DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO

PANEL:

Chairperson, RN Member, RPN Member, RN

Public Representative Public Representative

Independent Legal Counsel

BETWEEN

COLLEGE OF NURSES OF ONTARIO

• and- ALEXANDRA DOAK

#72-0581-8

Counsel for College of Nurses of Ontario

Counsel for Alexandra Doak

Heard: OCTOBER 23, 2000

DECISION AND REASONS

This matter came on for hearing before a panel of the Discipline Committee on October 23, 2000 at the College of Nurses of Ontario at Toronto. The Member was present as was defence counsel. The panel was advised that the hearing would proceed by way of an Agreed Statement of Facts and Joint Submission as to Penalty.

The allegations against Alexandra Doak as stated in the Amended Notice of Hearing, dated August 16, 2000, are as follows:

AMENDED NOTICE OF HEARING

1. You have committed an act of professional misconduct as provided by subsection 83(3)(c) of the Health Disciplines Act, R.S.O. 1980, as amended, and subsection 21(a) of Ontario Regulation 449, R.R.O. 1980, as amended, in that on or about [date], while employed as a registered nurse at an Ottawa hospital, you failed to maintain the standards of practice of the profession during the labour of the client, Mother Client, and the delivery of the client, Child Client and, more particularly, a) in your role as supervisor, you failed to make an appropriate client assignment, based on nursing experience and skill, for RN #1; b) you failed to adequately supervise RN #1; c) you failed to provide assistance to RN #1 when requested; d) you failed to identify the presence and significance of fetal heart monitor readings indicating fetal distress; e) you failed to promptly notify any member of the obstetric team of the presence and significance of fetal heart monitor readings indicating fetal distress and/or you prepared a record in respect of the observation or treatment of a client which you knew or ought to have known contained a false or misleading statement; and/or

2. You have committed an act of professional misconduct as provided by subsection B3(3)(c) of the Health Disciplines Act, R.S.O. 1980, as amended, and subsection 21(m) of Ontario Regulation 449, R.R.O. 1980, as amended, in that on or about [date], while employed as a registered nurse at an Ottawa hospital, 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 during the labour of the client, Mother Client, and the delivery of the client, Child Client, and more particularly, a) in your role as supervisor, you failed to make an appropriate client assignment, based on nursing experience and skill, for RN #1; b) you failed to adequately supervise RN #1; c) you failed to provide assistance to RN #1 when requested; d) you failed to identify the presence and significance of fetal heart monitor readings indicating fetal distress; e) you failed to promptly notify any member of the obstetric team of the presence and significance of fetal heart monitor readings indicating fetal distress and/or you prepared a record in respect of the observation or treatment of a client which you knew or ought to have known contained a false or misleading statement; and/or

3. You have committed an act of professional misconduct as provided by subsection 83(3)(c) of the Health Disciplines Act, R.S.O. 1980, as amended, and subsection 21(1) of Ontario Regulation 449, R.R.O. 1980, as amended, in that on or about [date], while employed as a registered nurse at an Ottawa hospital, you falsified a record in respect of the observation or treatment of the client, Mother Client, and/or the client, Child Client.

WITHDRAWAL OF ALLEGATIONS:

Counsel for the College advised the panel that the College was withdrawing allegations: #1(a) #1(c); #2(a) #2 (c) and #3 of the Amended Notice of Hearing.

INDEPENDENT LEGAL COUNSEL CONFERENCE CALL

Independent legal counsel informed the panel that a faxed letter had been received by a representative of the College of Nurses from the parents of Child Client. Independent legal counsel advised the panel that the letter from the parents of Child Client did not seek party status nor could a third party do so by a letter directly to the panel. She further advised that the letter did not contain evidence that was admissable and that neither counsel for the College nor the defence believed that the panel should see the letter. Independent legal counsel advised the panel that as the contents of the letter were not property admissable before the panel, the letter should not be reviewed by the panel as it could be very prejudicial and jeopardize the proceedings. Counsel for the College and the defence concurred with the advice of independent legal counsel.

Schedule 2 of the Health Professions Procedural Code, Section 41.1 (1) states a panel may allow a person who is not a party to participate in a hearing if:

a. the good character, propriety of conduct or competence of the person is an issue at the hearing: or

b. the participation of the person, would, in the opinion of the panel, be of assistance to the panel.

