College of Nurses of Ontario v. Isabelle Cabot, 2021 CanLII 153683

DISCIPLINE COMMITTEE

OF THE COLLEGE OF NURSES OF ONTARIO

PANEL: Dawn Cutler, RN Chairperson

Sylvia Douglas Public Member

Ian McKinnon Public Member

Michael Schroder, NP Member

Ingrid Wiltshire-Stoby, NP Member

BETWEEN:

COLLEGE OF NURSES OF ONTARIO ) JEAN-CLAUDE KILLEY for

) College of Nurses of Ontario

• and - )

ISABELLE CABOT ) ANDREW FAITH and

Registration No. 06293753 ) BROOKELYN KIRKHAM for

) Isabelle Cabot

) CHRISTOPHER WIRTH

) Independent Legal Counsel

) Heard: August 30, 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 30, 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 names of the patients, or any information that could disclose the identities of the patients referred to orally or in any documents presented in the Discipline hearing of Isabelle Cabot.

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 names of the patients, or any information that could disclose the identities of the patients referred to orally or in any documents presented in the Discipline hearing of Isabelle Cabot.

The Allegations

College Counsel advised the Panel that the College was requesting leave to withdraw the allegations set out in paragraphs 1(c), (d), (e), (f)(i), (ii), (iii), (iv), (v), (vi), (vii), (viii), (ix), (x), (xi), (xii), 2, 3, 4(a), (b), (c)(i), (ii), (iii), (iv), (v), (vi), (vii), (viii), (ix), (x), (xi), (xii), 5(a), (b)(i), (ii), (iii), (iv), (v), (vi), (vii), (viii), (ix), (x), (xi), (xii), 6(b), (d), (e), (f), (g), (i), (ii), (iii), (iv), (v), (vi), (vii), (viii), (ix), (x), (xi) and (xii) in the Notice of Hearing dated June 8, 2021. The Panel granted this request. The remaining allegations against Isabelle Cabot (the “Member”) are as follows:

IT IS ALLEGED THAT:

1. 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 in the Extended Class at one or both of the medical clinics located at 2 St. Lawrence Drive and/or 171 Montreal Road (the “Clinics”) in Cornwall, Ontario, you contravened a standard of practice of the profession or failed to meet the standards of practice of the profession as follows:

a. in or around April 2017 – December 2017, you failed to maintain the boundaries of the therapeutic nurse-client relationship with [Patient 1];

b. in or around April 2017 – October 2017, you failed to maintain the boundaries of the therapeutic nurse-client relationship with [Patient 2];

c. [withdrawn];

d. [withdrawn];

e. [withdrawn]; and/or

f. [withdrawn]:

i. [withdrawn];

ii. [withdrawn];

iii. [withdrawn];

iv. [withdrawn];

v. [withdrawn];

vi. [withdrawn];

vii. [withdrawn];

viii. [withdrawn];

ix. [withdrawn];

x. [withdrawn];

xi. [withdrawn]; and/or

xii. [withdrawn].

2. [withdrawn].

3. [withdrawn].

4. [withdrawn]:

a. [withdrawn];

b. [withdrawn]; and/or

c. [withdrawn]:

i. [withdrawn];

ii. [withdrawn];

iii. [withdrawn];

iv. [withdrawn];

v. [withdrawn];

vi. [withdrawn];

vii. [withdrawn];

viii. [withdrawn];

ix. [withdrawn];

x. [withdrawn];

xi. [withdrawn]; and/or

xii. [withdrawn].

5. [withdrawn]:

a. [withdrawn]; and/or

b. [withdrawn]:

i. [withdrawn];

ii. [withdrawn];

iii. [withdrawn];

iv. [withdrawn];

v. [withdrawn];

vi. [withdrawn];

vii. [withdrawn];

viii. [withdrawn];

ix. [withdrawn];

x. [withdrawn];

xi. [withdrawn]; and/or

xii. [withdrawn].

6. 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 working as a Registered Nurse in the Extended Class at one or both of the Clinics in Cornwall, Ontario, 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. in or around April 2017 – December 2017, you failed to maintain the boundaries of the therapeutic nurse-client relationship with [Patient 1];

b. [withdrawn];

c. in or around April 2017 – October 2017, you failed to maintain the boundaries of the therapeutic nurse-client relationship with [Patient 2];

d. [withdrawn];

e. [withdrawn];

f. [withdrawn]; and/or

g. [withdrawn]:

i. [withdrawn];

ii. [withdrawn];

iii. [withdrawn];

iv. [withdrawn];

v. [withdrawn];

vi. [withdrawn];

vii. [withdrawn];

viii. [withdrawn];

ix. [withdrawn];

x. [withdrawn];

xi. [withdrawn]; and/or

xii. [withdrawn].

Member’s Plea

The Member admitted the allegations set out in paragraphs 1(a), (b), 6(a) and (c) 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

1. Isabelle Cabot (the “Member”) obtained a Bachelor of Nursing degree in 1997 and a Master of Nursing Sciences degree in 2005, both from the Université de Montréal. The Member also completed a Graduate Diploma in Primary Health Care for Nurse Practitioners at the University of Ottawa in August 2016.

2. The Member registered with the College of Nurses of Ontario (“CNO”) as a Registered Nurse in September 2006. The Member registered as an RN in the Extended Class – Nurse Practitioner (“NP”) in November 2016.

3. The Member worked as an NP at a community medical clinic in Cornwall, Ontario (the “Clinic”).

4. The Clinic was operated by Dr. [1], who also worked there as one of two physicians, along with Dr. [2], both of whom specialized in family medicine. The Member worked at the Clinic from November 2016 until April 2018.

5. The Member is currently working at the Centre de Santé Communautaire de l’Estrie-Cornwall.

6. The Member has no prior CNO discipline history.

THE PATIENTS

Patient [1] and Patient [2]

7. Patient[1] was a [ ]-year-old patient with asthma, respiratory infections, and severe dental hygiene issues.

8. The Member started seeing Patient [1] in January 2017.

9. Patient [2] was a [ ]-year-old patient with sinus infection, and mental health issues.

10. The Member started seeing Patient [2] in February 2017.

11. Patient [1] and Patient [2] were spouses and had [ ] children together.

12. The Member was in a therapeutic nurse patient relationship with both Patient [1] and Patient [2] at the relevant times as described below.

INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT

Failure to Maintain Boundaries of the Therapeutic Nurse-Patient Relationship

13. On March 22, 2017, Patient [2] attended the Clinic with her husband, Patient [1], who was in pain from a tooth abscess.

