Standard, spring 2012 - College of Nurses of Ontario

the 

Standard 

Spring 2012 volume 37 issue 1 

www.cno.org 

Be Inspired! 

Why mentoring 

works 

Electronic 

Documentation 

How and when 

to advocate 

Quality Assurance 

The College answers 

your questions 

www.cno.org 

Have you visited the 

website lately? 

College of Nurses of Ontario 

101 Davenport Rd., Toronto, ON M5R 3P1 

Publications Mail Agreement No. 40062643

Ad removed for 

web publishing

COVER 

Be Inspired! 

Not all learning takes place in a 

classroom. In the cover story on 

page 10, meet nurses who develop 

new skills with colleagues in the 

workplace. 

in this issue 

42 

6 President’s Message 

8 News 

Renewal a success! 

Retiring the Retired Class, and other 

coming changes 

Fees By-Law revised 

New learning module 

Skills and abilities for nursing 

New national forum for nursing 

standards 

20 Take the Quiz 

Therapeutic nurse-client 

relationship 

26 You Asked Us 

Consulting with nurses 

The lockbox provision 

Authority to initiate IVs 

Recommending OTC medications 

28 Reflect on Professional Conduct 

Advocating for clients 

32 Summarized Discipline Decisions 

38 In Praise of Nurses 

42 The Standard of Care 

Cheryl Bower, NP, provides holistic 

assessments to clients in the ED. 

Photo: Swavek 

FEATURES 

14 


The most commonly asked questions and answers about the 

College’s QA Program. 

New Look 

The Standard has a new cover 

design — just in time for spring! 

16 

18 

The Best of cno.org 

The College’s website has tools and services designed to 

support your practice. 

Struggling with Electronic Documentation? 

How to advocate for documentation systems and policies 

that increase your ability to provide quality care. 

Watch for the summer 

issue of The Standard in 

mid-June.

www.cno.org/mym 

Contact CNO 

Updating your information is easier than ever! 

Visit the Maintain Your Membership section at 

www.cno.org to: 

■ update your Register address 

■ complete membership renewal and payment 

■ access and complete the QA Program 

■ obtain a copy of your membership receipt 

Other resources 

To enquire about application, registration or 

reinstatement matters: 

Customer Service Centre 

cno@cnomail.org 

www.cno.org/contact 

To ask a practice-related question: 

Practice Support Line 

ppd@cnomail.org 

www.cno.org/ask 

To voice a concern about a nurse’s conduct: 

Reports and Complaints 

investigations-intake@cnomail.org 

www.cno.org/protect 

To send comments to the Editor: 

The Standard 

editor@cnomail.org 

www.cno.org/standard 


101 Davenport Rd. 

Toronto, ON M5R 3P1 

Editor Deborah Jones 

Managing Editor Kristi Green 

Staff Writers Eugenia Afolabi, Mitchell Brown, 

Bill Clarke, Tanya Davies 

Editorial Associate Brooke Burns 

Proofreader Roberts Ink Communications 

Contributors 

Jasmine Chatha Investigator 

Anthony Derro, RN Practice Consultant 

Annetter Ellenor, RN Advanced Practice 

Consultant 

Ackeisha Hamilton, RPN Practice Liaison 

Heather Hickey, RN Advanced Practice 

Consultant 

Peter Kapakos Web/Intranet Coordinator 

Karen Kirkham, RN Practice Consultant 

Angela McNabb, RN Outreach Consultant 

Nancy Slater, RN Practice Consultant 

Production Coordinator Susan Abraham 

Designer Paul Brandejs 

Subscriptions 

The subscription rate to members is included in the 

annual payment fee. Subscriptions for non-members are 

$22.60 (includes 13% HST) per year. U.S. subscriptions 

are $22.60 per year. Other foreign and overseas 

subscriptions are $45.20 per year. The cost of an 

additional copy of The Standard is $4.52, or $7.91 with 

inserts. Postage and handling charges are extra please 

contact the College for more information. 

Circulation 

For extra copies of an issue or missed issues, please 

contact the Customer Service Centre at the address or 

phone number below. 

