College of Nurses of Ontario v. Christine Watkins, 2024 ONCNO 131479

DISCIPLINE COMMITTEE OF THE COLLEGE OF NURSES OF ONTARIO

PANEL: Michael Hogard, RPN Chairperson Carly Hourigan Public Member Susan Roger, RN Member Emilija Stojsavljevic, RPN Member

BETWEEN:

COLLEGE OF NURSES OF ONTARIO ) SARAH CORMAN for ) College of Nurses of Ontario

• and - )

CHRISTINE WATKINS ) LAURA JOHNSON for Registration No. AF178182 ) Christine Watkins ) CHRISTOPHER WIRTH ) Independent Legal Counsel

) Heard: May 14, 2024, via videoconference

DECISION AND REASONS

Publication Ban

By Order of the Discipline Panel dated May 14, 2024, pursuant to subsection s.45(3) of the Health Professions Procedural Code of the Nursing Act, 1991, no one shall publish or broadcast the name of the patient, or any information that could disclose the identity of the patient, referred to orally or in any documents presented at the Discipline hearing of Christine Watkins.

This matter was heard by a panel of the Discipline Committee (the “Panel”) of the College of Nurses of Ontario (the “College”) on May 14, 2024.

The Allegations

College Counsel advised the Panel that the College was requesting leave to withdraw the allegations set out in paragraphs 1(b) and 3(b) in the Notice of Hearing dated April 1, 2024. The Panel granted this request. The remaining allegations against Christine Watkins (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 between on or about April 2020 and November 2021, during and/or following your employment as a Registered Practical Nurse at Brockville Mental Health Centre (the “Facility”), you contravened a standard of practice of the profession or failed to meet the standard of practice of the profession in that:

(a) you breached the boundaries of the therapeutic nurse-patient relationship with [the Patient] by engaging in a personal and/or romantic relationship with [the Patient];

(b) [Withdrawn];

(c) you spent time with [the Patient] without documenting and/or for no therapeutic purpose;

(d) you spent excessive time with [the Patient] on a shift or shifts;

(e) you shared personal information with [the Patient];

(f) you exchanged text messages with [the Patient];

(g) you spoke on the telephone with [the Patient];

(h) you failed to document, intervene and/or follow up appropriately when [the Patient] expressed that he had feelings for you;

(i) you spoke with [the Patient] about spending time together in the future when he was released from the Facility;

(j) you expressed to [the Patient] that you had feelings for him and/or cared for him; and/or

(k) you bought personal item(s) for [the Patient] and/or brought personal item(s) into the unit for [the Patient].

2. 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(7) of Ontario Regulation 799/93, in that, between on or about April 2020 and November 2021, during and/or following your employment as a Registered Practical Nurse at the “Facility”, you abused a patient, verbally, physically and/or emotionally in that:

(a) you breached the boundaries of the therapeutic nurse-patient relationship with [the Patient] by engaging in a personal and/or romantic and/or sexual relationship with [the Patient] that caused harm to [the Patient].

3. 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, between on or about April 2020 and November 2021, during and/or following your employment as a Registered Practical Nurse at the “Facility”, you performed an act or acts 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:

(a) you breached the boundaries of the therapeutic nurse-patient relationship with [the Patient] by engaging in a personal and/or romantic relationship with [the Patient];

(b) [Withdrawn];

(c) you spent time with [the Patient] without documenting and/or for no therapeutic purpose;

(d) you spent excessive time with [the Patient] on a shift or shifts;

(e) you shared personal information with [the Patient];

(f) you exchanged text messages with [the Patient];

(g) you spoke on the telephone with [the Patient];

(h) you failed to document, intervene and/or follow up appropriately when [the Patient] expressed that he had feelings for you;

(i) you spoke with [the Patient] about spending time together in the future when he was released from the Facility;

(j) you expressed to [the Patient] that you had feelings for him and/or cared for him; and/or

(k) you bought personal item(s) for [the Patient] and/or brought personal item(s) into the unit for [the Patient].

Member’s Plea

The Member admitted the allegations set out in paragraphs 1(a), 1(c), 1(d), 1(e), 1(f), 1(g), 1(h), 1(i), 1(j), 1(k), 2(a), 3(a), 3(c), 3(d), 3(e), 3(f), 3(g), 3(h), 3(i), 3(j) and 3(k) 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 as amended reads, unedited, as follows:

THE MEMBER

1. Christine Watkins (the “Member”) registered with the College of Nurses of Ontario (“CNO”) as a Registered Practical Nurse (“RPN”) on December 7, 2016.