14. Before entering the Clinic, Patient [2] and Patient [1] noticed the Member in the parking lot and approached her to solicit her opinion on what they should do. The Member advised that Patient [1] should immediately go to the hospital.

15. Patient [2] and Patient [1] asked the Member if they could contact her later about Patient [1]’s condition. The Member provided both Patient [2] and Patient [1] with her personal cell phone number. The patients were grateful for her assistance.

16. Between June and July 2017, Patient [1] and the Member began exchanging text messages of a personal nature. For example, Patient [1] would inquire after the Member’s personal life and young child, and would comment on the quality of his marriage with Patient [2].

17. While the Member and Patient [1] were communicating via text, the Member continued providing in-person treatment for Patient [2] and Patient [1] at the Clinic, including writing antibiotic and asthma inhaler prescriptions for Patient [1] and referring him to a laboratory for a chest X-ray.

18. On July 11, 2017, the Member texted Patient [1], including but not limited to the following (all messages below reproduce the spelling and capitalization of the original messages):

…at the end of the day i need to respect my career that i have worked so hard for

This is not me saying we cannot be friends it’s simply me saying that this relationship/friendship needs to remain on a professional level . we both have a lot going on in our personal lives and I think it’s best we take a step back until a more appropriate time in our lives

i hope that you can understand

it’s nothing personal. i’ve just worked very hard to be where i am in my career and i can’t jeopardize that. It would be different if we were both at different times in our lives but unfortunately we are not :-(

i really wish the best for you xxx

19. Patient [1] texted the Member the following messages in response:

Well we can be doctor and patient and I’m done with our secret and getting to go further

Enjoy our ife and may you get the best out of it

Bye [kiss emoji]

Can u tell me the truth why you pushing me away?

Bc honestly I’m so fucking heart broken as I read that like wow really as if :-(

i can’t believe what I read all I can say is I’m so shocked and hurt but I’m a big boy I’ll be OK but as for doctor patient I think it’s best we don’t I’ll find a new one and was so happy to be in your life but for you to do this is too much for me so goodbye isabelle [kiss emoji]

It’s ok have your career I understand but I’m done with patient and secret

I’ll delete your number and ask [ ] to terminate my file, I just don’t understand why you pushed me away and led me to believe you had feelings for me and threw it out that fast I don’t understand

You never wanna be with me????? Like wtf what happened in a night? Grrrrr :@ What did I do I’m so lost and hurt this is bullshit Even introduced you to my parents and now look like an idiot

…I’ll call [ ] tomorrow and have me n [Patient 2] off the list xoxo

20. Despite what the Member and Patient [1] stated in their July 11, 2017 messages, the Member did not discontinue her therapeutic nurse-patient relationship with Patient [1].

21. The Member did not document this dialogue in Patient [1]’s chart. There are also no Clinic records indicating that the Member was concerned about her interactions with Patient [1] at any point in time.

22. Patient [1] did not call the Clinic and ask to be removed from the Member’s roster. He also did not ask that his wife be removed from the roster, as he had led the Member to believe in their July 11, 2017 messages.

23. The Member continued providing treatment to Patient [1] and Patient [2] at the Clinic.

24. In August 2017, the tenor of the messages between the Member and Patient [1] became more intimate, a sample of which is reproduced below from a text exchange on or around August 9, 2017:

Member: We are going out at parl lamoureux xoxo i love u

Patient [1]: Ok bye I’ll ttyl love u too

25. If Patient [2] were to testify, she would state that around this time, she became suspicious about the nature of her husband’s relationship with the Member.

26. At no point did the Member document in either Patient [1]’s or Patient [2]’s chart that any of this personal contact had taken place, or that she had any concerns about the integrity of her professional relationship with either patient.

27. On August 18, 2017, Patient [2] attended at the Member’s home. Patient [2] was angry about her husband’s apparent feelings for the Member, yelling words to the effect of “leave my husband alone” and “you are ruining my marriage”. Patient [2] refused to leave until the Member, fearing for her safety, threatened to call the police.

28. On August 18, 2017, Patient [1]’s chart indicates that he called the Clinic and asked to be removed from the Member’s roster. Patient [1] did not provide an explanation, and none was recorded in his chart.

29. On or around August 18, 2017, the Member explained to Dr. [2] that she thought Patient [1] was interested in a relationship outside the therapeutic nurse-patient boundaries and that she was also concerned about Patient [2]’s behaviour toward her. The Member asked Dr. [2] if she would take [Patient 1] and [Patient 2] over as patients.

30. On August 21, 2017, at Dr. [2]’s suggestion, the Member emailed Dr. [2], asking if she would assume treatment responsibilities over both [Patient 1] and Patient [2]. In her email, the Member did not repeat the explanation for why she wanted Dr. [2] to assume carriage of the patients’ files.

31. Dr. [2] did not add [Patient 1] or Patient [2] to her roster. If Dr. [2] were to testify, she would state that she advised the Member to document what had happened.

32. In or about August 2017, the Member developed and implemented a care plan for Patient [2] to manage her mental health concerns. This included but was not limited to prescribing Prozac, Fluoxetine and Clonazepam.

33. On August 22, 2017, despite having knowledge of her husband’s pursuit of the Member, Patient [2] wanted to see the Member at her scheduled appointment. No other medical care provider was available or willing to see Patient [2]. If the Member were to testify, she would state that [Patient 1] demanded she help Patient [2]. In Patient [2]’s chart, the Member made an entry stating that the patient was “going through separation” and that this was one of the factors detrimentally impacting her mental health.

34. Also on August 22, 2017, the Member presented Patient [2] with a Patient Agreement for Long-term Opioid Therapy, which the patient executed.

35. Patient [2] expressed her gratitude to the Member via text message after the appointment:

Yes i feel good leaving your office :-D im happy u were able too care for me :-D

36. In September 2017, [Patient 1] (now no longer a patient) moved in with the Member and they commenced a romantic, personal, and sexual relationship.

37. The Member did not discontinue her therapeutic nurse-patient relationship with Patient [2]. Patient [2] sought the Member’s medical advice via text message and attended at the Clinic. Despite knowing that [Patient 1] had moved in with the Member, Patient [2] insisted she wanted to see the Member. If the Member were to testify, she would state that she had directed Patient [2] to see another provider but that [Patient 1] made her feel that she had no choice but to help his wife. The Member continued to treat Patient [2], including at least the following:

a. the Member saw Patient [2] on September 12, 2017, to follow-up on her mental health concerns. The Member assessed Patient [2], revised and renewed her prescriptions for Prozac and Clonazepam, and ordered an electrocardiogram; and,

b. the Member revised and renewed Patient [2]’s Prozac prescription on September 28, 2017.