Advertising 

The views or opinions expressed in paid advertising are 

those of the advertisers. Publication of paid advertising 

in this magazine does not constitute College of Nurses 

of Ontario endorsement of, or assumption of liability for, 

any claims made in the advertisement. 

For information about placing an advertisement, 

please contact Dovetail Communications Inc. 

Tel.: 905 886-6640 

The Standard is published four times a year by the 

College of Nurses of Ontario. The editor welcomes 

comments and suggestions from readers. 

Email: editor@cnomail.org. 

ISSN 1708-9581 

L’Excellence est disponible en français. 

Copyright © College of Nurses of Ontario, 2012. 

Material published in The Standard may be reprinted 

without permission, provided that credit is given to the 

publication and to the College of Nurses of Ontario. 

The Standard is printed in Canada on recycled paper. 

It contains 50% recycled fibres, including 10% postconsumer 

waste. 

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www.cno.org


web publishing

President’s Message 

It’s a balancing act 

As a regulatory body, the College makes a commitment to the public that individuals 

entering the profession have the competence to practise safely. This commitment is 

balanced with our obligation to be fair to those seeking to become nurses. 

At a recent Council meeting, we were pleased to learn that the Ontario Divisional Court 

made a landmark decision that clarified and reinforced the role of all health professional 

regulators in protecting the public. 

At issue was a decision by our College’s Registration Committee to put conditions on a 

new nurse’s practice to ensure public safety in light of her disability. The nurse appealed 

that decision to the Health Professions Appeal and Review Board (HPARB), which 

found that the committee’s decision had appropriately balanced the nurse’s rights with its 

obligation to protect the public. 

vision 

Leading in regulatory 

excellence 

mission 

Regulating nursing in the 

public interest 

The nurse also made a complaint to the Human Rights Tribunal. The College asked that 

the Tribunal dismiss the matter because the nurse’s concerns had already been properly 

considered by both the committee and HPARB. The Tribunal did not agree. The College 

was concerned that the Tribunal’s decision to proceed on this matter set a precedent 

that would limit regulators’ ability to protect the public. We appealed the decision to the 

Ontario Divisional Court. 

The court made clear that the Tribunal should defer to the specialized expertise and 

public interest mandate of health professional regulators. It emphasized that the correct 

balance is “reasonable accommodation consistent with public protection in health, 

rather than reasonable accommodation up to the point of undue hardship.” This 

important decision supports what we believe is the appropriate balance that regulators 

must apply when making decisions. 

We are proud that our College has contributed to case law that supports health 

professional regulators in serving the public interest. 

This court decision reinforces what we know at Council: public protection is paramount 

in all that we do. If we fail, we fail in our mandate and put the public at risk. And we fail 

the nursing profession, which values safe and ethical care for clients above all. 

Fairness and transparency is also important. At its last meeting, Council approved a new 

document that outlines the basic skills and abilities required of any beginning nurse. 

Written in Plain Language with examples, we believe it will help future nurses and 

educators understand the basic expectations for entering nursing. Read more on the new 

document on page 9. 

Kris Voycey, RN 

President 

6 College of Nurses of Ontario the standard spring 2012


web publishing

NEWS 

Renewal a success! 

The College has completed its most 

successful renewal season ever. More 

than 139,000 nurses renewed their 

memberships before the Dec. 31, 2011 

deadline — an increase of over 2,300 

on-time renewals compared to 2010. 

“Nurses show commitment to the 

profession by renewing on time,” says 

Suzanne Vogler, Manager of Customer 

Service. “This was the second year that all 

of Ontario’s nurses had to renew by going 

online. Since launching online renewal in 

2006, we have seen yearly increases in the 

number of nurses who renew on time.” 

Online renewal became mandatory in 

2010 when the Ministry of Health and 

Long-Term Care requested adding new 

questions about nursing practice and 

education to the membership form. 

Throughout renewal season, the 

College received positive feedback 

from members. “A quick ‘thank you’ 

for making this year’s renewal so easy,” 

emailed one member after completing 

her renewal in November. 

