DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO
PANEL: Lalitha Poonasamy Public Member, Chairperson Ahamad Mohammed, RPN Member Edsel Mutia, RN Member Susan Roger, RN Member
BETWEEN:
COLLEGE OF NURSES OF ONTARIO ) EMILY LAWRENCE for ) College of Nurses of Ontario
- and - )
AZZA AZZA ) CARINA LENTSCH for Registration No. AC882578 ) Azza Azza ) CHRISTOPHER WIRTH ) Independent Legal Counsel
) Heard: November 7, 2023
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 November 7, 2023, 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 Azza Azza.
The Panel considered the submissions of College Counsel and the Member’s Counsel 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 Azza Azza.
The Allegations
College Counsel advised the Panel that the College was requesting leave to withdraw the allegations set out in paragraphs #1(a), #1(b), #1(c), #2(a), #2(b), #2(c), #3(a), #3(b) and #3(c) in the Notice of Hearing dated September 26, 2023. The Panel granted this request. The remaining allegations against Azza Azza (the “Member”) are as follows:
IT IS ALLEGED THAT:
- a. [Withdrawn];
b. [Withdrawn];
c. [Withdrawn].
- You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(1) of Ontario Regulation 799/93, in that during your employment as a Registered Practical Nurse at University Health Network, Toronto Rehab – Lyndhurst Centre in Toronto, Ontario, you contravened a standard or practice of the profession or failed to meet the standards of practice of the profession, in that on or about January 22 and/or February 2, 2022:
a. [Withdrawn];
b. [Withdrawn];
c. [Withdrawn];
d. you used an improper technique during catheterization when you failed to wear gloves during all steps in the procedure and/or asked [the Patient] if she could feel anything or words to that effect; and/or
e. you failed to maintain the boundaries of the therapeutic nurse-client relationship in respect of [the Patient] by addressing her as “my lady” or words to that effect and/or when you touched or rubbed [the Patient]’s thigh.
- You have committed an act of professional misconduct as provided by subsection 51(1)(c) of the Health Professions Procedural Code of the Nursing Act, 1991, S.O. 1991, c. 32, as amended, and defined in subsection 1(37) of Ontario Regulation 799/93, in that during your employment as a Registered Practical Nurse at University Health Network, Toronto Rehab – Lyndhurst Centre in Toronto, 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, in that on or about January 22, and/or February 2, 2022:
a. [Withdrawn];
b. [Withdrawn];
c. [Withdrawn];
d. you used an improper technique during catheterization when you failed to wear gloves during all steps in the procedure and/or asked [the Patient] if she could feel anything or words to that effect; and/or
e. you failed to maintain the boundaries of the therapeutic nurse-client relationship in respect of [the Patient] by addressing her as “my lady” or words to that effect and/or when you touched or rubbed [the Patient]’s thigh.
College Counsel advised the Panel that the College was not calling any evidence with respect to the portions of allegations #2(d) and #3(d) of the Notice of Hearing, insofar as they pertain to the Member using an improper technique during catheterization when he failed to wear gloves during all steps in the procedure.
Member’s Plea
The Member admitted the allegations set out in paragraphs #2(d) insofar as it pertains to the Member using an improper technique during catheterization when he asked [the Patient] if she could feel anything or words to that effect, #2(e), #3(d) insofar as it pertains to the Member using an improper technique during catheterization when he asked [the Patient] if she could feel anything or words to that effect and #3(e) 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 admissions were 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
Azza Azza (the “Member”) registered with the College of Nurses of Ontario (“CNO”) as a Registered Practical Nurse (“RPN”) on July 10, 2013.
The Member worked in the Spinal Cord Rehabilitation Program (the “Unit”) at the University Health Network’s Toronto Rehabilitation Institute – Lyndhurst Centre (the “Facility”) in Toronto, Ontario at the time of the alleged incidents of professional misconduct. He continues to be employed by the Facility and work in this Unit.
The Member has worked as a casual and, subsequently, part-time RPN at the Facility since September 1, 2013.
The Member has no prior CNO disciplinary history.