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2. The panel shall determine the extent to which a person who is allowed to participate may do so and, without limiting the generality of this, the panel may allow the person to make oral or written submissions, to lead evidence and to crosxamine witnesses. 1993, c. 37, s. 10.

Independent legal counsel advised the panel that the letter from the parent's of Child Client did not seek party status, and that the letter was not admissible as evidence or submissions. Independent Legal Counsel further advised the panel the letter may be prejudicial. Counsel for the College and Counsel for the Defence concurred with the advice of Independent Legal Counsel.

The panel accepted the advice of Independent Legal Counsel and the letter was not received as evidence.

POTENTIAL CONFLICT OF INTEREST

Panel member, [name], RN, indicated that she may have a conflict of interest. At the time or the incident, she was employed in the neonatal intensive care unit (NICU) at Children's Hospital of Eastern Ontario in Ottawa. This NJCU is a level three tertiary care unit which receives critically ill infants from the Ottawa hospital where the member wor1<ed. The panel member declared she had no knowledge of the incident. Neither Counsel, nor the Member, objected to the member participating on the panel.

AGREED STATEMENT OF FACTS

Counsel for the College advised the panel that agreement had been reached on the facts and introduced an Agreed Statement of Facts (Exhibit# 2) which provides as follows:

The Member

16. Ms Doak received her nursing training at the Stirling Royal Infirmary in Scotland in 1962. She subsequently practiced at the Viewforth Maternity Hospital for five years.

17. In 1967, she moved to Canada and underwent retraining at the Vanier School of Nursing graduating in 1971. From 1971 to 1981, she wor1<ed full-time in obstetrics at the Grace Hospital in Ottawa. Ms. Doak obtained her B.Sc.N. from the University of Ottawa in 1988. Previously, she obtained a Nursing Unit Administration Certificate following a one­ year course of study sponsored by the Ontario Hospital Association and the Canadian Nurses Association.

18. In 1981, she began full-time wor1< at an Ottawa hospital (the Hospital) in obstetrics, being promoted to Night Team Leader in 1983 and eventually lo Day Team Leader in 1993. In 1996, Ms Doak transferred to her current position as an RN on the Day Surgery Unit at the Hospital.

19. After several years teaching prenatal classes for the Ottawa Carleton Public Health Unit and Orleans Nursing Services, Ms Doak set up her own business offering prenatal and postnatal education, home visits and lactation counselling. ln 1994, she received her certification as an International Board Certified Lactation Consultant from the University of Ottawa.

20. Before becoming Team Leader in 1983, Ms. Doak estimates that she directly attended approximately 5,000 - 6,000 births. As Team Leader, Ms. Doak supervised approximately 8,000 - 9,000 further births. This complaint was the first complaint ever made to the College regarding Ms. Doak's nursing performance.

21. Ms. Doak has not wor1<ed in obstetrics since 1996 when she transferred to the Day Surgery Unit and she has no intention of returning to obstetrics in the future.

The Hospital, the Unit and the Staffing

22. The Hospital is an approximately 480 bed facility providing acute care services to the Ottawa region. The Hospital provides Level 3 high risk pregnancy and neonatal care for Ontario and western Quebec.

23. At the time period during which the allegations arise, the Obstetrical Unit (the Unit) consisted of an eight bed labour and delivery unit with two operating rooms. There were typically between 15 and 24 deliveries in a 24-hour period.

24. Nurses on the Unit wor1<ed eight-hour shifts. On the night shift the staffing consisted of a Night Team Leader and 6 RNs.

25. One RN would typically be assigned to the operating rooms. The remaining five RNs would be assigned to clients on the Unit, usually with two clients per nurse. If two clients were assigned to a nurse, only one of the clients would be in active labour. Client assignments could change rapidly depending upon admissions and the necessity for caesarean sections.

26. The Night Team leader role was to oversee the operation of the Unit. She was responsible for taking report and visiting all clients, assigning clients to nurses, attending at the Assessment Room to assess pregnant clients, assigning breaks, assessing clients following admission, checking and stocking rooms with the appropriate equipment, all paper work, assessing the nurse/client assignment for the next shift and identifying staffing concerns to the co-ordinator. The Night Team Leader did not usually have a client assignment. However, she would take over can of the clients during breaks and she would assist with clients if the Unit was busy.