38. The Member did not provide nursing care to Patient [2] after September 28, 2017.

39. On October 1, 2017, Patient [2] texted the following to the Member:

U ruined my family thanks

How do you live with yourself

Good bye

Im.not seeing you on the 24th I want that new doctor u said

Its funny u think [Patient 1] likes u Awell Not my business Bye

40. The Member did not respond to Patient [2]’s text messages.

41. According to her chart, Patient [2] officially transferred care providers as of October 11, 2017. [Patient 2]’s chart notes that she agreed to be transferred to another facility.

42. In December 2017, [Patient 1] – still living with the Member at the time – was charged with possession for the purpose of trafficking cocaine and fentanyl. He was arrested and released on bail, a term of which was that he was prohibited from contacting the Member.

43. In January 2018, the Member learned she was pregnant with [Patient 1]’s child. The Member and [Patient 1] were not living together at this time and were not communicating.

44. After discovering that the Member was pregnant, [Patient 1] began to send text messages to the Member on a daily basis. These messages included threats of violence against the Member, including the following messages sent by [Patient 1] to the Member on April 5, 2018:

Your a fucking idiot […]

You call mom and sister again I will have your fucking head […]

I will show blood

Your such a fucking retard […]

Fuck off […]

Loose lips sink ships […]

You fucking stop you fucking idiot you caused a lot of shit […]

You did this so explain to my family and courts your own shit […]

Fuck off and have a nice life bitch [… ]

I fucking swear I will destroy you […]

45. The Member’s relationship with [Patient 1] deteriorated due to his emotionally abusive and manipulative behaviour.

46. By July 2018, the Member and [Patient 1]’s romantic relationship had ended.

47. Between July and September 2018, [Patient 1] continued to send threatening text messages to the Member while she was pregnant with his child.

48. At the time the Member gave birth in September 2018, she disclosed to her medical providers that she had been abused by [Patient 1]. [Patient 1] attempted to see the new-born at the hospital and was stopped by staff. Hospital staff referred the Member to the assault and sexual abuse program, where she later attended for counselling.

49. After their child was born, [Patient 1] continued to text message the Member, demanding she respond, which she did not. On or around February 22, 2019, [Patient 1] messaged the Member as follows:

[…] MARK MY WORDS, IM IS TIME LIFE

ISNT OVER , ILL SEE U

You fucked up again …you wanna ignore my life to me lol I’m coming bad […]

[Child] is coming home

Without u

Blood test don’t lie […]

You n me will see one another soon […]

Show your lawyer this….IM COMING… you rat faced […]

I’m coming and I want my boy

50. On November 25, 2019, [Patient 1] was sentenced to five years and two months in jail for trafficking in cocaine and a fentanyl analogue. The sentencing judge made findings about [Patient 1]’s history of criminal charges, domestic violence, and deception, including: “You have lied to yourself, your family, and this Court. And demonstrated quite clearly that your needs take precedence over the needs of others.”

51. If the Member were to testify, she would state that she was in a vulnerable mental and emotional state during the currency of her nurse-patient relationships with Patient [1] and Patient [2] and that, due to challenging circumstances in her personal life, her judgment was compromised. These circumstances included a breakdown in the Member’s marriage, disputes with her former spouse over access to their child, and an estrangement from her friends and family as she lived in a new town and province.

52. The Member would further say that, [Patient 1], seeing her as a vulnerable target during this period, aggressively pursued and manipulated her psychologically. She was unable to appreciate the emotionally abusive, controlling, and dominating nature of [Patient 1]’s behaviour and its impact on her. She would say that she continued to treat Patient [2] after [Patient 1] moved in with her at [Patient 1]’s insistence.

53. The Member underwent a psychological assessment in Fall 2020. If the psychologist were to testify, he would say that the Member was a victim of domestic violence and suffers from post-traumatic stress disorder as a result of the abuse she received from [Patient 1]. The psychologist would further say that what happened with Patient [2] and [Patient 1] represented an extreme isolated incident that required the perfect storm of circumstances, including a lack of support at the Clinic, and the manipulative abilities of [Patient 1]. The psychologist would also say that he has no hesitation in opining that the Member is not a risk to future patients.

54. Still, the Member understands that her actions violated patient trust and her commitment to safe, ethical nursing.

55. The Member further recognizes that, despite the turmoil in her personal life, she had a duty to ensure both Patient [1] and Patient [2] were protected from being impacted by these circumstances. The Member admits that she did not fulfil this positive obligation by violating therapeutic nurse-patient boundaries and crossing the professional boundary with both patients. The Member takes full responsibility for her misconduct.

Complaints to CNO from the Patients

56. In April 2018, Patient [2] filed a complaint with, and was interviewed by, CNO. Patient [2] explained that she felt betrayed by both the Member and her husband, Patient [1]. If she were to testify, she would state that the situation involving the Member and her husband’s conduct has profoundly affected her and her three children.

57. In July 2018, Patient [1] filed a complaint with, and was interviewed by, CNO. Patient [1] explained that he felt misled and exploited by the Member. If he were to testify, he would state that he let the Member buy him material items and continue a romantic affair without his wife’s knowledge because the Member promised to take care of him.

CNO STANDARDS OF PRACTICE

58. CNO publishes standards to set out expectations for the practice of nursing. CNO’s standards inform nurses of their accountabilities and apply to all nurses regardless of their role, job description or area of practice.

Nurse Practitioner

59. CNO’s Nurse Practitioner Standard describes accountabilities specific to NPs.

60. NPs must not obtain any personal benefit that conflicts with their ethical duty toward their patients because of their NP practice. If NPs perceive issues in therapeutic relationships with their patients, they are expected to communicate their concerns, discontinue services, and document the reason for the decision to discontinue services, including a description of the actions taken to resolve issues prior to the decision.

Professional Standards

61. CNO’s Professional Standards provides that each nurse is responsible for ensuring that their conduct meets the standards of the profession.

62. Nurses are expected to take responsibility for their actions and the consequences of those actions. Nurses are also accountable for conducting themselves in ways that promote respect for the profession as a whole and reinforce public confidence in the integrity and respectability of its members.

