DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO
PANEL: Carly Gilchrist, RPN Chairperson Margarita Cleghorne, RPN Member Sylvia Douglas Public Member Aisha Jahangir, RN Member
BETWEEN:
COLLEGE OF NURSES OF ONTARIO
- and - ANDREA DE CESARE Registration No. 0300467
COUNSEL: DENISE COONEY for College of Nurses of Ontario JANE LETTON for Andrea De Cesare KIMBERLEY ISHMAEL Independent Legal Counsel
Heard: August 5, 2021
DECISION AND REASONS
This matter came on for hearing before a panel of the Discipline Committee (the “Panel”) of the College of Nurses of Ontario (the “College”) on August 5, 2021, via videoconference.
Publication Ban
College Counsel brought a motion pursuant to s.45(3) of the Health Professions Procedural Code of the Nursing Act, 1991, for an order preventing public disclosure and banning publication or broadcasting of the name of the patient, or any information that could disclose the identity of the patient referred to orally or in any documents presented in the Discipline hearing of Andrea De Cesare.
The Panel considered the submissions of the Parties and decided that there be an order preventing public disclosure and banning publication or broadcasting of the name of the patient, or any information that could disclose the identity of the patient referred to orally or in any documents presented in the Discipline hearing of Andrea De Cesare.
The Allegations
The allegations against Andrea De Cesare (the “Member”) as stated in the Notice of Hearing dated May 28, 2021 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 registered as a Registered Nurse (“RN”) and employed at the Kingsway Medical Centre in Etobicoke, Ontario (the “Clinic”), you contravened a standard of practice of the profession or failed to meet the standards of practice of the profession in that in or about May 2019 to May 2020:
(a) you failed to maintain the boundaries of the therapeutic nurse-patient relationship with [the Patient] when you engaged in a personal relationship with [the Patient], including but not limited to:
(i) communicating by text message and/or telephone with [the Patient] outside of the therapeutic relationship;
(ii) meeting with and/or socializing with [the Patient] in person, including in [the Patient]’s home, outside of the therapeutic relationship, including but not limited to doing so during a period of public health restrictions that discouraged in-person interactions;
(iii) accepting gifts, food, alcohol, loans of money, and/or gifts of money from [the Patient]; and/or
(iv) making disclosures to [the Patient] about your personal life, that were not for a therapeutic purpose; and/or
- 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 registered as an RN and employed at the Clinic, you engaged in conduct that would reasonably be regarded by members as disgraceful, dishonourable or unprofessional in that in or about May 2019 to May 2020:
(a) you failed to maintain the boundaries of the therapeutic nurse-patient relationship with [the Patient] when you engaged in a personal relationship with [the Patient], including but not limited to:
(i) communicating by text message and/or telephone with [the Patient] outside of the therapeutic relationship;
(ii) meeting with and/or socializing with [the Patient] in person, including in [the Patient]’s home, outside of the therapeutic relationship, including but not limited to doing so during a period of public health restrictions that discouraged in-person interactions;
(iii) accepting gifts, food, alcohol, loans of money, and/or gifts of money from [the Patient]; and/or
(iv) making disclosures to [the Patient] about your personal life, that were not for a therapeutic purpose.
Member’s Plea
The Member admitted the allegations set out in paragraphs 1(a)(i), (ii), (iii), (iv), 2(a)(i), (ii), (iii) and (iv) in the Notice of Hearing. The Panel received a written plea inquiry which was signed by the Member. The Panel also conducted an oral plea inquiry and was satisfied that the Member’s admission was voluntary, informed and unequivocal.
Agreed Statement of Facts
College Counsel and the Member’s Counsel advised the Panel that agreement had been reached on the facts and introduced an Agreed Statement of Facts, which reads, unedited, as follows:
THE MEMBER
Andrea De Cesare (the “Member”) obtained a diploma in nursing from the United Kingdom.
The Member registered with the College of Nurses of Ontario (“CNO”) as a Registered Nurse on January 8, 2003.
The Member has been employed at Kingsway Medical Centre in Etobicoke, Ontario (the “Clinic”) as staff nurse since 2018. Prior to working at the Clinic, the Member worked for [the Doctor] until his retirement.
PRIOR HISTORY
- In light of conduct that the Member engaged in between October 2018 to November 2018, the Member was ordered by the Inquires, Complaints and Reports Committee of CNO on August 26, 2020, to complete remedial activities with respect to the following CNO standards: Professional Standards, Ethics, Therapeutic Nurse-Client Relationship and Privacy and Confidentiality. On February 8, 2021, the Member completed the remedial activities which included, but was not limited to, meeting with a Regulatory Expert.