The Client and her course in hospital

27. Mother Client arrived at the Hospital in active labour accompanied by her husband at approximately 2300 hours on (date - day one). She was assessed in the Assessment Room and subsequently admitted to the Unit at approximately 0015 hours on (date -day two) for a term pregnancy of 41 weeks.

28. At approximately 0345 hours, Mother Client underwent an emergency caesarean section to deliver her daughter, Child Client. Child Client required resuscitation at birth and sustained severe brain damage during the Jabour and delivery.

Nursing staff and Client assignment on [date - day two]

28. Ms Doak was the Team Leader for the night shift of [date - day two). The Unit was short-staffed as only five RNs were working.

29. One of the RNs working the night shift was RN #1. RN #1 was a probationary casual nurse who had recently written her RN examinations and became registered with the College that month. She had completed her consolidation on the Unit earlier that year and had subsequently completed a 20 day orientation to the Unit. By [dale -day two), RN #1 had worked approximately 29 shifts following her orientation.

30. Sometime prior to the beginning of the night shift, Ms Doak spoke with the Head Nurse of the Unit regarding RN #1's progress. Ms Doak was aware that RN #1 was a probationary nurse. Ms Doak had previously noted that RN #1 was slow in application of nursing care and had difficulty priority setting. The Head Nurse told Ms Doak to give RN #1 the normal assignment of two clients, with a view to improving her organizational and prioritizing skills under Ms Doak's supervision.

31. At the beginning of the night shift, Ms Doak assigned RN #1 to the care of Client #2, a client admitted for her first pregnancy and in active labour. Client #2 was dilated 9 cm. She had an epidural in place but remained uncomfortable with contractions. When Mother Client was admitted to the Unit, Ms Doak assigned RN #1 to care for Mother Client a! well as Client #2

Care of Mother Client. by RN #1

18. At 0030 hours, the obstetrician completed a vaginal examination which revealed that Mother Client was 3 cm dilated, 50% effaced and at station -1. An artificial rupture of membranes was completed at this time. The fetal heart rate (FHR) was monitored using an external fetal heart monitor and was noted to be within normal range and reactive at 130-140 beats per minute.

19. Over a period of approximately two hours, RN #1 completed the admission history, drew blood and attempted to start an intravenous line. The intravenous line was eventually started by another nurse after RN #1 made several unsuccessful attempts. During this time, RN #1 also prepared Mother Client for and assisted with the insertion of an epidural catheter for anaesthetic purposes. Mother Client was very uncomfortable with her contractions.

20. Beginning at approximately 0110 hours, RN #1 noted decelerations in the FHR in conjunction with Mother Client's contractions. RN #1 wrongly identified the pattern as ·variable decelerations with good recovery", meaning that the FHR returned to the baseline heart rate following the contractions. In fact, by 0120 hours, the FHR monitor showed a non-reassuring pattern in which the FHR decreased to 60 - 70 beats per minute for a period of 60 seconds or more as well as evidence of the FHR overshooting prior to returning to baseline.

21. In response to the decelerations, RN #1 repositioned the client and administered oxygen at 8 litres/minute. Despite the fact that the decelerations continued, she did not notify any other staff as she felt that the FHR pattern was reassuring in that it returned to baseline.

22. During the two hour period that RN #1 was assigned to provide care to Mother Client and Client #2, she expressed that she was having difficulty managing her dient load. In response, another nurse assisted with the care provided to Client #2 at this time.

23. At approximately 0250 hours, RN #1 was required to provide one-to-one care for Client #2, who was by that time fully dilated and pushing. At this time, Ms Doak took over the care of Mother Client.

Allegation 1(b) and 2(b) - Failure to maintain the standards of practice; and

Disgraceful, dishonorable and unprofessional conduct with respect to inadequate supervision

24. From 0015 hours to 0250 hours, Ms Doak entered Mother Client's room two or three times. The first visit was at approximately 0030 hours when the obstetrician was completing a vaginal examination on Mother Client. The second visit occurred sometime around 0215 hours, when she assisted with the set-up for the insertion of the epidural. If she gave evidence, Ms Doak would say that she made a third visit between 0030 and 0215 hours.