THE FACILITY
The Unit is an inpatient rehabilitation program for patients with traumatic and non-traumatic spinal cord injuries. The nurse-patient ratio is 1:4 per shift. The Unit accommodates approximately 20 patients.
The Facility’s Hand Hygiene Policy and Urinary Catheterization Policy were in place at the time of the incidents. The Member was expected to adhere to both policies.
Nurses were expected change gloves multiple times during standard intermittent catheterization (IC) procedures to maintain a clean technique.
THE PATIENT
[The Patient] was a 29-year-old female with paralysis from the chest down due to an all-terrain vehicle (ATV) accident in November 2021, and suffered from neurogenic bowel and bladder disfunction. She was admitted to the Unit on December 9, 2021. She was discharged on March 10, 2022.
The Member was part of the Facility’s nursing team responsible for providing [the Patient] with treatment, assessment, documentation, medication administration, assistance with daily living, wound care, and complete bowel and bladder management.
While at the Facility, [the Patient] required IC procedures for bladder emptying.
Prior to the incidents described below, the Member had performed between 10-20 IC procedures for [the Patient]. [The Patient] did not report concerns about the Member’s nursing practice or professionalism prior to the incidents described below.
The Facility investigated the incidents described below and required the Member to meet with an Advanced Practice Nurse Educator at the Facility to review CNO’s Therapeutic Nurse-Client Relationship Standard and Ethics Standard, in addition to Facility-issued publications about professional boundaries and spinal cord diagnoses and care plans for his assigned patients. The Member was also issued a 3-day suspension.
INCIDENTS OF PROFESSIONAL MISCONDUCT
Interactions with [the Patient] on January 22, 2022
On January 22, 2022, the Member provided nursing care to [the Patient] during the day shift as assigned.
After administering [the Patient]’s medication, the Member temporarily left the room. Upon returning, [the Patient] heard the Member addressing her with “my lady” or words to that effect, instead of using her name when greeting her. This interaction made [the Patient] feel uncomfortable with the Member’s subsequent nursing care.
If the Member were to testify, he would state that he addressed the Patient in this way because he could not remember her name at that moment and not because he had any inappropriate intentions towards [the Patient], which he did not.
The Member acknowledges and admits that addressing [the Patient] as “my lady” or words to that effect was inappropriate and a poor choice of words, which in the context of the sensitive care being provided to a vulnerable patient, caused [the Patient] to question his motives towards her and brought about a breakdown of professional boundaries.
During the same shift, on January 22, 2022, the Member performed two IC procedures on [the Patient].
The IC procedure includes a cleansing step that involves wiping the genitals with a cleansing wipe or cotton ball in preparation for catheter insertion (the “cleansing step”).
[The Patient] routinely used the ceiling light’s reflective surface like a mirror to watch and observe how nurses performed the IC procedures so she could learn how to do it herself in preparation for discharge from the Facility.
Prior to the cleansing step of the IC procedure, the Member removed his gloves and did not show [the Patient] that he put on a new set of gloves before proceeding to cleanse the Patient’s genital area during the IC procedure or clearly explain this to her.
If [the Patient] were to testify, she would state that in the ceiling light reflection she observed the Member remove his gloves but did not see him putting on new gloves before proceeding to the cleansing step. She would further state that she believed that the Member was touching her genitals during the cleansing step without wearing gloves and feared that he was doing so for a non-therapeutic purpose, which made her feel uncomfortable and unsafe around the Member.
Following the cleansing step, [the Patient] observed the Member putting on a pair of new clean gloves before he proceeded to complete the remaining steps of the IC procedure including the insertion of the catheter.
If the Member were to testify, he would state that he was wearing gloves for all steps of the IC procedure that involved touching the patient’s body, including the cleansing step.
At some point during the IC procedure, the Member asked [the Patient] if she could feel anything or words to that effect without clearly explaining to [the Patient] his reason for asking this question during the procedure.
If the Member were to testify, he would state that he asked [the Patient] if she could feel anything because he was querying whether she could be regaining some feeling or sensation. The Member acknowledges that there was no documented or clinical basis to suggest that [the Patient] had regained feeling or sensation to support asking the patient such a question during the IC procedure.
