College of Nurses of Ontario v. Homer, 2013 ONCNO 93853

PANEL: Lindsay Hyslop, NP Chairperson Patrick Chiu, RN Member Grace Fox, NP Member Mary MacMillan-Gilkinson Public Member Margaret Tuomi Public Member

BETWEEN:

COLLEGE OF NURSES OF ONTARIO MEGAN SHORTREED for College of Nurses of Ontario

and -

BETTY-LOU HOMER Registration No. 7422322 CAROL STEPHENSON for Betty-Lou Homer

Heard: October 24, 2013

DECISION AND REASONS

This matter came on for hearing before a panel of the Discipline Committee on October 24, 2013 at the offices of Victory Mediations at Toronto.

The Allegations

At the outset of the hearing, Counsel for the College of Nurses of Ontario (“the College”) advised the panel that the College was requesting leave to withdraw the allegations set out in paragraphs 2 and 3 (d) of the Notice of Hearing dated September 30, 2013. The panel granted this request. The remaining allegations against Betty Lou Homer (the “Member”) as set out in the Notice of Hearing are as follows.

IT IS ALLEGED THAT:

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(1) of Ontario Regulation 799/93, in that while working as a Registered Nurse for [the Hospital] in [ ], Ontario (the “Hospital”), you contravened a standard of practice of the profession or failed to meet the standards of practice of the profession as follows:

a. between 2009 and 2012, you failed to maintain the boundaries of the nurse-client relationship in respect of [Client A]; and/or

b. between June and July, 2010, you failed to maintain the boundaries of the nurse-client relationship in respect of [Client B]; and/or

c. between May and August, 2010, you failed to maintain the boundaries of the nurse-client relationship in respect of [Client C]; and/or

[Withdrawn]
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 while employed as a Registered Nurse for the Hospital, 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, as follows:

a. between 2009 and 2012, you failed to maintain the boundaries of the nurse-client relationship in respect of [Client A]; and/or

b. between June and July, 2010, you failed to maintain the boundaries of the nurse-client relationship in respect of [Client B]; and/or

c. between May and August, 2010, you failed to maintain the boundaries of the nurse-client relationship in respect of [Client C]; and/or

d. [Withdrawn]

Member’s Plea

The Member admitted the allegations set out in paragraphs numbered 1, a, b, c and 3, a, b, c in the Notice of Hearing. The Member admitted that the allegations would be considered by members of the profession to be disgraceful and unprofessional. The panel conducted an oral plea inquiry and was satisfied that the Member’s admission was voluntary, informed and unequivocal.

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 which provided as follows.

THE MEMBER

Betty-Lou Homer (the “Member”) obtained a diploma [ ] in 1973.
The Member registered with the College of Nurses of Ontario (the “College”) as a Registered Nurse (“RN”) on January 1, 1974.
The Member was employed at [the Hospital] from January 7, 1974, to March 5, 2012.
The Member has no prior history of discipline at the College.

THE HOSPITAL

The Hospital is located in [ ], Ontario.
In 2002, the Member began working in [the Program], an outpatient mental health service for adults.
In 2010, the Member transferred to part-time work in [ ] an eight- to ten-week intensive outpatient mental health group-based day program. The Member co-assessed [clients], co-facilitated the group and provided individual treatment.

INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT

[Client A]

