmed attending two meetings with the child’s father and the advocate, with the purpose to assist the father to understand that his anger towards his wife was detrimental to her.
He confirmed attending many lunches with Ms. Munro, the client advocate and the client's mother. The purpose was to discuss strategies regarding insurance problems, plan of care and support for the entire family.
In cross-examination, the witness confirmed that from January to April 1995, he became involved in advocacy for the client's family regarding the 24-hour insurance coverage issue. He worked closely with Ms. Munro and the client advocate.
The witness commented on his observations regarding the relationship between Ms. Munro and the child’s mother. He indicated he spent a lot of time with Ms. Munro and the child’s mother and stated Ms. Munro was always professional with the mother. He denied that there was any evidence of befriending, only evidence of professional support. He stated Ms. Munro was always professional in the provision of health care for the child.
The witness (described the client’s mother).
In November, 1994, when the child was in hospital ill with pneumonia, the client's mother wanted to take the child home and was very insistent about this. Due to the level of care required by the child, the witness felt it was in the best interest of the child to remain in hospital and therefore, he refused to support the mother’s request. The witness stated that what the mother wanted was not always right.
CREDIBILITY
Witness #1, The Client's Mother
The panel found the witness to be credible. Her forthright testimony gave her perspective of Ms. Munro’s involvement with her and the rest of the family. The evidence supported her vulnerability and she was very emotional and at times tearful during her testimony. During cross-examination, the client's mother displayed anger and hostility towards Ms. Munro and her legal counsel. From the evidence, the panel concluded that the client's mother was grasping for acceptance, support and friendship and was dependent on Ms. Munro as a friend.
Witness #2, The Client's Father
The panel found the witness to be credible. He was very honest in his testimony. He admitted to behaviour which reflected very poorly on his character. He did not attempt to colour his testimony about Ms. Munro and, in fact, spoke positively of her support of his wife.
Witness #5, The New Family Physician
The panel questioned his objectivity in assessing Ms. Munro’s behaviour, as he had a close friendship with Ms. Munro. The panel did find he demonstrated integrity regarding the affidavit in that he stated he would not change his testimony when asked to do so. The panel also found the witness demonstrated professional expertise by refusing to support the child’s discharge from hospital when he was gravely ill. The panel agreed with the witness’s assessments of the client's mother.
Witness #3, Expert Witness
The expert witness gave her initial testimony in an assured, confident and knowledgeable manner. Her
testimony remained consistent throughout examination-in-chief and in cross-examination. When recalled, the witness steadfastly denied any knowledge regarding her employer’s expansion into the Sudbury area. The panel found her to be credible.
Witness #4, Ms Marilyn Munro
The panel found Ms. Munro to be evasive, defensive and hostile when questioned by the College’s counsel. Ms. Munro did not answer questions in a clear, concise, or convincing manner. Ms. Munro frequently gave unsolicited information in an attempt to defend herself. Ms. Munro’s answers were not always relevant and sometimes did not clearly respond to the question. Therefore, the panel concludes that Ms. Munro’s evidence is not credible.
EVIDENTIARY AND PROCEDURAL ISSUES
At the request of the College’s counsel the panel made an order excluding witnesses, and cautioned them not to discuss their evidence outside the hearing room. The panel extended this order to include both witnesses for the College and the defence. The panel’s reasons included issues of credibility, bias and conflict of interest.
The panel heard numerous objections relating to hearsay and is fully aware of the issues relating to hearsay evidence including exceptions to the hearsay rule.
Several objections were raised by the defence regarding the hypothetical situation presented to the expert witness. The panel agreed with both counsel for the College as well as Independent Legal Counsel, that the expert witness could give opinion evidence on assumed facts. Independent Legal Counsel clarified that the panel needed to assess how closely the assumed facts in the hypothetical situation corresponded to the facts as found by the panel. The panel considered the evidence as compared with the hypothetical situation to determine the weight to be given to the opinion evidence.