25. During the visits, Ms Doak noted that Mother Client was very uncomfortable. On the visit at 0215 hours, Ms Doak noted that RN #1 was having difficulty coping and assisted her with priority setting, suggesting that RN #1 should focus on having an epidural inserted so that Mother Client would be more comfortable. Ms. Doak asked RN #1 if she thought that she would be able to cope after the epidural took effect and RN #1 advised that she thought that she could.

26. On the other visit or visits, Ms Doak asked RN #1 something to the effect or, "Are you okay?" RN #1 responded that she was fine.

27. Ms Doak did not at any time ask RN #1 any specific questions regarding the status of the FHR, nor did she check the FHR monitor to satisfy herself of fetal well-being. She inappropriately relied upon RN #1 's assessment of fetal well­ being despite the fact that she knew RN #1 was an inexperienced nurse and that RN #1 was slow in her application o nursing care and had difficulty priority setting. In particular, Ms Doak had noted that RN #1 was taking a longer period of time to complete the admission charts, and in fact, was still struggling to complete them more than two hours after the admission.

28. Ms Doak also failed to ensure that the FHR monitor was placed on the central console as is the usual practice whens probationary nurse has two clients, so that any concerns regarding the FHR could be observed more easily by other staff. The central monitor was fully engaged with higher risk clients. Even if the central console was fully engaged wit/­ other monitors, the monitor for Mother Client should have been given priority since RN #1 was a probationary nurse with two clients.

29. Ms Doak admits that her conduct amounts to professional misconduct as set out in allegations 1(b) and 2(b) in the Notice of Hearing in that she failed to maintain the standards of practice of the profession and 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 and unprofessional during the labour of the client, Mother Client. and the delivery of the client, Child Client. In particular, Ms Doak admits that she failed to adequately supervise RN#1.

Allegation 1(d) and 2(d) - Failure to maintain the standards of practice and Disgraceful, dishonourable and unprofessional conduct with respect to failure to identify fetal distress

30. In her report, RN #1 informed Ms Doak that Mother Client was having variable decelerations with good recovery and had been having them since admission. She further reported that she had administered oxygen and repositioned the client in response.

31. Despite RN #1 's report regarding variable decelerations, when Ms Doak took over the care of Mother Client at approximately 0250 hours, she reviewed the ongoing FHR strip but did not review the previous FHR monitor strips to assess the pattern reported by RN #1. As noted previously, by 0120 hours, the FHR monitor strip showed a non­ reassuring pattern in which the FHR decreased to 60 - 70 beats per minute for a period of 60 seconds or more as well as evidence of the FHR overshooting prior to returning to baseline.

32. At approximately 0257 hours, Ms Doak noted that the FHR had decreased to 96 beats per minute by observing the number displayed by the monitor. She did not review the FHR strip to assess the length and pattern of the deceleration. She charted in the Progress of Labour Record that she observed variable decelerations with good recovery and that the FHR was 96 beats per minute. She further charted in the Progress Notes that variable decelerations were noted. In fact, the FHR monitor strip shows that at this lime the FHR had dropped to 58 beats per minute and stayed below 60 - BO beats per minute for over a two minute period.

33. In response to what she assessed as a prolonged variable deceleration, Ms Doak completed a vaginal examination to rule out prolapse of the umbilical cord. The results of the vaginal examination did not reveal a prolapsed cord. Ms Doak then completed peri-care on Mother Client and requested that the intern return to apply a scalp clip for more accurate monitoring of the FHR.

34. The intern applied the scalp clip at 0305 hours and Ms Doak attached the FHR monitor to the central console. At 031C hours, she noted the FHR pattern was persistent bradycardia at a rate of 68 - 74 beats per minute. The scalp clip dislodged and another was reapplied by the intern at this time. The FHR monitor strips shows a deceleration in the FHR to 68 beats per minute for a period of approximately one minute.

35. At 0312 hours, Ms Doak noted the FHR to be 54 beats per minute which she assessed to be "prolonged bradycardia [with] no recovery." At this time, Ms Doak applied oxygen by facial mask to Mother Client, changed her position and provided abdominal stimulation.