THE PATIENT
[The Patient] (the “Patient”) was 61 years old at the time of the incidents. He lived with his wife, who suffered a traumatic brain injury, and he was her primary caregiver. The Patient and his wife were patients of the Clinic and were formerly patients of [the Doctor], prior to [the Doctor]’s retirement.
The Member provided care to the Patient at the Clinic. The care the Member provided included taking the Patient’s vitals, administering shots to the Patient including B12 shots and providing other routine care to the Patient that a nurse in a family health setting would provide.
The Patient passed away after the incidents described below.
INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT
The Member engaged in a personal relationship with the Patient from approximately May 2019 until May 2020, at a time when she was also providing him with care, and in a therapeutic nurse-patient relationship. The Member did not document anything in the Patient’s chart with respect to any of the conduct described below, or consult with a manager or supervisor about any of this conduct.
During the personal relationship, the Member and the Patient spent time together outside of the Clinic, including at the Patient’s home. On some of these occasions the Member and the Patient drank alcohol together. In addition, the Member visited the Patient in his home on approximately two occasions during a period of the COVID-19 pandemic when public health restrictions discouraged in-person interactions.
If the Member were to testify, she would testify that on the two occasions she attended the Patient’s home during the COVID-19 restrictions it was for the purpose of delivering masks and to assist with a sick pet. She would further testify that she should not have attended the Patient’s home.
In addition to these in-person interactions, the Member had frequent phone and text message communications with the Patient outside of the therapeutic nurse-patient relationship. In the Patient’s phone, the Member’s contact was saved as “Andrea Nurse”. In those communications, the Member disclosed information about her personal life.
In their text message exchanges, the Patient regularly referred to the Member with terms of affection such as “sweetheart” and “love”. For example, in one text message exchange, the Member sent the Patient a link or document and asked, “Hope this is ok???”. The Patient responded, “That is very very good thank you so much love” “We have so much in common and we get along so well sweetheart” “So why can’t you live with me love” “And I’m a very clean man and you know that honey” “And you are telling [ ] that you are going to find a man in Cuba lol ” “I would have dinner ready for you when I retire every day honey”.
On occasion, the Member also accepted money and gifts from the Patient including a gift card and food. If the Member were to testify, she would say the money was a loan, and the gifts were of nominal value. In text messages, the Member and the Patient discussed the Patient bringing her lunch, buying her clothes and loaning her money including, but not limited to, those outlined below.
The Patient wrote, “Tell me what you want for lunch so I can pick it up sunshine” and the Member responded, “Was thinking the last time I had off was last Christmas” “A taco salad please”. The Patient replied “Wow” “Okay coming right up butter cup” “I’m off work today lol”. The Member then stated, “What do you mean wow you did ask me what I wanted” “Yep rub it in that your off”.
The Member wrote, “Can you lend me $100 till I get back” “Would like to get my nails done and kinda short”. The Patient replied, “Yes I could for andrea” (the Member’s given name) and the Member responded, “Thanks so much [ ]” (a nickname for the Patient).
The Member wrote, “Laundry room is busy can’t get in yet” “But you shouldn’t take advantage of that fact”. The Patient replied, “So come to my house and do it honey” “I’m coming tomorrow at 2 is my appointment sunshine”. The Member replied, “Ok” and the Patient then stated, “Are you coming over or what????” “Let’s go to the bay and get your clothes?????” “For when you go on vacation sweetheart”.
If the Member were to testify, she would testify that at the time she accepted the gift card it was during the holiday season and she did not want to rebuke a gesture of kindness. However, the Member admits and acknowledges that this was not appropriate. The Member would further testify that she declined the offer to shop for clothes at The Bay and did not attend his home to do laundry as suggested in the text messages.
The Member and the Patient also discussed marijuana and alcohol in text messages including, but not limited to, those outlined below.
The Patient wrote, “You are a very busy lady ” “I don’t know when I’m going to give you your weed” “Since you don’t want to see me today lol”. The Member responded, “You can bring it tomorrow when you have your appointment” and the Patient replied, “I’m going to have to cancel that appointment and come on Friday” “Because I have Friday off” “I have to work tomorrow” “Maybe I’m going to take a emergency day off with no pay bye bye”. The Member then texted, “[ ] is not in on Friday” and the Patient replied, “Hmmmmmm” “Okay”. The Member responded, […] “Plus your supposed to give 24 hours notice for a cancellation” “So you best come tomorrow”.