The Member admits and acknowledges asking [the Patient] if she could feel anything during a catheterization procedure was an improper technique, and that without clear explanation, his comment caused [the Patient] to have concerns about his nursing care and his intentions towards her.
At some point after the IC procedure the Member touched [the Patient]’s thigh.
If [the Patient] were to testify, she would state that the Member rested his hand on her thigh for approximately 15 seconds. Observing the Member touch her thigh made [the Patient] feel uncomfortable and question the Member’s intentions in light of her perceptions of their earlier interaction that day.
If the Member were to testify, he would state that he briefly touched or patted [the Patient]’s leg with the intention to reassure [the Patient] and express that the procedure was complete and not for any inappropriate intention or reason.
Interactions with [the Patient] on February 2, 2022
On February 2, 2022, the Member performed two IC procedures for [the Patient] at approximately 1700 and 2230 hours.
In the reflection of the ceiling light, [the Patient] observed the Member remove his gloves as he was preparing to clean her genital area to initiate the IC procedure. [the Patient] asked the Member, “Are you changing your gloves?”
If [the Patient] were to testify, she would state that she felt a heightened awareness with respect to the Member’s gloving technique on this occasion because of her perception that, on January 22, 2022, the Member failed to wear gloves during the portion of the IC procedure requiring the Member to clean the genital area, and because of the Member’s verbal and non-verbal communication in their prior interaction. [The Patient] would further state that she felt uncomfortable and felt vulnerable to abuse and/or inappropriate sexually motivated touching by the Member because she was unable to feel the nurse’s touch during the IC procedure because of her medical condition. [The Patient] feared she could be taken advantage of, given the power imbalance between herself and the Member, which caused her to worry for her safety.
The Member responded confirming that he was changing his gloves, and that it was good [the Patient] was paying attention to glove changing, especially as [the Patient] had just recovered from a bladder infection and she should ensure her nurses are engaging in hygienic practices to avoid the risk of infection.
The Member put on a new pair of clean gloves and continued with the IC procedure.
If the Member were to testify, he would state that he did not have any sexual or otherwise inappropriate non-therapeutic intentions towards [the Patient] at any time and that he sincerely regrets and apologizes that he caused [the Patient] to have such a mistaken impression.
The Member would further state that he has reflected on how he can maintain appropriate professional boundaries and communicate clearly with patients when performing IC procedures to avoid the future misunderstandings and to ensure that patient trust is maintained.
CNO STANDARDS OF PRACTICE
- CNO has published nursing standards to set out the expectations for the practice of nursing. CNO’s published standards inform nurses of their accountabilities and apply to all nurses regardless of their role, job description or area of practice.
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 consists of six principles:
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.
Nurses self-reflect on, and identify how, their behaviours and positions of power may impact the therapeutic nurse-patient relationship. In turn, nurses also recognize that many identity factors could impact not only their care of patients, but also patients’ perception of health care based on lived experience. It is important, therefore, that all nurses be continuously mindful of promoting patient dignity and compassion alongside safe clinical care.
Professional Standards and Therapeutic Nurse-Client Standard
CNO’s Professional Standards provides that each nurse is responsible for ensuring her or his practice and conduct meet legislative requirements and the standards of the profession. A nurse demonstrates the Professional Standards by providing, facilitating, and advocating the best possible care for patients while recognizing the potential for patient abuse or professional boundary crossing.
Reflective of several core indicators in the Therapeutic Nurse-Client Relationship Standard, the Professional Standards also requires that each nurse establishes and maintains respectful therapeutic relationships with patients.
The Therapeutic Nurse-Client Relationship Standard requires that nurses use a wide range of effective communication strategies and interpersonal skills to appropriately establish, maintain, re-establish and/or terminate the nurse-patient relationship. A nurse meets the standard by:
a. being aware of her/his verbal and non-verbal communication style and how [patients] might perceive it;
b. modifying communication style, as necessary, to meet the needs of the [patient];
c. recognizing that all behaviour has meaning and seeking to understand the cause of a [patient’s] unusual comment, attitude or behaviour; and
d. reflecting on interactions with a [patient] and the health care team and investing time and effort to continually improve communication skills.