[Client A] was 29 years old when she was admitted to the [Program] [in] 2009. She had a history of self-harm, suicide attempts, depression, childhood abuse, rape, Post-Traumatic Stress Disorder, alcohol and drug abuse, and had several psychiatric admissions and visits to Psychiatric Emergency Services. Her father died when she was 19 and her husband died in 2008. She was diagnosed with Borderline Personality Disorder, but exhibited no thought disorder, delusions or hallucinations.
The Member was assigned as [Client A]’s therapist to provide Dialectical Behaviour Therapy. The health records indicate that [Client A] was treated by the Member, alone or with other members of the health care team, on the following dates:
June 29, 2009
July 13, 2009
July 17, 2009
July 27, 2009
July 28, 2009
August 4, 2009
August 5, 2009
August 12, 2009
August 19, 2009
September 1, 2009
September 16, 2009
September 18, 2009
September 25, 2009
September 28, 2009
October 2, 2009
October 5, 2009
October 26, 2009
November 8, 2009
November 25, 2009
December 2, 2009 (noted as a “home visit”)
December 9, 2009
December 24, 2009
January 7, 2010
January 20, 2010
February 3, 2010
March 12, 2010
March 18, 2010.
On March 18, 2010, the Member transferred [Client A] to [Dr. A] for regular therapy. However, the Member saw the client in treatment with others, or by telephone call, or charted in her record after the transfer, on the following dates:
March 23, 2010
April 23, 2010
May 28, 2010
June 29, 2010
July 6, 2010
July 7, 2010
The following interactions of a personal nature occurred between [Client A] and the Member, both during and after the termination of the nurse-client relationship:

(a) a few months after entering into therapy with the Member, a personal relationship developed in which [Client A] viewed the Member as a mother figure;

(b) during the personal relationship, [Client A] continued one-on-one therapy with the Member;

(c) night time was exceptionally bad for [Client A]. She had difficulty coping and was distraught and suicidal. The Member began coming over to [Client A]’s house in the evenings and staying overnight (sleeping on the couch);

(d) they often hugged and said “I love you” to each other. They also kissed each other, mostly on the cheek. [Client A] says this was not sexual in nature;

(e) according to [Client C], over the summer of 2010, the Member was at [Client A]’s house on several occasions, just “hanging out”;

(f) on one occasion, [Client C] saw the Member was in her pyjamas;

(g) the Member made disclosures about her personal life to [Client A], including:

having two daughters and a son,
being a Jehovah’s Witness and discussing the differences in spiritual beliefs, as [Client A] is Christian,
information about one of her children’s spiritual beliefs;
the Member’s mother dying when she was a child;

(h) the Member bought groceries for [Client A];

(i) the Member and [Client A] attended a [dance] show [ ], and the Member paid for the tickets;

(j) [Client A] and the Member emailed, texted and telephoned each other regularly;

(k) the Member often drove [Client A] to places like work and school;

(l) the Member and [Client A] did not go out much in [their town] as they did not want to be seen together in public;

(m) [Client A] gave the Member a key to her house, following an incident when [Client A] had drunk a large amount of alcohol, taken her night medications, and passed out and the Member had the superintendent enter the apartment. They agreed the Member should have a key to avoid similar situations;

(n) on February 22, 2011, [Dr. A] saw one or several emails in [Client A]’s inbox from the Member, the discovery of which made [Client A] quite distraught and afraid the Member was going to get fired. [Client A] says she lied to [Dr. A] that the email was related to treatment;

(o) sometime in 2011, the Member arranged a weekend trip [ ] and paid for the hotel. [Client A] went with the Member and they shared a hotel room, with separate beds;

(p) the Member gave [Client A] a ring that “represented her commitment to stay in treatment, to take care of herself and not self harm”, which [Client A] was wearing in February 2012 and thereafter;

(q) the Member and [Client A] discussed the fact that the relationship was breaching boundaries of the therapeutic nurse-client relationship and the Member could get into a lot of trouble;

(r) on August 21, 2012, [Client A] disclosed to [Dr. A] that she had been in a personal relationship with the Member since about late summer or early autumn 2009. The relationship was terminated in early 2012 when [Client D] reported it to the nurse manager. [Client A] described the relationship to [Dr. A] as follows:

like “a mother and daughter”,
the Member would provide [Client A] with emotional and sometimes financial support, such as paying her bills,
the Member came to [Client A]’s home in the evening,
the Member would drive her places, and
the Member sometimes spent the night on [Client A]’s couch; and

(s) When the relationship ended in February 2012, it was painful for [Client A] because she loved the Member and missed her.

On March 5, 2012, the hospital terminated the Member’s employment.