The Member wrote, “It’s great I’m Stoned” to which the Patient replied, “You’ watching tv love”. The Member responded, “Yes dancing with the stars” and the Patient replied, “[ ] just went to bed”. The Member then wrote, “Late” “Why” to which the Patient replied, “That’s what I’m watching” “I don’t know” “She was not tired” “I told her to play with my dick and she said no”. The Member then stated, “Oh [ ] your funny”.
The Patient wrote, “I’m here waiting for you to call me sweetheart” “Hello sunshine” “Can I come over now love for one drink with you love” “[ ] is here I can come over now love ” “Talk to me butter cup”. The Member responded, “No lol, just got out of the bath, have been busy” “Have to pack some last minute things”. The Patient then asked, “Are you going to call me later love”.
The Member wrote, “Goodnight” to which the Patient responded, “It is only 7:30 pm . The Member stated, “I chat to people all day [ ]. need to unwind”. The Patient then asked, “Have you smoked one yet????” and the Member responded, “Just a little”. The Patient replied, “Not to [ ]” and the Member responded, “Bye bye”.
CNO STANDARDS
Code of Conduct
- CNO’s Code of Conduct is a standard of practice describing the accountabilities all Ontario nurses have to the public. The Code of Conduct consist of six principles including:
Nurses respect the dignity of patients and treat them as individuals;
Nurses work together to promote patient well-being;
Nurses maintain patients’ trust by providing safe and competent care;
Nurses work respectfully with colleagues to best meet patients’ needs;
Nurses act with integrity to maintain patients’ trust; and
Nurses maintain public confidence in the nursing profession.
- Regarding the principle requiring nurses to act with integrity to maintain patients’ trust, CNO’s Code of Conduct provides that:
Nurses do not accept gifts from patients, unless it harms the professional relationship with patients;
Nurses declare any conflict of interest that could affect their judgment. This includes a nurse’s personal, financial or commercial interest; and
Nurses maintain professional boundaries with patients.
- CNO’s Code of Conduct defines boundaries as:
The points when a relationship changes from professional and therapeutic to unprofessional and personal. Therapeutic nurse-patient relationships put patients’ needs first. Crossing a boundary means a nurse is misusing their power and trust in the relationship to meet personal needs, or behaving in an unprofessional manner with the patient. Crossing a boundary can be intentional or unintentional
Professional Standards
CNO’s Professional Standards provides an overall framework for the practice of nursing and a link with other standards, guidelines and competencies developed by CNO. It includes seven broad standard statements pertaining to accountability, continuing competence, ethics, knowledge, knowledge application, leadership and relationships.
CNO’s Professional Standards provides, in relation to the accountability standard, that nurses are accountable to the public and responsible for ensuring her or his practice and conduct meets the legislative requirements and the standard of the profession. Nurses are responsible for their actions and the consequences of those actions as well as for conducting themselves in ways that promote respect for the profession. Nurses demonstrate this standard by actions such as ensuring their practice is consistent with CNO’s standards of practice and guidelines as well as legislation.
Therapeutic Nurse-Client Relationship
CNO’s Therapeutic Nurse-Client Relationship Standard (“TNCR Standard”) places the responsibility for establishing and maintaining the therapeutic nurse-patient relationship on the nurse and provides that the nurse-patient relationship is built on trust, respect, empathy, professional intimacy and requires the appropriate use of power.
CNO’s TNCR Standard contains four standard statements which describe nurses’ accountabilities with respect to therapeutic communication, patient-centred care, maintaining boundaries and protecting the patient from abuse.
CNO’s TNCR Standard defines a boundary in the nurse-patient relationship as “the point at which the relationship changes from professional and therapeutic to unprofessional and personal.” CNO’s TNCR Standard places the responsibility for establishing and maintaining the limits and boundaries in the therapeutic nurse-patient relationship on the nurse. CNO’s TNCR Standard provides that:
Crossing a boundary means that the care provider is misusing the power in the relationship to meet his/her personal needs, rather than the needs of the [patient], or behaving in an unprofessional manner with the [patient].