CNO’s Therapeutic Nurse-Client Relationship Standard places the responsibility for establishing and maintaining the therapeutic nurse-patient relationship on the nurse. Underlying the establishment of an appropriate, compassionate nurse-patient relationship is an awareness of the power imbalance inherent in the dynamic between a professional care provider and a vulnerable patient.
As such, the Therapeutic Nurse-Client Relationship Standard requires nurses to protect patients from harm by ensuring that abuse, neglect and exploitation of the power imbalance is prevented, stopped and reported. With respect to protecting the patient from abuse, neglect and harm, a nurse meets the standard by:
a. not engaging in behaviours toward a [patient] that may be perceived by the [patient] and/or others to be violent, threatening or intending to inflict physical harm; and
b. not exhibiting physical, verbal and non-verbal behaviours toward a [patient] that demonstrate disrespect for the [patient] and/or are perceived by the [patient] and/or others as abusive.
ADMISSIONS OF PROFESSIONAL MISCONDUCT
CNO seeks leave from the Discipline Committee to withdraw the following allegations as set out in the following paragraphs of the Notice of Hearing: 1(a), 1(b), 1(c), 2(a), 2(b), 2(c), 3(a), 3(b) and 3(c).
CNO calls no evidence in respect of the first clause of the allegation in paragraphs 2(d) and 3(d) of the Notice of Hearing containing the words “failed to wear gloves during all steps in the procedure”.
With respect to the second clause of the allegation in paragraphs 2(d) and 3(d) of the Notice of Hearing, the Member admits that he used improper technique during catheterization when he asked [the Patient] if she could feel anything or words to that effect. He acknowledges that, for the purposes of making findings of professional misconduct, the fact that he asked this question without a clinical purpose or indication that there had been a change in [the Patient]’s paralysis at some point while [the Patient] was an inpatient at the Facility, discharges CNO’s onus to prove the allegations.
With respect to allegations 2(e) and 3(e) of the Notice of Hearing, the Member admits and acknowledges that he failed to maintain the boundaries of the therapeutic nurse-patient relationship when he addressed [the Patient] as “my lady” or words to that effect and touched her thigh after the catheterization procedure without a clinical purpose, in the context of [the Patient]’s perceptions of his gloving technique and his question about whether she could feel anything, as described in paragraphs 13-34 above.
The Member acknowledges that it is a nurse’s responsibility to ensure clear communication while providing treatment relating to intimate and sensitive areas of the body, which he failed to do. [The Patient]’s injury elevated the need for the Member to exercise professional judgment and be attentive to the importance of clear communication to ensure his patient felt safe. He acknowledges that misinterpretations can be detrimental to the therapeutic nurse-client relationship and can undermine the patient’s trust that their nurse will provide competent and safe nursing care.
The Member admits and acknowledges that his actions, when taken together, and regardless of his intent, could reasonably be seen to leave an improper impression with a vulnerable patient during a highly sensitive procedure. Without clear and appropriate communication, [the Patient] was left with the impression that his nursing care was compromised and inappropriate. The Member admits and acknowledges that he contravened the standards of practice, and in particular, CNO’s Code of Conduct, Professional Standards and Therapeutic Nurse-Client Relationship Standard during his care of [the Patient] in the incidents described in paragraphs 13-34 above and paragraph 2(d) and 2(e) in the Notice of Hearing.
The Member admits that he committed the acts of professional misconduct as described in paragraphs 13-34 above, and as alleged in paragraphs 3(d) and (e) of the Notice of Hearing, and in particular, that his conduct was unprofessional.
Submissions on Liability
College Counsel submitted that the Member has admitted to the allegations of the breach of standards and that his conduct is unprofessional. The Member acknowledged that the events and communications before and during the procedure led to the patient perceiving his conduct as inappropriate. Counsel submitted that the standards, specifically the Therapeutic Nurse Client Relationship standards, speak to the requirements for nurses to clearly and effectively communicate with clients to avoid any misperceptions. Counsel advised the Panel that the Member has agreed that his behaviour requires reflection of both his verbal and non-verbal communications. In that the Member has admitted to a breach of the standards, the allegations of professional misconduct may be proven.