Suspension date 

An additional 13,689 nurses renewed 

after the deadline between Jan. 1 and 

Feb. 14, and paid a late fee. The College 

suspended 2,002 members who did not 

pay the membership fee by Wednesday, 

Feb. 15, this year’s suspension date. 

Historically, about two per cent of 

members are suspended each year. 

Members who have been suspended 

must apply for reinstatement of their 

membership and pay additional fees. 

While suspended, nurses are prohibited 

from practising nursing in Ontario. To 

practise while suspended is considered 

professional misconduct. 

The College’s website, www.cno.org, 

lists suspended members in the “How 

We Protect the Public” section. This list is 

updated as members are reinstated. 

What’s your password? 

This year, the most frequent calls for 

renewal assistance were from nurses 

who had forgotten their passwords. 

You need your password to access 

online renewal and your account. S 

Retiring the Retired 

Class, and other 

coming changes 

Significant changes to the College’s 

Registration Regulation are on the 

horizon — changes that won’t just affect 

new applicants to the College. 

“Our proposed Registration Regulation 

sets out the requirements for entry to 

practice, ongoing membership and 

reinstatement for all members,” explains 

Cheri Vigar, RN, Manager of Regulatory 

Policy. 

While most of the changes will apply to 

applicants and former members who 

would like to return to nursing practice, 

some will affect current members, as 

well. 

For example, under the new regulation 

the Retired Class will be replaced by the 

Non-Practising Class, which will permit 

anyone, regardless of age, to remain 

a member of the College in a nonpractising 

capacity. New requirements for 

revised rules for evidence of practice will 

also affect the annual renewal process 

that all members must complete. 

Members who resign from the College 

but intend to return to practice in 

the future should note that proposed 

changes to the regulation could affect 

how they can request reinstatement to 

the College. 

Council approved amendments to the 

Registration Regulation in late 2010 

after reviewing member and stakeholder 

feedback on proposed changes. Once 

the Ministry of Health and Long-Term 

Care approves the amended regulation, 

the College will inform all members 

and applicants of the changes through 


news You can use 

its website, The Standard and other 

channels. 

Visit www.cno.org for updates on the 

proposed regulation changes and how it 

could affect you and your practice. S 

Fees By-Law revised 

In the polybag with this issue, you’ll 

find a copy of the College’s proposed 

revisions to the Fees By-Law. The by-law 

contains new fees for the jurisprudence 

exam and the Non-Practising Class. 

The new fees will not affect most 

members. The jurisprudence exam fee will 

apply to new applicants, nurses formerly 

registered with the College who want to 

reinstate, and nurses who want to apply 

to another nursing category (for example, 

from an RPN designation to an RN). 

These fees and the Non-Practising Class 

will not come into effect until the revised 

Registration Regulation is passed by 

government, which is expected this June. 

See page 2 of the enclosed document, 

or see the document on the website 

(www.cno.org/standard), for more 

information. S 

New learning module 

There’s a new medication learning 

module in the online Learning Centre at 

www.cno.org/modules. 

The new module reflects the Medication, 

Revised 2008 practice document more 

closely than the previous module did. 

It is based on assessing the client, the 

medication and the practice supports; 

planning the client’s care; implementing 

the medication safely and ethically; and 

evaluating client outcomes. 

“This module puts more emphasis on 

the principles that guide the medication 

process,” explains Angela McNabb, RN, 

Outreach Consultant for the mental 

health and correctional services sector. 

“The module also includes information 

on how to apply the indicators to your 

own practice.” 

For instance, the module now includes all 

eight “rights” of medication — right client, 

right medication, right reason, right dose, 

right frequency, right route, right site and 

right time — that are listed in the practice 

document. (The previous module only had 

five.) “These additional ‘rights’ help ensure 

client safety,” explains McNabb. 

In addition, the module includes 

information on consent — both implied 

and expressed — and emphasizes the 

importance of communicating with the 

client and the health care team. There is 

also a Test Yourself chapter, so you can 

test your knowledge of the Medication 

practice document. 