The panel acknowledged there had been a minor breach of disclosure. However, as the issue raised was similar to an incident described in the hypothetical situation, the panel believed the degree of breach was not sufficient to prejudice Ms. Munro. The panel acknowledged its responsibility and discretion under section 42 of the Health Professions Procedural Code, and denied the request for adjournment.
During the examination-in-chief of Ms. Munro, a voir dire was held to address the issue of the admissibility of evidence regarding credibility of the expert witness. The panel first heard from the expert witness in February, 1998. Subsequent to the February, 1998, portion of the hearing, Ms. Munro became aware of information which Ms. Munro believed proved that the expert witness had committed perjury in another hearing in July 1997. The alleged perjury related to the expert witness’s knowledge of her employer’s expansion into the Sudbury area. The panel believed it would be in the best interest of all concerned to recall the expert witness and as both counsel were in agreement, she was recalled.
DECISION AND REASONS
During deliberations, the panel was guided by the following principles: a) Standard of Proof, as outlined in Bernstein v. College of Physicians & Surgeons of Ontario that requires clear, cogent, and convincing evidence; and b) Credibility of Witnesses as outlined in Pitts v. Director of Family Benefits Branch of the Ministry of Community and Social Services. The panel was also guided by CNO’s Guidelines for Professional Behaviour.
With respect to Allegation #1, the panel finds the allegation to be proven.
Ms. Munro and the client's family agreed on the events of the initial meeting at the hospital. The panel concludes that Ms. Munro’s behaviour was not professional and reflected a relationship of friendship.
The panel concluded that Ms. Munro had recommended the change of physician for the child. The panel concluded that Ms. Munro was unprofessional and in a conflict of interest situation as she only referred the client's family to one particular physician, who was her personal friend. The panel also concluded that this behaviour would reasonably be perceived as fostering a friendship.
Therefore, the panel concluded the onus of proof was met by the College that Ms. Munro engaged in conduct relevant to the performance of nursing services, that having regard to all the circumstances would reasonably be regarded by members as disgraceful and unprofessional in that Ms. Munro fostered and maintained a close personal relationship with the client's mother.
With respect to Allegation #2, the panel finds this allegation to be proven.
Ms. Munro and the client's family agreed Ms. Munro accompanied the client's family to (the institute) in Philadelphia. The program at the Institute was restricted to immediate family only. In spite of this restriction, Ms. Munro insisted on attending under false pretences. The panel concludes Ms. Munro’s behaviour was unprofessional and reflected maintenance of a close personal friendship.
Testimony showed Ms. Munro and the client's family agreed that Ms. Munro had referred the client's family to legal counsel who was Ms. Munro’s personal choice, and who had expertise in arbitration hearings with insurance companies. The panel accepted testimony of the client's mother that Ms. Munro had paid a fee with no remuneration requested. The panel concluded Ms. Munro was unprofessional and the fee payment by Ms. Munro would be regarded as maintaining a close personal friendship.
Ms. Munro and the client's family agreed that Ms. Munro had recommended an advocate to the client's family. Ms. Munro stated in her testimony that the client advocate was a personal friend of hers who worked out of her office and had previously dealt with difficulties with the insurance company. The panel concluded that Ms. Munro was unprofessional and in a conflict of interest situation as she referred the client's family to one particular advocate, who was her personal friend. The panel also concluded this behaviour would reasonably be perceived as fostering and maintaining a friendship.
The panel noted there was conflicting testimony regarding the invitation of (Family Member #1) to stay at Ms. Munro’s home. The panel accepted the testimony of the client's mother as credible, and that Ms. Munro extended the invitation. The panel concluded that Ms. Munro’s behaviour confirmed that a friendship existed.
The panel noted conflicting testimony regarding restaurant meals attended by the member, the client's mother, the physician, the client advocate, and occasionally, the client's father. Ms. Munro and the physician testified that the meals were held to discuss plan of care for the child, strategies for dealing with the insurance company and to provide support to the client's family. The panel found the client's mother’s testimony to be credible in that she perceived these outings to be social events. Ms. Munro, the client's mother and the physician testified that the frequency of the outings escalated to a daily occurrence. The panel concludes this frequency reflects a social rather than a professional purpose and thus fostered and maintained a friendship.