College Counsel referred to evidence asserting that the Member’s conduct, which occurred during the provision of direct nursing care, is relevant to nursing. The Member has admitted to the allegations as presented and acknowledges that his behaviour is unprofessional.
Member’s Counsel asked that the Panel make findings on the allegations as presented, noting that the Agreed Statement of Facts included all relevant facts of the case, and applicable nursing standards. The Member has admitted to unprofessional conduct.
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 #2(d) insofar as it pertains to the Member using an improper technique during catheterization when he asked [the Patient] if she could feel anything or words to that effect, #2(e), #3(d) insofar as it pertains to the Member using an improper technique during catheterization when he asked [the Patient] if she could feel anything or words to that effect and #3(e) of the Notice of Hearing. As to allegations #3(d) and #3(e), the Panel finds that the Member engaged in conduct that would reasonably be regarded by members of the profession to be unprofessional.
The Panel dismissed the portions of allegations #2(d) and #3(d) of the Notice of Hearing, insofar as they pertain to the Member using an improper technique during catheterization when he failed to wear gloves during all steps in the procedure.
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 #2(d) insofar as it pertains to the Member using an improper technique during catheterization when he asked [the Patient] if she could feel anything or words to that effect and #2(e) in the Notice of Hearing are supported by paragraphs 13 to 34, 47, 48 and 50 in the Agreed Statement of Facts. The Member admitted that while employed as a Registered Practical Nurse (“RPN”) at the University Health Network’s Toronto Rehabilitation Institute – Lyndhurst Centre (the “Facility”) he breached the College’s Code of Conduct, the Professional Standards and the Therapeutic Nurse-Client Relationship Standard (“TNCR Standard”) by leaving [the Patient] with the perception that the Member had behaved in an inappropriate way. The Member did not account for [the Patient]’s vulnerability or take the necessary steps to avoid misperceptions. The Member should have considered his verbal and non-verbal communication and he admitted that his actions could have undermined the therapeutic relationship with [the Patient].
Allegations #3(d) insofar as it pertains to the Member using an improper technique during catheterization when he asked [the Patient] if she could feel anything or words to that effect and #3(e) in the Notice of Hearing are supported by paragraphs 13 to 34, 47 and 48 in the Agreed Statement of Facts. The Panel finds that the Member’s conduct in addressing [the Patient] as “my lady” or words to that effect and touching her thigh after the catheterization procedure without a clinical purpose, in the context of [the Patient]’s perceptions of his gloving technique and his question about whether she could feel anything was clearly relevant to the practice of nursing. It was unprofessional as it demonstrated a serious and persistent disregard for his professional obligations in breaching the College’s Code of Conduct, the Professional Standards and the TNCR Standard. [The Patient] perceived these comments to undermine the trust between herself and the Member. The Member’s conduct occurred in the context of delivery of direct nursing care and is therefore relevant to the practice of nursing.
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 2 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 2 meetings with a Regulatory Expert (the “Expert”), at the Member’s own expense and within 6 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 CNO in advance of the meetings;
ii. At least 5 days before the first meeting, or within another timeframe approved by the Expert, 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 and decision tools (where applicable):
Code of Conduct, and
Therapeutic Nurse-Client Relationship Standard;
iv. At least 5 days before the first meeting, or within another timeframe approved by the Expert, the Member provides the Expert with a copy of the completed Reflective Questionnaires;
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 their report to CNO, 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 the Member’s 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 the Member’s certificate of registration;
b) For a period of 12 months from the date the Member returns to the practice of nursing, the Member will notify the Member’s employers of the decision. To comply, the Member is required to:
i. Inform any employer of the decision at least 14 days before commencing or prior to resuming employment in any nursing position;
ii. Ensure that CNO 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;
iii. Provide the Member’s 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;
iv. 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 CNO, in which it will confirm:
that they received a copy of the required documents, and
that they agree to notify CNO 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 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 asked the Panel to accept the Joint Submission on Order and reviewed the principles concerning acceptance of Joint Submissions.
College Counsel further submitted that the aggravating factors in this case were:
The Member addressing [the Patient] as “my lady” was inappropriate in the context of the sensitive care being provided to a vulnerable patient; and
Due to a lack of communication by the Member during the cleansing step, [the Patient] felt uncomfortable and unsafe.