2. The Member was employed with The Royal Ottawa Health Care Group at their Brockville Mental Health Centre site beginning on November 7, 2016. The Member’s employment ended on May 13, 2021.

3. The Member has been working as a full-time RPN at Bayshore HealthCare - Home and Community Care in Brockville, Ontario since May 1, 2021.

4. The Member has no prior CNO discipline history.

THE FACILITY

5. At the time of the incidents, the Member was employed on the B3 - Forensic Treatment Unit (“the Unit”) at the Brockville Mental Health Centre (“the Facility”).

6. The Unit is an in-patient ward with a focus on preparing inpatients for eventual community transition or return to a formal trial process. Unit residents either have already been found Not Criminally Responsible (“NCR”) on account of a mental disorder, have been deemed unfit to stand trial or could be found NCR or unfit at a later date depending on their response to multidisciplinary health services provided by Facility staff.

7. Patients are assigned one or more prime nurses. The nurse-patient ratio is approximately 5:8.

8. Nurses on the Unit are responsible for administering medication to patients, engaging in therapeutic interventions, assisting with activities of daily living, documenting patients’ responses and progression, conducting mental status assessments, attending to medical concerns, and responding to crises or code calls from colleagues.

9. In the context of the Unit, care includes therapeutic interventions of a social nature, such as playing games, accompanying patients during off-premises excursions, assisting patients with homework, and helping them with basic tasks, such as laundry.

10. Unit nurses are responsible for maintaining patient and staff safety given the high-risk patient population by conducting themselves professionally and remaining vigilant about maintaining appropriate physical and emotional boundaries with patients.

THE PATIENT

11. (the “Patient”) was a 35-year-old male inpatient on the Unit. He presented with complex overlapping psychological diagnoses, including but not limited to sexual sadism disorder, schizoaffective disorder, bipolar disorder, and substance use disorders. The Patient also had a history of depression and episodes of psychosis, as well as a longstanding history of auditory hallucinations. He had several prior psychiatric hospitalizations, in addition to a lengthy incarceration history involving violent assaults, weapons charges and drug offences.

12. The Patient was found NCR on October 6, 2015, for a series of offences, and was transferred to the Facility on April 20, 2017, from a separate secure lockdown institution. In mid-2019, the Patient was transferred from the Facility’s Secure Treatment Unit to the Unit.

13. The Member was not the Patient’s prime nurse during the time of the incidents described below; however, the Member was one of the nurses providing care to the Patient. The Member had access to the Patient’s health records at all relevant times because she was expected to provide nursing services and document all medications administered, care provided, and assessments conducted.

INCIDENTS RELEVANT TO ALLEGATIONS OF PROFESSIONAL MISCONDUCT

Failure to Maintain Boundaries of the Therapeutic Nurse-Patient Relationship with the Patient

14. In or around April 2020, the Member and the Patient commenced a personal and romantic relationship while the Member was one of the Patient’s nurses on the Unit. This relationship continued until mid-April 2021.

15. The Member breached therapeutic nurse-patient boundaries with the Patient in respect of several non-clinical and non-therapeutic interactions, including:

• Conversing with the Patient to an excessive degree, despite not being the Patient’s prime nurse;

• Actively seeking out the Patient to spend time with him during shifts when she was not directly assigned to his care;

• Playing cards with the Patient for hours, despite being assigned to other patients;

• Sitting beside one another, playing romantic country music songs off the Member’s cell phone;

• Conversing with the Patient at night in response to the Patient’s questions despite Unit rules requiring lights out at a particular time;

• Breaching Unit protocol with respect to bedtime schedules, by allowing the Patient to leave his room and approach the Nursing Station in the morning so they could speak before her shift ended, creating hostility between the other patients and Unit nurses who enforced the schedule;

• Purchasing a cell phone case and screen protector for the Patient, rather than redirecting the Patient to appropriate Facility channels;

• “Giggling and whispering” at the dining table while discussing their families and talking about drinking alcohol;

• Accompanying the Patient to the laundry room as a pair and staying around the laundry room with the Patient for lengthy stretches of time (20+ minutes); and

• Telling the Patient that they had to keep their relationship secret because the Member could lose her job over their relationship.