The panel heard testimony from Ms. Munro and the client's mother concerning the client's mother sleeping at Ms. Munro’s home. The panel concludes this situation is highly indicative of a friendship relationship existing.
The panel heard conflicting testimony regarding the client's mother’s trip to Los Angeles. Ms. Munro stated that the client's mother requested money from her to finance this trip, while the client's mother testified that Ms. Munro offered to pay for the flight ticket and no repayment was required. Ms. Munro maintained that the money was not from her personal resources but a loan from Elite Nursing Services Inc. The fact that money was made available to the client's mother by Ms. Munro from whatever source made the trip possible and reflected the continuing friendly relationship.
The panel put no weight on the evidence presented regarding (Family Member #2).
The panel concluded the onus of proof was met by the College that Ms. Munro engaged in conduct, while acting in the capacity of owner and director of Elite Nursing Services Inc., relevant to the performance of nursing services, that having regard to all the circumstances would be reasonably regarded by members as disgraceful and unprofessional in that Ms. Munro fostered and maintained a close personal relationship with the client's mother.
The panel found hypothetical situation #2 closely reflected the events described in the hearing and therefore concludes the expert’s testimony is relevant and supports the College’s case as presented.
The panel determined that Ms. Munro failed to maintain proper boundaries in her relationship with the client's mother. Ms. Munro also failed to recognize the impact of her behaviour on the client's mother’s emotional stability. The panel noted Ms. Munro’s disagreement with aspects of the CNO’s Guidelines for Professional Behaviour. The panel has grave concerns regarding Ms. Munro’s lack of insight and understanding of the nurse’s responsibilities in maintaining boundaries in the nurse-client relationship.
PENALTY SUBMISSIONS
The panel reconvened November 3, 1999 to hear penalty submissions.
At the outset of the penalty hearing, a brief recess was granted for the purpose of reproducing a compendium of character evidence for the defence.
Upon resumption, counsel for the College indicated he had no objection to the panel receiving as an exhibit the compendium of character evidence referred to below as the “Book of Letters”.
Penalty Submissions by Prosecution
Counsel outlined to the panel the position of the College pertaining to the Submission on Penalty.
Counsel referred to the allegations as set out in the Notice of Hearing. He went on to make reference to the panel’s findings of professional misconduct. The panel was reminded that the type of conduct exhibited by Ms. Munro was over a significant period of time and was therefore not an isolated incident. The fostering and maintaining of a close personal relationship went beyond the nurse/client boundaries and led to far reaching emotional harm.
College counsel identified two principles to be considered by the panel in arriving at a penalty decision, i.e., deterrence and rehabilitation. The three components of deterrence included imposing a sanction on Ms. Munro which sends a message to both Ms. Munro and the profession that the panel views the misconduct as serious and should never be repeated. As well, it is appropriate to send a message to the public that the Discipline Committee does not tolerate such conduct.
The rehabilitation component of penalty is to assist Ms. Munro to better understand the misconduct to prevent future repetition.
Counsel for the College then presented the following Submission on Penalty, as follows:
Requiring Ms. Munro to appear before the panel of the Discipline Committee to be reprimanded, at a date to be arranged but in any event within three months of the date this order becomes final;
Directing the Executive Director to suspend Ms. Munro’s certificate of registration for a period of six months; and
Two months of the suspension described in paragraph (2) above shall be remitted if Ms. Munro completes a consultation session with an expert in nursing ethics, acceptable to the Director of
Investigation and Hearings (the “Director”), within 60 days of the date on which the order becomes final, or by such later date acceptable to the Director provided Ms. Munro is able to demonstrate that unforeseen events or circumstances reasonably prevented Ms. Munro from completing the consultation. The consultation session shall be at Ms. Munroís expense and shall address the issues of therapeutic nurse-client relationships and boundary violations of the nurse- client relationship. Prior to the consultation, the expert shall be provided with a copy of the Discipline Committee’s decision and reasons in this matter. Ms. Munro shall request that the expert provide a written report of the consultation to the Director within 30 days of the consultation.