36. When the above stated nursing measures did not improve the FHR pattern, Ms Doak called the obstetrician at 0314 hours. Mother Client was subsequently taken for an emergency caesarean section.

37. Ms Doak admits that her conduct amounts to professional misconduct as set out in allegations 1(d) and 2(d) in the Notice of Hearing in that she failed to maintain the standards of practice of the profession and 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 and unprofessional during the labour of the client, Mother Client. and the delivery of the client, Child Client. In particular, Ms Doak admits that she failed to identify the presence and significance of fetal heart monitor readings indicating fetal distress by:

• Failing to review and assess the entire FHR monitor strip upon taking over the care of Mother Client, despite a report by RN #1 that the client had been having variable decelerations;

and

• Failing to identify a pattern of fetal distress which was or should have been evident from the FHR monitor strips at the time she took over the care of Mother Client.

Allegation 1(e) and 2(e) - Failure to maintain the standards of practice and Disgraceful, dishonourable and unprofessional conduct with respect to making incomplete charting entries which had a misleading effect

38. At approximately 0257 hours, Ms Doak noted that the FHR had decreased to 96 beats per minute by observing the number displayed by the monitor. She did not review the FHR strip to assess the length and pattern of the deceleration. She charted in the Progress of Labour Record that she observed variable decelerations with good recovery and that the FHR was 96 beats per minute. She further charted in the Progress Notes that variable decelerations were noted. In fact, the FHR monitor strip shows that at this time the FHR had dropped to 58 beats per minute and stayed below 60 - BO beats per minute for over a two minute period.

39. At 0310 hours, she noted in the Progress of Labour Record that the FHR pattern was persistent bradycardia at a rate of 68 - 74 beats per minute. The FHR monitor strips shows a deceleration in the FHR to 68 beats per minute for a period of approximately one minute.

40. Ms Doak admits that her conduct amounts to professional misconduct as set out in allegations 1(e) and 2(e) in the Notice of Hearing in that she failed to maintain the standards of practice of the profession and 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 and unprofessional during the labour of the client, Mother Client. and the delivery of the client, Child Client. In particular, Ms Doak admits that she made incomplete charting entries which had a misleading effect with respect to the events of [date] by failing to accurately chart the presence, length and pattern of the decelerations, thus creating a misleading effect regarding the status of the FHR.

Allegations 1(a), 1(c), 2(a), 2(c) and 3

41. The College withdraws these allegations.

Amendments to the Agreed Statement of Facts

The following amendments were made to the Agreed Statement of Facts following discussion regarding the term "active labour" in paragraph 10. Agreement was unanimous amongst the panel, the Defence and College counsel to

a. amend the term •active labour" in paragraph 10, to read "final phase of labour" b) amend the term "in active labour" in paragraph 12 to read "in established labour" and c) amend the term "in active labour" in paragraph 17 to read "in established labour".

MEMBER'S PLEA

The Member admitted the allegations set out in paragraphs numbered 1(b), 1(d), 1(e), 2(b), 2(d), and 2(e), of the Amended Notice of Hearing.

The panel made its usual "plea inquiry" and was satisfied that the Member's admission was voluntary, informed, and unequivocal.

DECISION

The panel considered the Amended Agreed Statement of Fact and found that the facts supported a finding of professional misconduct and, in particular, that the Member committed an act of professional misconduct as alleged in paragraphs 1(b), 1(d), 1(e), and 2(b),2(d), and 2(e) of the Amended Notice of Hearing. In particular, the Discipline Panel finds that the Member's conduct amounts to professional misconduct in that she failed to maintain the standards of practice of the profession and 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 and unprofessional during the labour of the client, Mother Client, and delivery of the client Child Client, in that she failed to adequately supervise RN #1, failed to identify the presence and significance of fetal heart monitor readings indicating fetal distress, as particularized in paragraph 37 of the Agreed Statement of Facts. The Member also made incomplete charting entries which had a misleading effect with respect to the events of [date), by failing to accurately chart the presence, length and pattern of the decelerations, thus creating a misleading effect regarding the status of the FHR.