16. Between April and November 2020, management received complaints from the Member’s colleagues concerning potential boundary breaches by the Member with the Patient. Unit management arranged a mediation to address the issue in November 2020.

17. If the Member were to testify, she would state that at this time she received commendations from Facility leadership on her ability to connect with the Patient and make him feel supported while on the Unit so she did not readily appreciate which actions were overstepping her role as a nurse and care provider.

18. In early January 2021, Unit management responded to further staff complaints about the Member’s engagement with the Patient. Serious concerns arose about the Member’s failure to follow Unit precautions when interacting with the Patient, who was known to be volatile and aggressive.

19. Concerned for staff safety and the integrity of their therapeutic relationships with all inpatients, the Unit Manager told the Member that she was spending too much time with the Patient. She needed to cultivate a trusting atmosphere in which the Patient could feel comfortable reaching out and interacting with other Unit staff for his care needs. The Member was limited to interacting with the Patient no more than 3-4 times per shift.

20. Several colleagues also approached the Member personally to discuss their unease about what they were witnessing between her and the Patient. They explained their concerns to the Member about her lack of clear boundaries with the Patient.

21. The Member replied to her colleagues, words to the effect of, “[a]t the end of the day, I’m responsible for my actions and it’s my nursing license on the line”, or “[a]t the end of the day my license is my license”.

22. On January 16, 2021, the Patient approached the Nursing Station on the Unit. He began kicking the door and yelling that he was “sick of staff”.

23. In response to this episode, the Unit implemented a new protocol involving the Patient: staff were only permitted to interact with the Patient in pairs and were limited to interacting with the Patient for no longer than 15-minute intervals.

24. The Patient was routinely agitated when the Member reminded him of this rule because he had become accustomed to being with her one-on-one. When other staff carried out the new expectation, it was documented in the Patient’s chart that he would become tearful, “shut down”, stop talking and slam the door to his room.

25. In an e-mail to the Unit Manager on January 21, 2021, the Member relayed, “I have tried to pull back from spending so much time with [the Patient] the past few shifts I have worked. Since doing so it has been noted by myself and other staff that his behaviour is escalating quickly and dangerously.”

26. Despite noting these concerns, the Member did not end her relationship with the Patient.

27. On or about February 13, 2021, the Patient texted the Member’s personal cell phone number. The Patient told the Member that his sister died and he wanted to “talk to someone”.

28. By mid-February 2021, the Member and the Patient began texting each other daily. The Member disclosed personal information to the Patient about her romantic relationship that had recently ended traumatically. In turn, the Patient discussed his children, their mother, and his abusive relationship with his birth mother.

29. In March 2021, the Member and the Patient began speaking on the phone for periods of time ranging from a few minutes to an hour or more.

30. The Member and the Patient also expressed feelings of mutual attraction and affection for each other. The Patient shared his romantic feelings for the Member and discussed wanting to spend time with her in the future once he was discharged.

31. The Patient also expressed feelings of jealously after seeing the Member interact with another male patient. The Member told the Patient how they needed to wait one year before being able to have a romantic relationship in accordance with the legislative prohibition on nurse-patient relationships within one year following discontinuation of care.

32. At no point did the Member report, document or appropriately follow up on these discussions or her interactions with the Patient.

33. The Member states that on or around April 10, 2021, she realized the extent to which her relationship with the Patient was inappropriate and “had gotten out of hand”. She decided to take steps to end the relationship and disclosed it to management at this time. The Member stopped communicating with the Patient around this time.

34. On April 12, 2021, the Member was administratively suspended pending a Facility investigation into her relationship with the Patient.

35. A nurse providing care to the Patient documented on this date that the Patient was uncharacteristically “guarded and withdrawn”. He was “rocking back and forth in the chair with his hands clenched […] he began to cry, little to no eye contact was made the entire conversation”.

36. Another nurse documented in the Patient’s chart that he said, “I don’t know why she stopped talking to me, she ruined our whole life plan.” The Patient went on to say that he and the Member had discussions that they would “wait one year as per CNO guidelines to pursue a romantic relationship further […] with the money he would receive from his lawsuit settlement they would pay off her car payment, pay her school debt, buy a house, and have three children”.