[Client B]

[Client B] first consulted with the Hospital in October 2008 when she was 42 years old. She was sexually abused as a child and physically abused by her husband. She has periods of amnesia, and by 2009, was diagnosed with Dissociative Identity Disorder, Major Depression and Post-Traumatic Stress Disorder.
[Client B] was admitted to the [Program] in the spring of 2009. She presented [at least nine] different “alters” or “parts” in therapy [ ]. Some of the alters had different email addresses. At times, [Client B] had little conscious knowledge of the activities of her alters using her body. As she has undergone therapy, [Client B] has gained greater insight into all aspects of her personality, and the activities of her alters.
The Member was assigned as [Client B]’s therapist and she treated [Client B], alone or together with others, on the following dates:
March 30, 2009
April 2009 ([ ] Assessment Note)
April 6, 2009
April 7, 2009
April 14, 2009
April 23, 2009
May 13, 2009
May 26, 2009
June 3, 2009
June 9, 2009
June 15, 2009
June 24, 2009
July 2, 2009
July 16, 2009
August 4, 2009
August 13, 2009
August 20, 2009
September 2, 2009
September 21, 2009
September 29, 2009
October 6, 2009
October 14, 2009
October 21, 2009
October 28, 2009
November 4, 2009
November 16, 2009
November 23, 2009
December 4, 2009
December 11, 2009
December 15, 2009
December 23, 2009
December 31, 2009
January 6, 2010
January 20, 2010
January 29, 2010
February 3, 2010
February 10, 2010
March 5, 2010

mm. March 9, 2010

March 17, 2010
March 19, 2010
March 24, 2010
April 7, 2010
April 13, 2010
April 16, 2010
April 21, 2010
May 11, 2010
May 18, 2010

ww. May 26, 2010

June 1, 2010
June 8, 2010
By June 2009, [Client B] had disclosed to the Member in therapy that [one] alter, [ ] was not well known to [Client B], and was sexually experimental. [The alter] believed she had no need for therapy. Starting on August 20, 2009, [the alter] sometimes “came to session” with the Member.
The Member advised [Dr. B] that she felt overwhelmed with [Client B,] who was a very challenging client.
If the Member were to testify, she would say that just prior to the June 4 – 6, 2010 weekend, the Member received a telephone call from [the alter], who indicated that she was going to engage in high risk sexual behaviour. This telephone call preceded and precipitated the telephone call described in paragraph 19, during which the Member disclosed much of the personal information described in paragraph 28.
On the weekend of June 4-6, 2010, the Member and [the alter] had several email/text exchanges, and a long telephone call in the middle of the night. On Saturday night, June 5, 2010, [the alter] emailed:

I have to say Im so confused about everything right now, everything. Its like ok the line has moved which Im ok with, the problem is I don’t know where the line has moved to and I feel I don’t know confused I suppose…

On Sunday evening, June 6, 2010, the Member replied:

I know the line has moved and we need to work on where its comfortable for both of us without having anyone else involved that’s all. We will work on it together okay?? …

[The alter] then emailed:

Its obvious that you regret that conversation big time its ok I understand no big deal, you don’t have to call me it ok I have to figure out these emotions by myself anyway. Its not worth it for you Betty lou and hopefully now that you regret it, I am presuming you have finally realized that.

The Member responded at 10:00 pm on Sunday night:

NO NO NO YOU HAVE IT ALL WRONG!!!! My problem is that I only see you as you and I forget most of the time that you are connected to others. See you are definitely a whole person. Call me on my cell please. I told you more things that night then I have told anyone in my life. Do I think you are worth it a millions times over, do I worry bout someone finding out? Absolutely because I have just spent the last month in hell. So just call me and block everyone else. I can feel you over the phone. By email or text I think “is this really [another alter] pretending to be [the alter]?” so pease [sic] call but no all nighters lol.

On June 16, 2010, the Member added [the alter]’s email address as a friend [ ].
Also on June 16, 2010, the Member and [Client B] had numerous email exchanges about some of the other alters discovering [the alter]’s email relationship with the Member and reporting it to [Dr. B] at the Hospital. The Member emailed [Client B] from her personal email address and expressed concern about others learning of the relationship. At 12:04 a.m. on June 17th, the Member wrote:

I guess I’m hoping and praying nothing is going to happen to me, But as well I am worried about what is going to happen to you and the others. I definitely do not want to have my license questioned but I’m hopeful we can work it out.