Penalty Submissions by Defence Counsel
Counsel for Ms. Munro commenced penalty submissions by describing the client's mother as “a very bitter lady.” Further on in the submission, it was emphasized that the client's mother was not a victim and in the counsel’s opinion was not vulnerable. He told the panel that when the client's mother realized Ms. Munro was not prepared to support her wish to bring the child home against medical advice, the client's mother’s attitude changed to bitterness and revenge. He told the panel that there was no evidence of any nursing misconduct with regard to the nursing care of the child. The panel was asked to consider Ms. Munro’s motive which was the welfare of the child and the client's mother. Counsel emphasized intent has not been proven. Ms. Munro’s kind compassionate conduct made her “a special character” and counsel emphasized the therapeutic effect of Ms. Munro on the client's mother.
A certificate from the Institutes for the Achievement of Human Potential issued in Ms. Munro’s name was entered as Exhibit 29. The “Book of Letters” prepared by Ms. Munro was received as Exhibit 30. Included in the “Book of Letters” were letters of reference for Elite and Ms. Munro, thank-you notes and other miscellaneous items.
On behalf of Ms. Munro, Counsel agreed to a penalty order that would entail a consultation session with an expert in Nursing Ethics. The Panel was asked not to consider a suspension of Ms. Munro’s certificate in light of all the good Ms. Munro has done and her potential financial loss.
Prosecution’s Reply Submissions
In reply, counsel for the College raised the question of whether Ms. Munro has yet recognized that maintaining appropriate relationships is part of nursing care. Counsel for the College also submitted that Ms. Munro’s conduct in developing a close personal relationship with the client's mother was in fact intentional and that the severing of this relationship was harmful.
DECISION AND REASONS
The panel deliberated and made the following decision regarding penalty:
Requiring Ms. Munro to appear before the panel of the Discipline Committee to be reprimanded, at a date to be arranged but in any event within three months of the date this order becomes final;
Directing the Executive Director to suspend Ms. Munro’s certificate of registration for a period of six months; and
Two months of the suspension described in paragraph (2) above shall be remitted upon the Ms. Munro completing a consultation session with an expert in nursing ethics, acceptable to the Director of Investigation and Hearings (the “Director”), within 60 days of the date on which the order becomes final, or by such later date acceptable to the Director provided Ms. Munro is able to demonstrate that unforeseen events or circumstances reasonably prevented Ms. Munro from completing the consultation. The consultation session shall be at Ms. Munro’s expense and shall address the issues of therapeutic nurse-client relationships and boundary violations of the nurse-
client relationship. Prior to the consultation, the expert shall be provided with a copy of the Discipline Committee’s decision and reasons in this matter. Ms. Munro shall request that the expert provide a written report of the consultation to the Director within 30 days of the consultation.
The Panel recognized the need to reinforce for Ms. Munro, the profession and the public, the importance of nurses to establish and maintain the appropriate boundaries in nurse-client relationships
In arriving at its decision, the panel took into consideration that the misconduct was not an isolated incident but rather occurred over an extended period of time, and resulted in emotional harm to the client's mother. The panel believes an oral reprimand will reflect the seriousness of the misconduct.
The panel also believes the suspension of Ms. Munro’s certificate of registration for a period of six months is appropriate.
The panel strongly recommends that Ms. Munro actively embrace the consultation session with the expert in nursing ethics. Ms. Munro’s successful completion of the consultation session would serve to guide her positively in her nursing practice. The panel would recognize this effort on behalf of Ms.
Munro and supports the potential reduction of the term of suspension by two months.
In arriving at its decision, the panel was cognizant of its responsibility to protect the public.
I, , sign this decision and reasons for the decision as Chairperson of this Discipline Panel and on behalf of the members of the Discipline Panel as listed below:
, Chairperson Date
Page last reviewed September 28, 2010