63. This practice standard indicates that a nurse demonstrates these expectations by, among other actions:

a. ensuring practice is consistent with CNO’s standards of practice and guidelines as well as legislation;

b. ensuring [patients’] needs remain the focus of the nurse-patient relationship;

c. recognizing, preventing and reporting patient abuse;

d. maintaining boundaries between professional therapeutic relationships and non-professional personal relationships; and

e. providing, facilitating, advocating and promoting the best possible care for patients.

Therapeutic Nurse-Client Relationship Standard

64. CNO’s Therapeutic Nurse-Client Relationship Standard (“TNCR Standard”) provides guidance on establishing and maintaining appropriate nurse-patient boundaries.

65. The TNCR Standard states that therapeutic nursing services “contribute to the [patient’s] health and well-being” and that meaningful relationships are built on a foundation of “trust, respect, empathy and professional intimacy” that requires an acknowledgement of the “appropriate use of power inherent in the care provider’s role.”

66. While the TNCR Standard notes that establishing safe and compassionate therapeutic relationships with patients is a key component of nursing practice, the TNCR Standard clarifies that setting appropriate boundaries with patients is also an important aspect of a nurse’s job.

67. The TNCR Standard explains that nurses meet the standard for patient-centred care by guaranteeing that all professional behaviour and actions meet the therapeutic needs of the patient. More precisely, nurses meet the standard by, among other actions:

a. helping [patients] understand when their requests are beyond the limits of the therapeutic relationship;

b. 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;

c. ensuring that the nurse does not interfere with the [patient’s] personal relationships;

d. clarifying one’s role in the relationship continuously to help reinforce and/or clarify boundaries for patients who may become uncertain about the limits of their relationship with the nurse;

e. 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;

f. documenting patient-specific information in the patient’s record regarding instances in which it was necessary to consult with a colleague/manager about an uncertain situation, such as boundary crossing or inappropriate interactions between the nurse and his/her patient; and,

g. refraining from self-disclosure unless it meets a specific, identified therapeutic [patient] need.

ADMISSIONS OF PROFESSIONAL MISCONDUCT

68. The Member admits that her interactions with Patient [1] and Patient [2] between April 2017 and October 2017 contravened the boundaries of the therapeutic nurse-patient relationship. She acknowledges that she was required to maintain the standards of the practice of the profession as set out in CNO’s Professional Standards and Nurse Practitioner Standard at all times during her practice.

69. Specifically, the Member admits that she breached the standards of practice of the profession in CNO’s Therapeutic Nurse-Client Relationship Standard while providing care to Patient [1] and Patient [2].

70. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 1(a) and 1(b) of the Notice of Hearing in that she failed to maintain the standards of practice of the profession, specifically the boundaries of the therapeutic nurse-patient relationship, as described in paragraphs 13 to 55 above.

71. The Member admits that she committed the acts of professional misconduct alleged in paragraphs 6(a) and (c) in the Notice of Hearing and that her failure to maintain therapeutic nurse-patient boundaries is disgraceful, dishonourable and unprofessional, as described in paragraphs 13 to 55 above.

72. CNO withdraws the following allegations in the Notice of Hearing, with leave of the Discipline Committee:

a. 1(c), (d), (e), (f)(i)-(xii)

b. 2

c. 3

d. 4(a), (b), (c)(i)-(xii)

e. 5(a) and (b)(i)-(xii)

f. 6(b), (d), (e), (f) and g(i)-(xii)

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), (b), 6(a) and (c) of the Notice of Hearing. As to allegations #6(a) and (c), 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.

Allegation #1(a) in the Notice of Hearing is supported by paragraphs 11-24, 26-31, 33, 36, 37 and 42-70 in the Agreed Statement of Facts. The Member provided Patient [1] with primary care services in the context of a nurse-patient therapeutic relationship from January 2017 to August 2017 inclusive. Between June and July 2017, the Member began exchanging text messages of a personal nature with Patient [1] which discussed the personal life of the Member and her young child and the quality of Patient [1]’s marriage with Patient [2]. The text messages between Patient [1] and the Member became more intimate in August 2017. On August 18, 2017, Patient [1] called the clinic to remove himself from the Member’s primary care roster. The Member clearly violated the College’s Therapeutic Nurse-Client Relationship Standard (“TNCR Standard”) by not maintaining boundaries between professional therapeutic relationships and non-professional personal relationships. The TNCR Standard outlines that setting appropriate boundaries with patients is part of a nurse’s job. More precisely, the Member failed to help Patient [1] understand that his request for a personal relationship was beyond the limits of the therapeutic relationship.

Allegation #1(b) in the Notice of Hearing is supported by paragraphs 9-17, 19, 22, 23, 25, 26, 27, 29-35, 37(a), 37(b), 38, 39, 40, 41, 52-56 and 58-70 in the Agreed Statement of Facts. The Member provided Patient [2] with primary health care services in the context of a nurse-patient therapeutic relationship from January 2017 to October 11, 2017. The Member also provided primary health care services to Patient [2]’s spouse, [Patient 1], from January 2017 to August 2017. During August 2017, Patient [2] became suspicious about her husband ‘s relationship with the Member. The Member continued to see Patient [2] for mental health concerns (on August 22, 2017) while engaged in a romantic and personal relationship with Patient [2]‘s husband (September 12, 2017 and September 28, 2017). The Member’s simultaneous relationships with Patient [2] and Patient [2]’s husband violated the College’s TNCR Standard which indicates that a Member must maintain boundaries between professional therapeutic relationships and non-professional personal relationships. Furthermore, the text messages sent on October 1, 2017 by Patient [2] to the Member clearly demonstrate that the Member interfered with Patient [2]’s personal and marital relationship with [Patient 1] which also contravenes the College’s TNCR Standard.

With respect to allegations #6(a) and 6(c), the Panel finds that the Member’s conduct in failing to maintain the boundaries of the therapeutic nurse-client relationship was unprofessional as it demonstrated a serious and persistent disregard for her professional obligations.

The Panel also finds that the Member’s conduct was dishonourable. It demonstrated an element of dishonesty and deceit through continuing to provide primary health care services to Patient [2] while engaged in a romantic, personal and sexual relationship with Patient [2]’s husband. The Member knew or ought to have known that her conduct was unacceptable and fell below the standards of a professional.