37. In the days and weeks following this event, the Patient often presented with a sad affect and would weep in the presence of staff.

38. On May 13, 2021, the Member’s employment at the Facility ended.

39. During a psychology appointment on May 27, 2021, at the Facility, the Patient reported that his sleep was consistently disturbed because of the situation with the Member. He was ruminating throughout the night, including having a distressingly violent dream about the Member.

40. Between July 21, 2021, and September 7, 2021, the Patient sent the Member a series of Facebook messages in which he communicated his anger, hurt and sadness resulting from his relationship with the Member, his love for the Member and his desire to talk to her again. The Member did not view these messages at that time and did not respond.

41. Three RPN nursing staff co-documented the following quotations in the Patient’s chart on August 15, 2021:

I don’t want to be a rat but she has fucked me over in so many ways and this is effecting me more than I let on to anyone.

I am so upset about all this and don’t know what to do that I have contemplated picking up a 10mg Fentanyl patch and ending it all, I cant (sic) keep doing this and playing her games.

I told her that I am done with her games and lies. I need to start thinking about myself and my plans for release. As I’m not even sure if she will be there for me when I’m released.

42. A nurse documented on August 17, 2021, that the Patient disclosed that he loved the Member, and that she loved him, and that “no one should say that what is happening is wrong”.

43. The Patient’s relationship with the Member had a significant negative impact on his mental health, including by accentuating feelings of traumatization, and distrust. Ultimately, the Patient expressed that he felt taken advantage of by the Member, who was in a position of power in the nurse-patient relationship.

44. If the Member were to testify, she would state she sincerely regrets and is remorseful for her poor judgment. The Member would testify that a significant personal challenge that she was experiencing at the time of the events in question detrimentally impacted her judgment and boundaries. The Member acknowledges the impact her actions had on the Patient and, given the unique practice environment on the Unit, that her boundary crossing amplified the risk of harm to herself, patients, Facility staff, and her immediate Unit colleagues.

45. The Member admits that she breached the therapeutic nurse-patient boundaries with the Patient for personal gain when she engaged in a personal and romantic relationship with the Patient. The Member takes full responsibility for her misconduct.

CNO STANDARDS OF PRACTICE

Code of Conduct

46. 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 including:

• Nurses respect the dignity of patients and treat them as individuals;

• Nurses work together to promote patient well-being;

• Nurses maintain patients’ trust by providing safe and competent care;

• Nurses work respectfully with colleagues to best meet patients’ needs;

• Nurses act with integrity to maintain patients’ trust; and

• Nurses maintain public confidence in the nursing profession.

47. With respect to the principle requiring nurses to work respectfully with colleagues to best meet patients’ needs, CNO’s Code of Conduct provides that nurses take action to stop unsafe, unethical or unlawful practice, including any type of abuse.

48. With respect to the principle requiring nurses act with integrity to maintain patient trust, CNO’s Code of Conduct provides that nurses maintain professional boundaries and place their professional responsibilities ahead of their personal gain.

Professional Standards

49. CNO’s Professional Standards, Revised 2002 (“Professional Standards”) provides an overall framework for the practice of nursing and a link with other standards, guidelines and competencies developed by CNO. It includes seven broad standard statements pertaining to accountability, continuing competence, ethics, knowledge, knowledge application, leadership, and relationships.

50. CNO’s Professional Standards provides, in relation to the accountability standard, that nurses are accountable to the public and responsible for ensuring that their practice and conduct meets the legislative requirements and the standard of the profession. Nurses are responsible for their actions and the consequences of those actions as well as for conducting themselves in ways that promote respect for the profession.

51. Effectively addressing patients’ needs is central to patient-centered care. For patients to feel safe, the building of trust, empathy and respect between members and their patients is critically important.

52. Members must never lose sight, however, of the clear line between professional and non-professional therapeutic relationships in meeting patients’ needs. Even if a nurse’s actions do not appear outwardly harmful, such as physical abuse, boundary violation can take many forms and cause tacit harm, such as producing feelings of distrust toward members of the profession.

Therapeutic Nurse-Client Relationship Standard

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

54. The TNCR Standard explains that nurses meet the standard for patient-centered care by guaranteeing that all professional behaviour and actions meet the therapeutic needs of the patient. 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.