REASONS FOR DECISION

The Member admitted that she failed to maintain the standards of practice of the profession during the labour of Mother Client, and the delivery of Child Client, and more particularly, failed to promptly notify any member of the obstetric team of the presence and significance of fetal heart monitor readings indicating felal distress. In the matter of the falsified charting i was established by College Counsel and Defence Counsel, that it was not an intentional act. The Member admitted to incomplete assessment of the fetal heart monitoring which resulted in incomplete documentation.

The Member admitted that she 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, dishonourable and unprofessional during the labour of Mother Client, and the delivery of Child Client, in that she failed to promptly notify any member of the obstetric team of the presence and significance of fetal heart monitoring readings indicating fetal distress and providing incomplete documentation.

PENALTY

Counsel for the College advised the panel that a Joint Submission on Penalty had been agreed upon. The Joint

Submission on Penalty was received as Exhibit #3 and provides as follows:

The Member and the College jointly submit that the appropriate penalty in this case is for the Discipline Committee to make the following order:

1. Requiring the Member to appear before the panel to be reprimanded;

2. Directing the Executive Director to suspend the Member's certificate of registration for a period of two months commencing on November 23, 2000 (30 days from the date of this order);

3. Directing the Executive Director to impose the following specified terms, conditions and limitations on the Member's certificate of registration:

a. That she meet with a Nursing Practice Consultant from the College prior to her return to nursing practice to review the standards of practice with respect to the supervision of nursing staff; the identification of fetal heart monitor readings indicating fetal distress; and accurate documentation.

DECISION ON PENALTY

College Counsel indicated the penalty related to fetal heart monitoring was not intended to be a formal course. This portion of the penalty was to serve as a theoretical review of the Member's nursing practice. The penalty does not preclude the Member from practicing in obstetrics. Therefore, she would benefit from a review in this area.

The panel deliberated. The panel advised counsel that they had some concern related to the two-month suspension and the review of fetal heart monitoring. The panel invited further submissions from both counsel related to these concerns. Thi College counsel advised the panel that the penalty for a standards case is usually one to four months. He further indicated that two months was in the appropriate range in that this incident was a single event in a lengthy career, the incident took place [date - a number of years ago], and a suspension of two months was considered adequate. Defence Counsel concurred with College Counsel. The Panel did not accept the Joint Submission as to penalty insofar as the length of the suspension was concerned and accordingly, orders that:

1. The Member appear before the Panel to be reprimanded:

2. The Executive Director is directed to suspend the Member's certificate of registration for a period of three months commencing on November 23, 2000.

3. The Executive Director is directed to impose the following specified terms, conditions and limitations on the Member's certificate of registration:

That the Member meet with a Nursing Practice Consultant from the College prior to her return to nursing practice to review the standards of practice with respect to the supervision of nursing staff; the identification of fetal heart monitor readings indicating fetal distress; and accurate documentation.

REASONS FOR PENALTY DECISION

The panel recognized that the intent of penalty decisions is not to punish the Member and exact retribution, but rather to protect the public, maintain high professional standards and preserve public confidence in the nursing profession. It is from this perspective that the panel assessed the penally and decided to extend the length of suspension to three months. The panel weighed the mitigating and aggravating factors in this incident. From a mitigating perspective the panel recognized this as a single, isolated incident in the Member's exemplary nursing career of 38 years, of which 25 years were in obstelrics. She had attended approximately 5,000 to 6,000 births and supervised approximately 8, 000 to 10,000 births.

The Member was cooperative with the College and by agreeing to the facts avoided unnecessary costs to the College. Aggravating factors that contributed to the incident included, a staffing ratio below the nonn for the acuity level of the unit on that shift. The staffing ratio was further compromised by the inexperience of a new graduate/staff member.

The Amended Penalty balances the need for specific and general deterrents. The panel concluded that the Amended Penalty is reasonable and in the public interest

RECOMMENDATION

Given the current situation in health care related to increasing client acuity and nursing shortages, the panel strongly recommends that the Member and other members of the profession advocate for safe, adequate nurse-client ratios to support quality outcomes.

I, (chairperson), RN, sign this decision and reasons for the decision as Chairperson of this Discipline Panel and on behalf o the members of the Discipline Panel as listed below:

__________. Chairperson _ _.Date

Member, RPN Member, RN

Public Representative Public Representative