Finally, the Panel finds that the Member’s conduct was disgraceful as it shames the Member and by extension the profession. The conduct of maintaining a sexual and personal relationship with a former patient that caused distress to the patient’s spouse, who was also a patient, and failing to transfer care of Patient [2] while carrying on an affair with Patient [2]’s spouse 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 partial Joint Submission on Order had been agreed upon. The Panel was left with deciding on both the length and start date of the suspension. The partial Joint Submission on Order requests that this Panel make an order as follows:

1. Requiring the Member to appear before the Panel to be reprimanded within 3 months of the date that this Order becomes final.

2. Directing the Executive Director to suspend the Member’s certificate of registration for a period of time to be determined by the Panel. This suspension shall take effect on a date to be fixed by the Panel and shall continue to run without interruption as long as the Member remains in a practicing class.

3. 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 2 meetings with a Regulatory Expert (the “Expert”) at her own expense and within 6 months from the date of 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 of 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 of Professional Conduct (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:

1. the Panel’s Order,

2. the Notice of Hearing,

3. the Agreed Statement of Facts,

4. this Joint Submission on Order, and

5. 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):

1. Code of Conduct,

2. Nurse Practitioner,

3. Professional Standards, and

4. Therapeutic Nurse-Client Relationship;

iv. Before the first meeting, the Member reviews and completes the CNO’s self-directed learning package, One is One Too Many, at her own expense, including the self-directed Nurses’ Workbook;

v. At least 7 days before the first meeting, the Member provides the Expert with a copy of the completed Reflective Questionnaires, online participation forms and Nurses’ Workbook;

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

1. the acts or omissions for which the Member was found to have committed professional misconduct,

2. the potential consequences of the misconduct to the Member’s patients, colleagues, profession and self,

3. strategies for preventing the misconduct from recurring,

4. the publications, questionnaires and modules set out above, and

5. the development of a learning plan in collaboration with the Expert;

vii. 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:

1. the dates the Member attended the sessions,

2. that the Expert received the required documents from the Member,

3. that the Expert reviewed the required documents and subjects with the Member, and

4. the Expert’s assessment of the Member’s insight into her behaviour;

viii. 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’s suspension ends, 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:

1. the Panel’s Order,

2. the Notice of Hearing,

3. the Agreed Statement of Facts,

4. this Joint Submission on Order, and

5. 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 will confirm:

1. that they received a copy of the required documents, and

2. 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.

c) The Member shall not practice nursing in an independent setting, including but not limited to, establishing a sole-practitioner clinic or business, self-employed nursing care and/or home-care settings, for a period of 18 months from the date the Member’s suspension ends.

4. 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.

College Counsel advised that there was no agreement on both the length and start date of the suspension. The College was seeking a suspension in the range of 12-14 months. College Counsel acknowledged recent decisions from the Discipline Committee have provided for a delayed commencement of suspensions by 1-2 months due to the ongoing challenges with availability of health human resources related to the COVID-19 pandemic. College Counsel submitted that a couple of months delay in the commencement of the suspension so that the Member may continue to provide nursing services during the COVID-19 pandemic would be consistent with this.

The mitigating factor in this case was that there was considerable abusive conduct by Patient [1] towards the Member. However, despite this untoward conduct, Patient [1] was still entitled to benefit from the protections inherent to the nurse-patient relationship.

The aggravating factors in this case were the seriousness of the misconduct and that the responsibility for guarding the boundaries of the nurse-client relationship lies with the nurse. The patient does not have a license or a professional obligation to safeguard the boundaries. The Member treated Patient [2] for depression which was partly attributed to Patient [2] going through a separation with her husband in which the Member was involved. The Member provided intense treatment to Patient [2] which involved prescribing psychoactive substances. This conduct is quite serious when it comes to boundary breaches of the nurse-client relationship. The Member made a series of judgement errors over a period of time.

The penalty sought by the College provides for general deterrence through the 12-14 month suspension proposed by the College.

The penalty sought by the College provides for specific deterrence through the oral reprimand and the 12-14 month suspension proposed by the College.

The penalty proposed by the College provides for remediation and rehabilitation through a minimum of 2 meetings with a Regulatory Expert.

Overall, the public is protected through the 18 months of employer notification and the restriction on independent practice for a period of 18 months as both will offer the Member increased supervision on her return to practice.

College Counsel submitted cases to the Panel to demonstrate that the penalty proposed by the College fell within the range of similar cases from this Discipline Committee.

CNO v. Trzop (Disciplinary Committee, 2018): This case involved two notices of hearing. The member failed to maintain the boundaries of the nurse-patient relationship in respect of a family member of the client. The member engaged in a personal and sexual relationship with the patient's grandson. The member engaged in a financial relationship with the patient’s daughter by agreeing to pay rent. The second notice of hearing included allegations that the member drank alcoholic beverages with the patient’s grandson when not on shift. The member gave the patient’s daughter 2-3 oxycodone tablets which were not prescribed for the patient’s daughter. The member provided almost daily palliative home care to the patient who was in her late 90’s. The member brought her daughter to the patient’s home. The member was pregnant with the patient’s grandson’s baby. The member withdrew herself from care when she decided to move into the patient’s residence. The penalty included an oral reprimand, a 12 month suspension, 2 meetings with a Nursing Expert, a 12 month employer notification, and legal costs and expenses of the College in the amount of $1500.00.

CNO v. Riehl (Disciplinary Committee, 2019): In this case, the member did not attend or participate in the hearing. This case involved a member who was practicing as a nurse practitioner in a family medicine context. For a period of just under 2 years, the member maintained a sexual relationship with a patient that included sexual intercourse which constituted sexual abuse. The member also maintained a professional and personal relationship with the spouse of the patient. The distinguishing feature in this case is that the patient and sexual relationship coexisted. The similarity in this case is the problematic and traumatic effect on relationships that resulted from the breaching of the therapeutic boundaries. Both patients and their daughter had difficulty accessing healthcare in their community when the relationships eventually dissolved. The penalty in this case included an oral reprimand and revocation of the member’s certificate of registration.

CNO v. Hawil (Disciplinary Committee, 2016): In this case, the allegation was failing to maintain the therapeutic nurse-client boundaries in respect of the client. The client was 40 years old and admitted to a psychiatric unit following a suicide attempt. The client had a long standing history of depression and borderline personality disorder. During the admission, the member was her assigned nurse for 14 shifts. Six weeks after the client was discharged, the member called her and asked to meet in person. The member took the client to lunch and then went to a motel where the member and the client had sex. Afterwards, the member drove the client home and provided the client with $50.00 to buy cigarettes. The client reported the incident to the hospital more than a year later. The member admitted that the relationship happened due to the established nurse-client relationship and the corresponding trust and professional intimacy involved. The penalty included an oral reprimand and revocation of the member’s certificate of registration. Similarities in the case involve a sexual relationship with a former patient arising out of the nurse-client relationship.