55. 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.”

56. 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.

ADMISSIONS OF PROFESSIONAL MISCONDUCT

57. The Member admits and acknowledges that she contravened CNO’s Code of Conduct, Professional Standards, and TNCR Standard when she failed to maintain the boundaries of the nurse-patient relationship with the Patient between April 2020 and November 2021, as alleged in paragraphs 1(a) and 1(c) to (k) of the Notice of Hearing, as described in paragraphs 2 to 56 above, when the Member:

a. breached the boundaries of the therapeutic nurse-patient relationship with the Patient by engaging in a personal and romantic relationship with the Patient;

b. spent time with the Patient without documenting and for no therapeutic purpose;

c. spent excessive time with the Patient on shifts;

d. shared personal information with the Patient;

e. exchanged text messages with the Patient;

f. spoke on the telephone with the Patient;

g. failed to document, intervene and follow up appropriately when the Patient expressed that he had feelings for her;

h. spoke with the Patient about spending time together in the future when he was released from the Facility;

i. expressed to the Patient that the Member had feelings for him and cared for him; and

j. bought and brought personal items, namely a cellular telephone case and screen protector, into the unit for the Patient.

58. The Member admits and acknowledges that, regardless of her intent, she emotionally abused the Patient by engaging in a personal and romantic relationship with the Patient as alleged in paragraph 2(a) of the Notice of Hearing and as described in paragraphs 2 to 56 above.

59. The Member does not admit to engaging in a sexual relationship with the Patient and does not plead to that alternative clause in allegation 2(a) of the Notice of Hearing.

60. The Member admits that she committed the acts of professional misconduct as alleged in paragraphs 3(a) and 3(c) to (k) of the Notice of Hearing, and as described in paragraphs 2 to 56 above, and that her conduct was dishonourable, disgraceful, and unprofessional.

OTHER

61. With leave of the Panel of the Discipline Committee, CNO withdraws the remaining allegations in the Notice of hearing which are as follows:

• 1(b)

• 3(b)

Submissions on Liability

College Counsel’s Submissions

College Counsel submitted that several standards had been breached by the Member’s conduct. The Professional Standards, the Code of Conduct and the Therapeutic Nurse-Client Relationship Standard (“TNCR Standard”) were reviewed and clearly outline the expectations of nurses and further inform nurses of their accountabilities. College Counsel submitted that the Member breached her professional boundaries by engaging in a romantic relationship with a vulnerable mental health patient who was being treated in a secure facility. The Member’s conduct posed significant harm to the Patient and risk to her colleagues and other patients. Despite being counselled by management and her colleagues to end the relationship, the Member intensified her contact with the Patient including texting, talking by phone and eventually expressing feelings of attraction and discussing a future together. When the Member ended the relationship, the Patient suffered from feelings of sadness and anger towards the Member. The Patient was unable to sleep and suffered from violent dreams.

College Counsel submitted that the Member’s conduct would be considered to be disgraceful, dishonourable and unprofessional. The Member demonstrated serious and persistent disregard for her professional obligations despite feedback from her colleagues and management. Her behaviour showed an element of moral failing when she knew or ought to have known that her conduct was wrong. College Counsel submitted that the Member brought shame on herself and the profession.

The Member’s Counsel’s Submissions

The Member’s Counsel submitted that the Member had been a member of the College for 7.5 years and that this was her first time before the Discipline Committee. The Member’s Counsel further submitted that the Member acknowledged the seriousness of the allegations and deeply regrets the harm caused to the Patient, her colleagues and the hospital community. The Member’s Counsel submitted that, at the time of the allegations:

• the Member was experiencing personal hardship and that subsequently influenced her to make poor choices,

• admitted to her employer that she had crossed a professional boundary,

• had consistently co-operated with the College, and

• has admitted all allegations.

The Member’s Counsel submitted that the Member has engaged in deep reflection and reviewed the College standards. Since the time of the allegations, the Member has maintained her professional boundaries and sought mental health care for herself.

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), 1(c), 1(d), 1(e), 1(f), 1(g), 1(h), 1(i), 1(j), 1(k), 2(a), 3(a), 3(c), 3(d), 3(e), 3(f), 3(g), 3(h), 3(i), 3(j) and 3(k) of the Notice of Hearing. With respect to allegation #2(a), the Panel finds that the Member emotionally abused the Patient. As to allegations #3(a), 3(c), 3(d), 3(e), 3(f), 3(g), 3(h), 3(i), 3(j) and 3(k), the Panel finds that the Member engaged in conduct that would reasonably be regarded by members of the profession to be disgraceful, dishonourable and unprofessional.