On June 18, 2010, the Member spoke with [Dr. B] about her email, text and telephone relationship with [Client B]’s alter [ ], because another alter had sent the doctor the emails. They agreed that [Client B]’s care should be transitioned away from the Member. However, the Member continued to email with [Client B] on June 18 and 19. The client, not the Member, suggested that they only have contact in the office for therapy. The Member then wrote, “I just wanted to touch base once and awhile to say hi and see how u are doing. Is that ok with you?”
On July 19, 2010, [Dr. B] saw [Client B] in a session to “clear the air” and wrap up therapy with [the Member]. [Client B] was angry about the perceived crossing of boundaries by the Member. The doctor noted, “This caused inner chaos and conflict.” [Dr. B] and the [Client] agreed that [Client B]’s therapy with the Member would terminate due to lack of trust.
In March 2011, [Client B] made a detailed report to the Hospital about the Member’s behaviour with some of the alters, including personal disclosures, phone calls, emails and texts. At that time, the Hospital suspended the Member for five days.
In particular, [Client B] reported that the Member:

(a) disclosed personal information to [Client B] including the Member’s history of sexual abuse;

(b) told [Client B] she had been married twice and left an abusive marriage;

(d) told [Client B] she had a friendship with another [client] and visited that [client]’s home;

(e) answered [Client B]’s questions about her religious beliefs and offered her a Bible;

(f) asked [the alter] to hide the Bible from [Client B];

(g) told [Client B] personal information about the Member’s daughter;

(h) told [the alter] she loved her;

(i) told [the alter] to hide information from the alters, and [the alter] agreed to lie for her to [Dr. B];

(j) tried to convince an alter to terminate therapy at the Hospital and enter into private therapy with the Member, at a reduced rate; and

(k) criticized other members of the health care team.

If the Member were to testify, she would say that the context of the comment referred to paragraph 28(h) was as follows. Out of habit with others, the Member mistakenly ended one telephone conversation with [Client B] by saying “love ya”. Once the Member made the comment, she did not know how to take it back and she only said it on this one occasion.

[Client C]

[Client C] first consulted with the Hospital on March 6, 2003, when he was 26 years old. He was diagnosed with major depressive disorder, anxiety, borderline personality disorder and abused alcohol. He had a history of child sexual abuse.
The Member treated [Client C] in group therapy in May 2010.
[Client C] was friends with [Client A]. He saw the Member several times at [Client A]’s house, where she engaged in a social relationship with both patients. These interactions included making personal disclosures. The Member also played poker once with [Client A] and [Client C].
[Client C] says that on one occasion, he went over to the Member’s house to fix her car and that she took him on a tour of her house, invited him to stay for dinner and gave him food to take home. [Client C] indicates the Member encouraged him to change therapists to her. The Member denies all of the foregoing. If the Member were to testify, she would say that [Client C] fixed her car in a public parking lot and when he refused payment for the work, she gave him food instead.
If the Member were to testify, she would say that her personal relationship with [Client A] arose out of the trust and intimacy that developed in her clinical relationship with [Client A], and that her communications and interaction with [Client B] and [Client C] outside of work arose out of her clinical relationships with them. The Member therefore acknowledges that her relationships and/or communications and interaction outside of work with [Client A], [Client B] and [Client C] breached the boundaries of the therapeutic nurse-client relationship.

ADMISSIONS OF PROFESSIONAL MISCONDUCT

The Member admits that she committed the acts of professional misconduct as described in paragraphs 8 to 33 above, as alleged in the Notice of Hearing in the following paragraphs:

1(a), (b) and (c)
3(a), (b) and (c), in that her conduct was disgraceful and unprofessional.