CNO v. Seymour (Disciplinary Committee, 2017): In this case, the member failed to maintain the boundaries of the nurse-client relationship. The client was diagnosed with diabetes and saw the member three times at a diabetes clinic. Subsequently, the member and the client became entangled in a personal and romantic relationship. The member and the client eventually got married. The penalty proceeded by way of a Joint Submission on Order which included an oral reprimand, a 3 month suspension, two meetings with a Nursing Expert and 12 months of employer notification.

CNO v. Bowlby (Discipline Committee, 2015): This case involved a personal relationship with a significant other rather than the patient. The client lived with her significant other. The member provided periodic homecare to the client. The member entered into a personal and romantic relationship with the client’s significant other. The penalty proceeded by way of a Joint Submission on Order which included an oral reprimand, a 4 month suspension, two meetings with a Nursing Expert and 12 months of employer notification.

CNO v. Wright (Discipline Committee, 2007 & 2017): In 2007, the member had been found guilty of sexual exploitation contrary to the Criminal Code. In 2017, the member was alleged to have engaged in touching of a sexual nature and behaviour of a sexual nature towards a client. In the 2007 decision, the panel took into account a report from an expert witness who provided an opinion on the member’s likelihood of reoffending. The panel ordered a lengthy penalty which included a number of restrictions on the member’s practice. The member reoffended. In 2017, the member had his certificate of registration revoked by the Disciplinary Committee. The case provided the Panel with context that even though an expert report is filed indicating a low likelihood of the member reoffending, the member did subsequently reoffend.

College Counsel further submitted that nurses are expected not to breach the standards, to correct a breach and that it is not less serious to give into a pursuit, while acknowledging that the Member faced challenging circumstances and abusive conduct by Patient [1].

The Member’s conduct was at the high end of seriousness. As a nurse practitioner, she was engaged in treating [Patient 2] for depression, which related in part to her separation from [Patient 1], and in which the Member was involved. It involved a series of judgment errors over a period of time and was not a momentary lapse.

The Member could have done more to terminate the patient relationship and transfer care and cannot abdicate responsibility for this. Except for the mitigating factors, the College would have asked for revocation.

After the Member’s conduct, the legislation was changed and the conduct would now be considered sexual abuse and informs the seriousness of the Member’s conduct.

Submissions were made by the Member’s Counsel.

The Member’s Counsel proposed a suspension of no longer than 3 months with a range of 2-3 months and submitted that there has never historically been an upheld suspension from the College in excess of 12 months. Given this, a suspension of 12 months must be reserved for the most egregious cases. The Member’s Counsel submitted that this case involves several special, unique and extraordinary mitigating factors which warrant a suspension in the lower range.

The Member’s Counsel submitted the psychological report authored by Dr. Peter Jaffe (“Dr. Jaffe“) dated November 24, 2020. Dr. Jaffe is an experienced psychologist and a professor at Western University. The Member was assessed by Dr. Jaffe using a lengthy interview and psychological testing. Dr. Jaffe opined that this case was an isolated incident and that the Member is not at risk to reoffend. Furthermore, Dr. Jaffe reported that a negative power dynamic existed between Patient [1] and the Member and this caused psychological harm to the Member. The Member currently suffers from PTSD as a result of the abuse that she endured from her relationship with Patient [1].

The Member’s Counsel submitted a letter from a therapist, Maureen Reid dated January 8, 2021. This letter confirms that the Member is engaged in counselling which was recommended as part of Dr. Jaffe’s recommendations.

The Member’s Counsel submitted two letters dated December 10, 2020 and August 24, 2021 from Marc Bisson who is the Member’s current employer. The Member has been under conditions and supervision which the Member has been abiding by. The letter confirms the importance that the Member’s service has to the medical centre. The letter outlines that the Member’s absence will have a negative effect on the medical centres‘ ability to serve their vulnerable patients. The second letter speaks to the Member’s key involvement in the medical centre’s youth hub.

The Member’s Counsel submitted three letters of support. An e-mail dated January 29, 2021 from Deena Shirley, Director, Child and Youth Mental Health Services at the Cornwall Hospital in Cornwall, Ontario which speaks to the Member’s importance with two youth clients with complex needs. A letter dated May 19, 2021 from Bernadette Clement, the former mayor of Cornwall, Ontario which explains the Member’s valued role at the youth centre and the importance that the youth centre plays in the community. A letter dated August 26, 2021 from Leanne Clouthier, Manager Primary Care – Programs and Services at Seaway Valley Community Health Centre which speaks to the Member’s valued contribution to clients from the Deer Lake First Nation, Ontario evacuation.

The Member’s Counsel submitted two letters of support from patients. The e-mails dated June 22, 2021 and July 19, 2021 speak to the importance of the Member’s care of two autistic children and the Member’s proactive care which saved a patient’s life.

The Member’s Counsel submitted two character references. The first is an email dated December 28, 2020 from Ghislaine Blais which speaks to the Member’s resilience and perseverance in her professional and personal life during the COVID-19 pandemic. The second is a letter dated December 18, 2020 from Caroline Therrien which speaks to the Member’s good character and professionalism.

The Member’s Counsel submitted the sentencing submissions of Patient [1]. The submissions outline that Patient [1] was a manipulative and abusive partner.

The Member’s Counsel submitted that the Member is a single mother of two children. The Member is an accomplished nurse practitioner. The Member obtained her Bachelor of Nursing at 21 years of age and subsequently obtained a Master of Science in Nursing. The Member was enrolled in a PhD program in biomedical sciences, but instead of defending her thesis, the Member chose to pursue a career as a nurse practitioner. The Member is a former competitive swimmer and diver and previously served as a community health nurse in Nunavut. The Member currently serves at a community health centre as a nurse practitioner who serves her clients in both official languages. The Member works closely with youth clients at the Cornwall Youth Hub. The Member has no discipline history with the College.

The Member’s Counsel submitted that the aggravating factors include that the Member should have been more forthright and diligent with setting boundaries with Patients [1] and [Patient 2] and should not have treated Patient [2] while she was involved in a personal and sexual relationship with Patient [1].