- CNO’s TNCR Standard provides, in relation to maintaining boundaries, that nurses meet this standard by:
Setting and maintaining the appropriate boundaries within the relationship, and helping [patients] understand when their requests are beyond the limits of the therapeutic relationship;
Abstaining from disclosing personal information, unless it meets an articulated therapeutic need of the [patient];
Ensuring that the nurse-[patient] relationship and nursing strategies are developed for the purpose of promoting the health and well-being of the [patient] and not to meet the needs of the nurse, especially when considering self-disclosure, giving a gift to or accepting a gift from a [patient];
Continually clarifying her/his role in the therapeutic relationship, especially in situations in which the [patient] may become unclear about the boundaries and limits of the relationship;
Ensuring that any approach or activity that could be perceived as a boundary crossing is included in the care plan developed by the health care team; and
Consulting with colleagues and/or the manager in any situation in which it is unclear whether a behaviour may cross a boundary of the therapeutic relationship.
CNO’s TNCR Standard outlines guidance regarding the acceptance of gifts and provides that nurses meet the standard by abstaining from accepting individual gifts unless, in rare instances, the refusal will harm the nurse-patient relationship. If the refusal of the gift could be harmful, nurses are to consult with a manager and document the consultation before accepting the gift.
CNO’s TNCR Standard provides, in relation to protecting the patient from abuse, that nurses protect the patient from harm by ensuring that abuse is prevented or stopped and reported. Nurses demonstrate having met the standard by:
Not entering a friendship, or a romantic, sexual or other personal relationship with a [patient] when a therapeutic relationship exists; and
Not engaging in behaviours with a [patient] or making remarks that may reasonably be perceived by other nurses and/or others to be romantic, sexually suggestive, exploitive and/or sexually abusive.
In addition, CNO’s TNCR Standard provides that financial abuse includes, but is not limited to, borrowing money or property from a patient and soliciting gifts from a patient.
The Member admits and acknowledges that she contravened CNO’s Code of Conduct, Professional Standards and TNCR Standard by failing to maintain the boundaries of the therapeutic nurse-patient relationship with the Patient when she engaged in a personal relationship with the Patient.
The Member further admits and acknowledges that her personal relationship with the Patient involved communicating by text message and telephone with the Patient outside of the therapeutic relationship; meeting with and socializing with the Patient in person, including in the Patient’s home, outside of the therapeutic relationship, including but not limited to doing so during a period of public health restrictions that discouraged in-person interactions; accepting gifts, food, alcohol, loans of money, and gifts of money from the Patient; and making disclosures to the Patient about her personal life, that were not for a therapeutic purpose.
ADMISSIONS OF PROFESSIONAL MISCONDUCT
The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 1 (a) (i), (ii), (iii) and (iv) of the Notice of Hearing in that she contravened a standard of practice of the profession or failed to meet the standards of practice of the profession, as described in paragraphs 8 to 29 above.
The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 2 a) (i), (ii), (iii) and (iv) of the Notice of Hearing, and in particular her conduct was disgraceful, dishonourable and unprofessional, as described in paragraphs 8 to 29 above.
If the Member were to testify, she would apologize to the Patient and his family for not setting and maintaining appropriate professional boundaries and engaging in a personal relationship with the Patient. She profoundly regrets her actions and the impact it has had on others and regard for the profession.
Decision
The College bears the onus of proving the allegations in accordance with the standard of proof, that being the balance of probabilities based upon clear, cogent and convincing evidence.
Having considered the evidence and the onus and standard of proof, the Panel finds that the Member committed acts of professional misconduct as alleged in paragraphs 1(a)(i), (ii), (iii), (iv), 2(a)(i), (ii), (iii) and (iv) of the Notice of Hearing. As to allegations 2(a)(i), (ii), (iii) and (iv), the Panel finds that the Member engaged in conduct that would reasonably be regarded by members of the profession to be unprofessional, dishonourable and disgraceful.
Reasons for Decision
The Panel considered the Agreed Statement of Facts and the Member’s plea and finds that this evidence supports findings of professional misconduct as alleged in the Notice of Hearing.
Allegations #1(a)(i), (ii), (iii) and (iv) in the Notice of Hearing are supported by paragraphs 8 to 29, 30 and 32 in the Agreed Statement of Facts. The Panel finds that the Member failed to maintain the boundaries of the therapeutic nurse-client relationship with the Patient when the Member engaged in a personal relationship with the Patient, including but not limited to: communicating by text message and/or telephone with the Patient outside of the therapeutic relationship; meeting with and/or socializing with the Patient in person, including in the Patient’s home, outside of the therapeutic relationship, including but not limited to doing so during a period of public health restrictions that discouraged in-person interactions.