With leave of the Discipline Committee, the College withdraws the allegations of professional misconduct alleged in the Notice of Hearing, as set out in paragraphs:

2(a)
3(d)

Decision

The panel considered the Agreed Statement of Facts and finds that the facts support a finding of professional misconduct and, in particular, finds that the Member committed acts of professional misconduct as alleged in paragraphs 1, a, b, c, and 3, a, b, c of the Notice of Hearing in that the Member contravened a standard of practice of the profession and engaged in conduct, relevant to the practice of nursing, that, having regard to all the circumstances, would reasonably be regarded by members as disgraceful and unprofessional.

Reasons for Decision

The panel accepted the Member’s plea of admission to her actions as being disgraceful and unprofessional based on the agreed statement of facts, which was clear and comprehensive.

Penalty

The parties jointly requested that this panel should make an Order as follows.

Requiring the Member to appear before the Panel to be reprimanded within three months of the date that this Order becomes final.
Directing the Executive Director to suspend the Member’s certificate of registration for four months. This suspension shall take effect from the date that this Order becomes final and shall continue to run without interruption as long as the Member remains in the practising class.
Directing the Executive Director to impose the following terms, conditions and limitations on the Member’s certificate of registration:

a) The Member will attend two meetings with a Nursing Expert (the “Expert”), at her own expense and within six months of the date of this Order. To comply, the Member is required to ensure that:

i. The Expert has expertise in nursing regulation and boundary violations and has been approved by the Director of Professional Conduct (the “Director”) in advance of the meetings;

ii. At least seven days before the first meeting, the Member provides the Expert with a copy of:

the Panel’s Order,
the Notice of Hearing,
the Agreed Statement of Facts,
this Joint Submission on Order, and
if available, a copy of the Panel’s Decision and Reasons;

iii. Before the first meeting, the Member reviews the following College publications and completes the associated Reflective Questionnaires and online learning modules:

Professional Standards
Therapeutic Nurse-Client Relationship

iv. At least seven days before the first meeting, the Member provides the Expert with a copy of the completed Reflective Questionnaires and online participation forms;

v. The subject of the sessions with the Expert will include:

the acts or omissions for which the Member was found to have committed professional misconduct,
the potential consequences of the misconduct to the Member’s clients, colleagues, profession and self,
strategies for preventing the misconduct from recurring,
the publications, questionnaires and modules set out above, and
the development of a learning plan in collaboration with the Expert;

vi. Within 30 days after the Member has completed the last session, the Member will confirm that the Expert forwards his/her report to the Director, in which the Expert will confirm:

the dates the Member attended the sessions,
that the Expert received the required documents from the Member,
that the Expert reviewed the required documents and subjects with the Member, and
the Expert’s assessment of the Member’s insight into her behaviour;

vii. If the Member does not comply with any of the requirements above, the Expert may cancel any session scheduled, even if that results in the Member breaching a term, condition or limitation on her certificate of registration;

b) For a period of 12 months from the date the Member’s suspension ends, the Member will notify her health care employers of the decision. To comply, the Member is required to:

i. Ensure that the Director is notified of the name, address, and telephone number of all employer(s) within 14 days of commencing or resuming employment in any health care position;

ii. Provide her health care employer(s) with a copy of:

the Panel’s Order,
the Notice of Hearing,
the Agreed Statement of Facts,
this Joint Submission on Order, and
a copy of the Panel’s Decision and Reasons, once available;

iii. Ensure that within 14 days of the commencement or resumption of the Member’s employment in any health care position, the employer(s) forward(s) a report to the Director, in which it will confirm:

that they received a copy of the required documents, and
that they agree to notify the Director immediately upon receipt of any information that the Member has breached the standards of practice of the profession; and
All documents delivered by the Member to the College, the Expert or the employer(s) will be [delivered] by verifiable method of delivery, the proof of which the Member will retain.

Penalty Submissions

College Counsel submitted that the overriding concern was protection of the public interest in light of the seriousness of the offen[c]es [involving] three separate psychiatric [clients] and the breach of boundaries. College Counsel also submitted there were three objectives the proposed penalty sought to achieve, namely general deterrence for the membership at large, specific deterrence for the Member and the remediation and rehabilitation of the Member.