The Member’s Counsel submitted that the mitigating factors in this case were that Patient [1] was the person who initiated the intimate relationship with the Member. Furthermore, Patient [1] aggressively pursued the Member and engaged in boundary crossing in order to do so. The Member was not preying on or pursuing her client. Patient [1] was the dominant actor exhibiting abusive and manipulative power to secure and maintain his relationship with the Member. The Member was in a vulnerable position due to the separation from family and friends that she endured while having just moved to a new community to secure employment. The Member felt compelled to treat Patient [2] given Patient [1]’s insistence to do so. The Member did make attempts to transfer Patient [2]‘s care to another provider, however, the Member was unsuccessful in doing so.

The facts of the case do not support that the Member is a threat to the public or her patients. The public’s confidence in the profession would be best served by emphasizing the Member’s rehabilitation. A long suspension will not assist with deterring any future conduct. There is no need for a lengthy suspension to deter others in her situation given that there has not been any historical similar situation that has come before the Discipline Committee. A lengthy suspension would be grossly disproportionate given the typical suspensions levied in historical similar cases.

The Member’s Counsel reviewed the cases put forward by College Counsel in light of College Counsel seeking a 12-14 month suspension. The Member’s Counsel highlighted that there have been no prior cases of the Discipline Committee where an ordered suspension higher than 12 months has been successfully upheld. The Member would have to pose a high risk to patients to warrant a suspension greater than 12 months. As a whole, the Member’s Counsel outlined several differences between the cases presented by College Counsel and the case before this Panel. The clients in the cases presented were extremely vulnerable and had well developed relationships with the members compared to the case before this Panel. None of the cases involved a member who was a victim of a manipulative and abusive client. The members in the cases initiated and pursued the relationship and showed no attempt to maintain boundaries.

CNO v. Trzop (Discipline Committee, 2018): The penalty in this case included a 12 month suspension. The College presented no prior cases to support the proposed penalty given that there were no similar cases. The client in this case was extremely vulnerable given that she was in her late 90’s and receiving palliative care in her home. The member in this case was not manipulated, abused or controlled. With respect to the case before this Panel, the degree of vulnerability with Patient [1] was significantly less.

CNO v. Riehl (Discipline Committee, 2019): This case involved mandatory revocation in light of the findings of sexual abuse. This case involved the member having a sexual relationship with her patient while they were simultaneously engaged in a nurse-client relationship. With respect to the case before this Panel, the Member’s sexual relationship with Patient [1] occurred after the termination of the nurse-client relationship. The Riehl case also involved deception by the member given that she tried to alter the electronic medical records to show that the patient was attached to a care provider other than herself.

CNO v. Hawil (Discipline Committee, 2016): This case involved a penalty of revocation where the member had already resigned. The differences in this case was the relationship was more intense compared to the case before this Panel. In the Hawil case, the member took advantage of the intimacy that had developed in order to initiate contact with the client outside of the hospital environment.

CNO v. Bowlby (Discipline Committee, 2015): This case involved the member providing homecare to a vulnerable patient who was hearing impaired and highly dependent on her significant other. The member initiated the relationship with the patient’s significant other after the member was terminated from the nursing agency which should warrant a higher suspension compared to the case before this Panel.

CNO v. Wright (Discipline Committee, 2017): The Member’s Counsel submitted that this is such an extreme case involving sexual abuse of minors that it is not even appropriate for the purpose of exerting caution.

In conclusion, the Member’s Counsel submitted that the case before this Panel does not warrant a lengthy suspension given that there was no exploitation of the patient by the Member and that the Member does not pose a risk to the public.

The Member’s Counsel submitted cases to the Panel to demonstrate that the penalty proposed by the Member fell within the range of similar cases from this Discipline Committee.

CNO v. Seymour (Discipline Committee, 2017): In this case, the member made the first gesture that led to the relationship. The member and the client did not engage in sexual contact until after the client was discharged from the member’s care. There was the intertwining of family members given that the client divorced his wife as a result of this new affair. The penalty included an oral reprimand, a 3 month suspension, two meetings with a Nursing Expert and 12 months of employer notification.

CNO v. Baker (Discipline Committee, 2012): This case proceeded by way of a Joint Submission on Order. The member engaged in an intimate personal relationship with the husband of a client with Alzheimer’s Disease while continuing to provide care to the client. The member concealed the relationship from both the patient and the facility. The penalty included an oral reprimand, a 3 month suspension, 2 sessions with a Nursing Expert and 12 months of employer notification. This case differs from the case before this Panel as the Member told her employer right away and Patient [1]’s spouse knew that the Member and [Patient 1] were involved in a relationship.

CNO v. Christo (Discipline Committee, 2017): In this case, the client at the facility had special needs. The member exerted her position of power by seeking out a relationship with the client. The member provided the client with money and sent messages to the client. The Penalty included an oral reprimand, a 3 month suspension, two meetings with a Nursing Expert and 18 months of employer notification.

CNO v. Premji (Discipline Committee, 2017): In this case, the member was a male paediatric emergency nurse and the client was a minor. The member failed to maintain boundaries by allowing the client to watch an R rated movie on his iPad, exchanging phone numbers with the client, engaging in personal text messages with the client and asking for the client’s marijuana supplier. The client was a minor and was extremely vulnerable. The member initiated the contact with the client using his power inherent in his position as a nurse. The Penalty included an oral reprimand, a 3 month suspension, two meetings with a Nursing Expert and 12 months of employer notification.

College Counsel’s Reply

College Counsel acknowledged that there are no cases which provide for a 14 month suspension and only one with a 12 month suspension, but that while the College is asking for the high end of duration of the suspension, it is not asking for the high end of penalties given that penalties that have been imposed for boundary breaches include revocation of the member’s certificate of registration. The severity is compounded by there being two patient relationships and the College would have asked for revocation but for the mitigating factors.

Although the College accepts the report from Dr. Jaffe, the College points out that Dr. Jaffe is not an expert in boundaries of the nurse-client therapeutic relationship and therefore the report should not be used as an opinion to assess the seriousness of the breaches. The Panel should not refer to the Dr. Jaffe report for any of the underlying facts in the case, but it should give it some comfort as to the unique circumstances. The College recognizes the strength of the character references as a mitigating factor in this case.

Delay in Commencement of Suspension

The Member’s Counsel submitted that the Member would endure financial hardship given that she is a single mother tasked with raising 2 children on her own. The Member's Counsel has requested a 3 month delay with respect to commencement of the suspension which will afford the Member a chance to build savings to allow her to support her family. The delay will also allow the Member to transfer care for the vulnerable patients that she serves. College Counsel submitted that there is evidence from the Member’s employer with respect to the importance of her role. Accordingly, College Counsel largely defers the decision on the delay of the suspension to the Panel.