Allegations #2(a)(i), (ii), (iii) and (iv) in the Notice of Hearing are supported by paragraphs 8 to 29, 31 and 32 in the Agreed Statement of Facts. The Panel finds that the Member failed to maintain the boundaries of the therapeutic nurse-client relationship with the Patient when the Member engaged in a personal relationship with the Patient, including but not limited to: accepting gifts, food, alcohol, loans of money, and/or gifts of money from the Patient; and making disclosures to the Patient about your personal life, that were not for a therapeutic purpose.
With respect to Allegations #2(a)(i), (ii), (iii) and (iv), the Panel finds that the Member’s conduct in having a personal relationship with the Patient was unprofessional as it demonstrated a serious and persistent disregard for her professional obligations.
The Panel finds that the Member’s conduct in accepting gifts, food, alcohol, loans of money, and/or gifts of money was dishonourable and disgraceful as it shames the Member and by extension the profession and the Member ought to have known that her conduct was unacceptable and fell below the standards of a professional. The conduct casts serious doubt on the Member’s moral fitness and inherent ability to discharge the higher obligations the public expects professionals to meet.
Penalty
College Counsel and the Member’s Counsel advised the Panel that a Joint Submission on Order had been agreed upon. The Joint Submission on Order requests that this Panel make an order as follows:
Requiring the Member to appear before the Panel to be reprimanded within 3 months of the date that this Order becomes final.
Directing the Executive Director to suspend the Member’s certificate of registration for 4 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 a practicing 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 a minimum of 1 meeting with a Regulatory Expert (the “Expert”) at her own expense and within 6 months from the date that this Order becomes final. If the Expert determines that a greater number of sessions are required, the Expert will advise the Director of Professional Conduct (the “Director”) regarding the total number of sessions that are required and the length of time required to complete the additional sessions, but in any event, all sessions shall be completed within 12 months from the date that this Order becomes final. To comply, the Member is required to ensure that:
i. The Expert has expertise in nursing regulation and has been approved by the Director in advance of the meetings;
ii. At least 7 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 CNO publications and completes the associated Reflective Questionnaires, online learning modules, decision tools and online participation forms (where applicable):
Professional Standards,
Therapeutic Nurse-Client Relationship, and
Code of Conduct;
iv. At least 7 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 patients, 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 one or more 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 18 months from the date the Member returns to the practice of nursing, the Member will notify her 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 nursing position;
ii. Provide her 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 nursing 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.
All documents delivered by the Member to the CNO, the Expert or the employer(s) will be delivered by verifiable method, the proof of which the Member will retain.
Penalty Submissions
Submissions were made by College Counsel.
The aggravating factors in this case were:
The Member failed to maintain the boundaries of the TNCR Standard;
The text message exchanges between the Member and the Patient showed a degree of intimacy and affection;
The Member failed to maintain the basic expectations of the TNCR Standard;
The Member’s behaviour continued for an extended period of time from May 2019 to May 2020;
The Member had a familiarity with and personal relationship with the Patient;
The Member received personal gain by accepting monetary loans and gifts from the Patient;
The Member’s conduct raises questions about her moral fitness and inherent ability to discharge her higher obligations.
The mitigating factors in this case were:
The Member took accountability;
The Member was remorseful;
The Member accepted responsibility by agreeing to the Agreed Statement of Facts and the Joint Submission on Order.
The proposed penalty provides for general deterrence through the 4 month suspension, which sends a message to the Member and the membership at large that a personal relationship with a patient is unacceptable and also ensures this conduct is not repeated by the Member and other nurses.
The proposed penalty provides for specific deterrence through an oral reprimand and the 4 month suspension where the Member will gain greater understanding on how her actions are perceived.
The proposed penalty provides for remediation and rehabilitation through one meeting, at minimum, with the Regulatory Expert to ensure that this conduct is not repeated.
Overall, the public is protected because the Member’s certification of registration is suspended for 4 months. Also, 18 months of employer notification and employer oversight will ensure public awareness.
College Counsel submitted cases to the Panel to demonstrate that the proposed penalty fell within the range of similar cases from this Discipline Committee.