College Counsel submitted there were both aggravating and mitigating factors to consider in the determination of the penalty.

The aggravating factors were that the Member has a long history in psychiatric nursing and is familiar with the boundaries. The misconduct involved three [clients] over three years, all the [clients] were vulnerable, all had suffered significant trauma and sought assistance with their problems and put their trust in the Member. The Member’s breach resulted in hurting the [clients].

The mitigating factors were that the Member has a long history of nursing since 1974, has no prior history of discipline, has cooperated with the College, has made admissions making it unnecessary for the vulnerable [clients] to testify.

College Counsel submitted that based on these factors, remediation of the Member is possible.

Defence Counsel for the Member submitted that she supported College Counsel’s submissions and proposed penalty.

Penalty Decision

The panel accepted the Joint Submission as to Order and accordingly orders.

The Member is required to appear before the Panel to be reprimanded within three months of the date that this Order becomes final.
The Executive Director is directed to suspend the Member’s certificate of registration for four months. This suspension shall take effect from the date that this Order becomes final and shall continue to run without interruption as long as the Member remains in the practising class.
The Executive Director is directed to impose the following terms, conditions and limitations on the Member’s certificate of registration:

a. The Member will attend two meetings with a Nursing Expert (the “Expert”), at her own expense and within six months of the date of this Order. To comply, the Member is required to ensure that:

i. The Expert has expertise in nursing regulation and boundary violations and has been approved by the Director of Professional Conduct (the “Director”) in advance of the meetings;

ii. At least seven days before the first meeting, the Member provides the Expert with a copy of:

the Panel’s Order,
the Notice of Hearing,
the Agreed Statement of Facts,
this Joint Submission on Order, and
if available, a copy of the Panel’s Decision and Reasons;

iii. Before the first meeting, the Member reviews the following College publications and completes the associated Reflective Questionnaires and online learning modules:

Professional Standards
Therapeutic Nurse-Client Relationship

iv. At least seven days before the first meeting, the Member provides the Expert with a copy of the completed Reflective Questionnaires and online participation forms;

v. The subject of the sessions with the Expert will include:

the acts or omissions for which the Member was found to have committed professional misconduct,
the potential consequences of the misconduct to the Member’s clients, colleagues, profession and self,
strategies for preventing the misconduct from recurring,
the publications, questionnaires and modules set out above, and
the development of a learning plan in collaboration with the Expert;

vi. Within 30 days after the Member has completed the last session, the Member will confirm that the Expert forwards his/her report to the Director, in which the Expert will confirm:

the dates the Member attended the sessions,
that the Expert received the required documents from the Member,
that the Expert reviewed the required documents and subjects with the Member, and
the Expert’s assessment of the Member’s insight into her behaviour;

b. For a period of 12 months from the date the Member’s suspension ends, the Member will notify her health care employers of the decision. To comply, the Member is required to:

i. Ensure that the Director is notified of the name, address, and telephone number of all employer(s) within 14 days of commencing or resuming employment in any health care position;

ii. Provide her health care employer(s) with a copy of:

the Panel’s Order,
the Notice of Hearing,
the Agreed Statement of Facts,
this Joint Submission on Order, and
a copy of the Panel’s Decision and Reasons, once available;

that they received a copy of the required documents, and
that they agree to notify the Director immediately upon receipt of any information that the Member has breached the standards of practice of the profession; and
All documents delivered by the Member to the College, the Expert or the employer(s) will be [delivered] by verifiable method of delivery, the proof of which the Member will retain.

Reasons for Penalty Decision

The panel concluded that the proposed penalty is reasonable and in the public interest. The Member has cooperated with the College and, by agreeing to the facts and a proposed penalty, has accepted responsibility for her actions.

I, Lindsay Hyslop, NP, 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

Panel Members:

Patrick Chiu, RN

Grace Fox, NP

Mary MacMillan-Gilkinson, Public Member

Margaret Tuomi, Public Member