Penalty Decision

The Panel accepts the partial Joint Submission on Order and accordingly orders:

1. The Member is required to appear before the Panel to be reprimanded within 3 months of the date that this Order becomes final.

2. The Executive Director is directed to suspend the Member’s certificate of registration for 10 months. This suspension shall take effect November 30, 2021 and shall continue to run without interruption as long as the Member remains in a practicing class.

3. 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 2 meetings with a Regulatory Expert (the “Expert”) at her own expense and within 6 months from the date of 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 of 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 of Professional Conduct (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:

1. the Panel’s Order,

2. the Notice of Hearing,

3. the Agreed Statement of Facts,

4. this Joint Submission on Order, and

5. 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):

1. Code of Conduct,

2. Nurse Practitioner,

3. Professional Standards, and

4. Therapeutic Nurse-Client Relationship;

iv. Before the first meeting, the Member reviews and completes the CNO’s self-directed learning package, One is One Too Many, at her own expense, including the self-directed Nurses’ Workbook;

v. At least 7 days before the first meeting, the Member provides the Expert with a copy of the completed Reflective Questionnaires, online participation forms and Nurses’ Workbook;

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

1. the acts or omissions for which the Member was found to have committed professional misconduct,

2. the potential consequences of the misconduct to the Member’s patients, colleagues, profession and self,

3. strategies for preventing the misconduct from recurring,

4. the publications, questionnaires and modules set out above, and

5. the development of a learning plan in collaboration with the Expert;

vii. 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:

1. the dates the Member attended the sessions,

2. that the Expert received the required documents from the Member,

3. that the Expert reviewed the required documents and subjects with the Member, and

4. the Expert’s assessment of the Member’s insight into her behaviour;

viii. 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’s suspension ends, 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:

1. the Panel’s Order,

2. the Notice of Hearing,

3. the Agreed Statement of Facts,

4. this Joint Submission on Order, and

5. 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 will confirm:

1. that they received a copy of the required documents, and

2. 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.

c) The Member shall not practice nursing in an independent setting, including but not limited to, establishing a sole-practitioner clinic or business, self-employed nursing care and/or home-care settings, for a period of 18 months from the date the Member’s suspension ends.

4. 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 Panel concluded that the partial proposed penalty contained in the partial Joint Submission on Order is reasonable and in the public interest. The Member has co-operated with the College and, by agreeing to the facts and a partial proposed penalty, has accepted responsibility.

With respect to the length of the suspension, the Panel considered that the Member made a series of profoundly poor decisions over a period of time. In the course of a nurses’ duties, the nurse has an obligation to not interfere with a patient’s personal relationships. In the context of the therapeutic nurse-client relationship, a nurse must enforce boundaries, anticipate boundary breaches and implement appropriate correction of boundary breaches. The public entrusts the nurse with the responsibility of safeguarding the boundaries of the therapeutic nurse-client relationship. The public does not expect that the patient be tasked with being the guardian of those boundaries.

The multiple letters and e-mails which speak to the Member’s good character and the importance of the services that she offers to her community as a nurse practitioner were provided little weight by the Panel given that they do not directly address the incidents of professional misconduct. The letter and e-mails reassure the Panel that through her actions, the Member had no intention of harm toward Patient [1] and Patient [2].

The report authored by Dr. Jaffe describes the Member as having a “serious lapse in judgment” referring to both the development of a sexual relationship with Patient [1] and providing treatment to Patient [2] while the Member was in a relationship with (former) Patient [1]. The Panel agreed with Dr. Jaffe that the Member is not a risk to future patients, however, the Member must be held accountable for the seriousness of the professional misconduct that occurred.

Patient [1]’s behaviour was emotionally abusive, manipulative, harassing and threatening. Patient [1] was charged with possession for the purposes of trafficking cocaine and fentanyl and was sentenced. Patient [1] was himself vulnerable and would have derived benefit from the Member’s clear enforcement of the boundaries of the therapeutic nurse-client relationship. The unsuccessful attempt to transfer the care of Patient [1] after recognizing his untoward behaviours did not permit the Member to continue developing her relationship with Patient [1].

The Member exhibited poor judgment by assessing and prescribing psychoactive medications to Patient [2] given the clear conflict of interest that existed from the Member’s concurrent sexual relationship with Patient [2]’s husband [Patient 1].

Despite Patient [1]’s persistent abusive and manipulative behaviour towards the Member, Patient [1] was still entitled to benefit from the protections that the therapeutic nurse-client relationship affords with respect to maintaining boundaries. Furthermore, the Member is still held responsible for upholding the boundaries of the therapeutic nurse-client relationship even though she did not actively exploit the patient, but rather took a passive approach which allowed the personal and intimate relationship to develop.

Although there are no perfectly similar historical cases from this Discipline Committee, the Panel finds similarities in the Trzop and Hawil cases given the sexual relationship that arose with the nurse as a result of therapeutic nurse-client boundary violations. Similar to the case before the Panel, the Trzop and Hawil cases involved vulnerable patients. The penalties included a 12 month suspension and revocation respectively. The Panel acknowledges the mitigating factors which stem from the uniqueness in the case before the Panel in that Patient [1] pursued the Member and exhibited the behaviour which resulted in the boundaries of the nurse-client relationship being breached. Given the seriousness of the conduct and the associated mitigating factors, the Panel ordered a 10 month suspension of the Member’s certificate of registration.

A 10 month suspension demonstrates the seriousness of the Member’s failure to set and maintain the boundaries of the therapeutic nurse-client relationship with respect to Patients [1] and [2]. With this penalty, members of the profession will be reminded that there are serious sanctions that accompany boundary breaches of the therapeutic nurse-patient relationship.

The Panel finds that the penalty satisfies the principles of specific and general deterrence, rehabilitation and remediation and public protection. Specific and general deterrence are achieved through the oral reprimand and the 10 month suspension. Rehabilitation and remediation is achieved through a minimum of 2 meetings with a Regulatory Expert. Public protection is achieved through the 10 month suspension, the 18 month period of employer notification and the 18 month restriction on independent practice.

The penalty is in line with what has been ordered in previous cases.

I, Dawn Cutler, RN sign this decision and reasons for the decision as Chairperson of this Discipline panel and on behalf of the members of the Discipline panel.