Reasons for Decision

The Panel considered the Agreed Statement of Facts and the Member’s plea and finds that this evidence supports findings of professional misconduct as alleged in the Notice of Hearing.

Allegations #1(a), 1(c), 1(d), 1(e), 1(f), 1(g), 1(h), 1(i), 1(j) and 1(k) in the Notice of Hearing are supported by paragraphs 2 to 57 in the Agreed Statement of Facts. The Panel found that the Member breached the Professional Standards, the Code of Conduct and the TNCR Standard. The Panel considered the entirety of the Member’s conduct: the Member’s cultivation of the romantic relationship with the Patient; the attempts by colleagues and management to correct the Member’s conduct, the Member’s subsequent disregard for those warnings; and, most significantly, the described impact on the Patient when the Member finally ended the relationship.

Allegation #2(a) in the Notice of Hearing is supported by paragraphs 2 to 56 and 58 in the Agreed Statement of Facts. The Panel found that the Member had fostered and participated in a non-therapeutic relationship with the Patient and as a result, the Patient became emotionally dependent on the Member. Despite warnings from her colleagues, the Member continued to encourage the Patient and, indeed, further that dependence. The Member acknowledged and the Panel found this behaviour to be emotional abuse, in that the Member engaged in a personal and romantic relationship with the Patient that caused the Patient harm.

Allegations #3(a), 3(c), 3(d), 3(e), 3(f), 3(g), 3(h), 3(i), 3(j) and 3(k) in the Notice of Hearing are supported by paragraphs 2 to 56 and 60 in the Agreed Statement of Facts. The Panel finds that the Member’s conduct in breaching the standards of the profession by developing a personal relationship with a patient in her care was relevant to the practice of nursing and was unprofessional as it demonstrated a serious and persistent disregard for her professional obligations by breaching the Code of Conduct, the Professional Standards and the TNCR Standard.

The Panel also finds that the Member’s conduct was dishonourable. It demonstrated an element of moral failing through conducting a personal relationship with the Patient. The Member was warned by management and her colleagues and despite those warnings, continued to develop and sustain that relationship. The Member knew or ought to have known that her conduct was unacceptable and fell well 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 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 that a Joint Submission on Order had been agreed upon and requested that the Panel make the following order:

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 10 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.

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

a) Within 6 months from the date that this Order becomes final, or a longer period as approved by CNO, at the Member’s own expense, the Member will successfully complete the CPEP PROBE: Ethics and Boundaries Program (the “PROBE program”). The Member must receive a grade of “unconditionally passed”. The Member must provide proof of successful completion to CNO;

b) After the Member has successfully completed the PROBE program and provided proof of successful completion to CNO, the Member will attend a minimum of 2 meetings with a Regulatory Expert (the “Expert”) at the Member’s 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 CNO regarding the total number of sessions that are required and the length of time required to complete the additional sessions, but in any event, all sessions shall be completed within 12 months from the date that this Order becomes final. To comply, the Member is required to ensure that:

i. The Expert has expertise in nursing regulation and has been approved by 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:

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 and decision tools (where applicable):

1. Code of Conduct, and

2. 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 the Member’s own expense, including the self-directed Nurses’ Workbook;

v. 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 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 their report to CNO, 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 the Member’s 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 the Member’s certificate of registration;

c) For a period of 18 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 prior to 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:

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;

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:

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

2. that they agree to notify CNO immediately upon receipt of any information that the Member has breached the standards of practice of the profession;

d) The Member shall not practice independently in the community for a period of 18 months from the date the Member returns to the practice of nursing.

4. 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.

College Submissions on Penalty

College Counsel made submissions which included the following:

The Member had no prior discipline history with the College and had accepted responsibility for her conduct, thereby avoiding the need for a contested hearing. However, College Counsel argued that the seriousness of the conduct and disregard for the safety of herself, colleagues and the Patient presented significant aggravating factors in this case. The Member was dishonest by her attempts to hide the relationship. Her conduct caused significant emotional harm to the Patient.