The mitigating factors in this case were:
The Member had no past disciplinary history with the College;
The Member had cooperated with the hearing process;
The Member had taken responsibility for his actions as demonstrated by his plea and admissions and entered into an Agreed Statement of Facts and a Joint Submission on Order with the College, thereby avoiding a lengthy contested hearing; and
The Member has shown remorse and has accepted the consequences of his actions.
The proposed penalty provides for general deterrence through the 2-month suspension of the Member’s certificate of registration, which sends a strong signal to the membership that this type of conduct is unacceptable.
The proposed penalty provides for specific deterrence through the oral reprimand and the 2-month suspension of the Member’s certificate of registration.
The proposed penalty provides for remediation and rehabilitation through the 2 meetings with a Regulatory Expert and the review of the College’s Code of Conduct and TNCR Standard. These meetings with the Regulatory Expert will serve to help the Member meet his professional obligations through reflection, introspection and education.
Overall, the public is protected through the 12 months of employer notification, which will allow for the Member’s practice to be assessed and monitored by his employer when he returns to practice. This additional measure to protect the public is a necessary step to demonstrate the profession’s accountability to the public.
College Counsel submitted the following case to the Panel to demonstrate that the proposed penalty fell within the range of similar cases from this Discipline Committee:
CNO v. Isaac (Discipline Committee, 2019): In this case, the hearing proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. This case was very similar to the case before this Panel in terms of how a member’s communication failure or series of interactions can leave an impression with a patient of inappropriate conduct by a member. The penalty included an oral reprimand, a two-month suspension of the member’s certificate of registration, two meetings with a Regulatory Expert and 6-six months of employer notification.
The Member’s Counsel asked the Panel to accept the Joint Submission on Order as it meets the goals of penalty, including specific and general deterrence and remediation and rehabilitation and is similar to prior decisions. The Member has no prior discipline history, continues to work for the Facility without any other concerns and is a long-valued member of the team. The Member has received much positive feedback from patients and hopes to continue working there. The Member has taken responsibility and saved the College resources and avoided the need for a long and difficult hearing. The Member has expressed remorse, reflected, learned and gained insight. He understands that he needs to be clear, careful and sensitive in his nursing care to those that are vulnerable. The Member understands that miscommunication can break down trust.
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 2 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 2 meetings with a Regulatory Expert (the “Expert”), at the Member’s own expense and within 6 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 CNO in advance of the meetings;
ii. At least 5 days before the first meeting, or within another timeframe approved by the Expert, 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 and decision tools (where applicable):
Code of Conduct, and
Therapeutic Nurse-Client Relationship Standard;
iv. At least 5 days before the first meeting, or within another timeframe approved by the Expert, the Member provides the Expert with a copy of the completed Reflective Questionnaires;
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 their report to CNO, 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 the Member’s 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 the Member’s certificate of registration;
b) For a period of 12 months from the date the Member returns to the practice of nursing, the Member will notify the Member’s employers of the decision. To comply, the Member is required to:
i. Inform any employer of the decision at least 14 days before commencing or prior to resuming employment in any nursing position;
ii. Ensure that CNO 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;
iii. Provide the Member’s 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;
iv. 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 CNO, in which it will confirm:
that they received a copy of the required documents, and
that they agree to notify CNO 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 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 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 Panel finds that the penalty satisfies the principles of specific and general deterrence, rehabilitation and remediation, and public protection. Specific deterrence will be achieved through an oral reprimand and the 2-month suspension of the Member’s certificate of registration. General deterrence will be achieved through the 2-month suspension of the Member’s certificate of registration. Remediation and rehabilitation will be achieved through the 2 meetings with a Regulatory Expert and the review of the College’s Code of Conduct and TNCR Standard. The public is protected through the 12 months of employer notification.
The penalty is also in line with what has been ordered in previous cases in similar circumstances as demonstrated by the case submitted and referred to by College Counsel.
I, Lalitha Poonasamy, Public Member, sign this decision and reasons for the decision as Chairperson of this Discipline Panel and on behalf of the members of the Discipline Panel.