CNO v. Forrester (Discipline Committee, 2019). This case is similar in that the member failed to maintain the boundaries of the therapeutic nurse-client relationship. The member was providing in-home nursing care and brought coffee to the patient at his home and was texting the patient from her personal phone. The member also accessed the patient’s health care record after the professional relationship had stopped. In this case, the penalty included an oral reprimand, a 4 month suspension, two meetings with a Regulatory Expert and 18 months of employer notification.
CNO v. Vecchio (Discipline Committee, 2018). This case is also similar in that the member failed to maintain the boundaries of the therapeutic nurse-client relationship. The member provided care to a patient in a substance abuse unit and admitted to having personal and romantic feelings towards the patient. The member also exchanged a gift of a book with the patient. In this case, the penalty included an oral reprimand, a 4 month suspension, two meetings with a Nursing Expert and 12 months of employer notification.
CNO v. Premji (Discipline Committee, 2017). This case is also similar in that the member failed to maintain the boundaries of the therapeutic nurse-client relationship. The member was practicing in a hospital on the pediatric unit and the patient in this case was 16 years of age. The member showed pictures to the patient on his phone, allowed the patient to use his personal iPad to watch an “R” rated movie and also exchanged personal cell phone numbers and sent text messages to the patient. In this case, the penalty included an oral reprimand, a 3 month suspension, two meetings with a Nursing Expert and 12 months of employer notification.
In each of the above cases there are two meetings with an expert, however, in this case there is a minimum of one meeting with a Regulatory Expert due to the completion of remedial activities indicated in paragraph 4 of the Agreed Statement of Facts.
The Member’s Counsel had the following submissions:
There was no sexual relationship between the Member and the Patient;
There were no sexual comments made by the Member via text;
There was a personal relationship;
There were no concerns identified by the College prior to this incident.
Penalty Decision
The Panel accepts the Joint Submission on Order and accordingly orders:
The Member is required to appear before the Panel to be reprimanded within 3 months of the date that this Order becomes final.
The Executive Director is directed to suspend the Member’s certificate of registration for 4 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 a practicing 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 a minimum of 1 meeting with a Regulatory Expert (the “Expert”) at her own expense and within 6 months from the date that this Order becomes final. If the Expert determines that a greater number of sessions are required, the Expert will advise the Director of Professional Conduct (the “Director”) regarding the total number of sessions that are required and the length of time required to complete the additional sessions, but in any event, all sessions shall be completed within 12 months from the date that this Order becomes final. To comply, the Member is required to ensure that:
i. The Expert has expertise in nursing regulation and has been approved by the Director in advance of the meetings;
ii. At least 7 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 CNO publications and completes the associated Reflective Questionnaires, online learning modules, decision tools and online participation forms (where applicable):
Professional Standards,
Therapeutic Nurse-Client Relationship, and
Code of Conduct;
iv. At least 7 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 patients, 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 one or more 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 18 months from the date the Member returns to the practice of nursing, the Member will notify her 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 nursing position;
ii. Provide her 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 nursing 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.
All documents delivered by the Member to the CNO, the Expert or the employer(s) will be delivered by verifiable method, the proof of which the Member will retain.
Reasons for Penalty Decision
The Panel understands that the penalty ordered should protect the public and enhance public confidence in the ability of the College to regulate nurses. This is achieved through a penalty that addresses specific deterrence, general deterrence and, where appropriate, rehabilitation and remediation. The Panel also considered the penalty in light of the principle that joint submissions should not be interfered with lightly.
The Member failed to maintain the boundaries of the TNCR Standard by having a familiarity with and personal relationship with the Patient; The Member failed to maintain the basic expectations of the TNCR Standard. It is imperative that nurses follow the TNCR to maintain a high quality of care and to ensure that patients receive the highest standard of care. The Member received personal gain by accepting monetary loans and gifts from the Patient. The Member’s conduct raises questions about her moral fitness and inherent ability to discharge her higher obligations.
The Panel finds that the oral reprimand and a four month suspension of the Member’s certificate of registration, satisfies the principles of specific and general deterrence. A minimum of 1 meeting with a Regulatory Expert, satisfies the principle of rehabilitation and remediation, and the 18 months of employer notification, provides public protection.
The Panel concluded that the proposed penalty is reasonable and in the public interest. The Member has co-operated with the College and, by agreeing to the facts and a proposed penalty, has accepted responsibility.
The penalty is in line with what has been ordered in previous cases.
I, Carly Gilchrist, RPN sign this decision and reasons for the decision as Chairperson of this Discipline panel and on behalf of the members of the Discipline panel.