General and specific deterrence will be achieved by the oral reprimand and the 10-month suspension of the Member’s certificate of registration. The Joint Submission on Order provides for rehabilitation and protection of the public by way of the terms, conditions and limitations including, completion of the intensive PROBE program, a minimum of two meetings with a Regulatory Expert, 18 months of employer notification and 18 months of no independent practice in the community.

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

CNO v. Ramos (Discipline Committee, 2020): This hearing proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. In this case, the member engaged in a personal relationship with a patient after they had met in a social setting. This case involved texts, photos and sexually suggestive messaging. Findings of sexual abuse were made. The penalty included an oral reprimand, an 18-month suspension of the member’s certificate of registration and terms, conditions and limitations including a minimum of 2 meetings with a Regulatory Expert and 24 months of employer notification.

CNO v. Cosgrove (Discipline Committee, 2019): This hearing proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. This case, similarly, included a vulnerable mental health patient. The member behaved in a sexual nature with a patient, concealed their romantic relationship and, further, undermined her relationships with her co-workers. The penalty included an oral reprimand, an 8-month suspension of the member’s certificate of registration and terms, conditions and limitations on her certificate including 2 meetings with a Regulatory Expert and 12 months of employer notification.

CNO v. O’Connell (Discipline Committee, 2019): This hearing proceeded by way of an Agreed Statement of Facts and a Joint Submission on Order. In this case, the member failed to maintain boundaries with a patient in supportive living when she developed a personal relationship with the patient. The penalty included an oral reprimand, a 5-month suspension of the member’s certificate of registration and terms, conditions and limitations including 2 meetings with a Regulatory Expert and 12 months of employer notification.

College Counsel submitted that these cases help demonstrate reasonable range while recognizing that every case is unique. The proposed penalty for this case, addresses the contravention of standards and professional boundaries that the Member displayed in developing a personal and intensified relationship despite warning and escalation of the Patient’s behaviour. In doing so, the Member amplified the risk to others and caused sustained harm to the Patient.

Member’s Submissions on Penalty

The Member’s Counsel made submissions which included the following:

The Member had admitted and acknowledged the seriousness of her misconduct and as a result, accepted the significant and meaningful penalty. The Member’s statement of remorse was summarised by the Member’s Counsel for the Panel. The Panel was told that the Member did not want to put anyone in “danger” and that this matter “will stay with (her) for the rest of (her) life”. The Member’s Counsel submitted that the Member demonstrated acceptance of responsibility.

Penalty Decision

The Panel accepted the Joint Submission on Order and made the order requested.

Reasons for Penalty Decision

There is a high threshold for departing from a Joint Submission on Order established by the Supreme Court of Canada in R. v. Anthony-Cook, 2016 SCC 43. Departing from a joint submission would require a finding that the proposed penalty would bring the administration of justice into disrepute or is otherwise contrary to the public interest.

The Panel concluded that the proposed penalty is not contrary to the public interest and does not bring the administration of justice into disrepute.

The Panel concluded that the proposed penalty is reasonable and in the public interest. It promotes public confidence in the ability of the College to regulate nurses.

The Panel finds that the proposed penalty satisfies the penalty goals of specific and general deterrence, rehabilitation and remediation, and public protection.

The proposed penalty provides for general and specific deterrence through the oral reprimand and the 10-month suspension of the Member’s certificate of registration. The period of suspension, in particularly, demonstrates to the profession and the Member that the Member’s conduct will not be tolerated by members of the profession and the public.

The proposed penalty provides for remediation and rehabilitation through the terms, conditions and limitations including a minimum of 2 meetings with a Regulatory Expert and the completion of the intensive PROBE program.

Overall, the public is protected through the 18 months of employer notification and subsequent oversight and reporting required. The restriction on the Member’s ability to practice independently for a period of 18 months will further prepare the Member for entry to ethical practice.

The Panel acknowledges that the Member has co-operated with the College and, by agreeing to the facts and a proposed penalty, has accepted responsibility, which is a mitigating factor.

The penalty is in line with the range of what has been ordered in previous similar cases as demonstrated by the cases submitted and referred to by College Counsel.

I, Michael Hogard, RPN, sign this decision and reasons for the decision as Chairperson of this Discipline Panel and on behalf of the members of the Discipline Panel.