This module is the latest in a number of 

learning modules designed to further 

your understanding of College practice 

documents and programs, and engage 

you in practice reflection and continuous 

learning. You can view a module at any 

time. Participation is self-directed and 

anonymous; the College does not record 

your participation in the module or your 

score in the Test Yourself chapter. S 

Skills and abilities 

for nursing 

A new fact sheet clarifies the basic 

mental and physical abilities nurses 

should have to provide the public with 

safe and efficient care. 

The document, called Requisite Skills 

and Abilities (RSAs), is a helpful guide 

for educators, guidance counsellors and 

people who provide disability services to 

advise potential students about a career 

as a nurse before they enter a nursing 

program. 

“Seven aspects related to nursing skills 

and physical abilities are identified in the 

document,” explains Cheri Vigar, RN, 

Manager of Regulatory Policy. 

“These include cognitive function, 

communication and interpersonal skills, 

and sensory and motor abilities. Each 

is illustrated with examples of different 

procedures that nurses often perform.” 

One example is using a syringe to 

administer medication. To do this safely, 

nurses must know the purpose and 

side effects of the medication they are 

about to give to a client. But nurses 

must also be able to see and read the 

numbers printed on the syringe, possess 

manual dexterity and good hand-eye 

coordination, and recognize when a 

client is anxious about receiving needles 

and address that anxiety appropriately. 

“Nurses rely on their full range of 

faculties — sight, hearing, and senses of 

touch and even smell — when providing 

care,” says Erin Bruce, RN, Manager of 

Entry to Practice. “People thinking about 

nursing as a career should consider their 

abilities in relation to the criteria in this 

document.” 

Those with questions about meeting the 

RSAs should contact the nursing school 

they intend to apply to, to determine 

if they will require any special support 

or accommodation to complete the 

program. When assessing applicants 

for registration, the College will work 

with applicants to determine whether 

continued on page 21 

College of Nurses of Ontario the standard spring 2012 

9

Alison MacDonald, RN, (left) 

clinical practice leader specializing 

in clinical informatics, and 

Jennifer Huron, RPN, (right) 

clinical informatics analyst at 

Ontario Shores Centre for Mental 

Health Sciences in Whitby. 

Learning 

From the 

Best 

Mentoring is a great way 

to inspire a colleague—and 

be inspired yourself. 

“Some of the most valuable learning I’ve had occurred with colleagues in the 

workplace—not in a classroom,” says Alison MacDonald, RN. “The health care 

sector is a team environment and each team member has knowledge, skills and 

experience to bring to the table. It is important for nurses to watch and learn 

from each other.” 

MacDonald practises at Ontario Shores Centre for Mental Health Sciences in 

Whitby, where she is a clinical practice leader specializing in clinical informatics. 

She credits the inspiration and learning she received from colleagues early on in 

her career with leading her to the field she works in now. Her colleague, Jennifer 

Huron, RPN, a clinical informatics analyst, agrees: “What I’ve learned here isn’t 

something I could have learned anywhere else.” 

Nurses have a professional obligation for continuing competence. This can be 

achieved by taking advantage of learning opportunities throughout their careers, 

and by sharing knowledge and providing feedback to help each other grow 

professionally. Learning among colleagues can take the form of an ongoing 

mentor-learner relationship. It can also happen “in the moment” while care is 

Photo: Swavek 

College of Nurses of Ontario the standard spring 2012 11

Feature 

being provided, or when nurses take time to reflect on a 

process and how it could be improved. 

One of the best ways to develop new skills is with 

colleagues in the workplace. “Most often, learning from a 

colleague is spontaneous,” says MacDonald. “The learning 

experience is relevant to the learner at that moment. One 

of the principles of adult learning is that the learner sees 

the reason for learning something. 

“Nurses who preceptor 

or mentor should have 

a desire to educate 

and inspire.” 

People can be more open to instruction when they are 

taught by a colleague. “Being taught by someone who 

works on the unit alongside you and who understands 

the struggles you face while providing care is less 

intimidating,” says Karen Adams, RN, who practises at 

Northumberland Hills Hospital in Cobourg. 

The College’s Supporting Learners practice document 

outlines the roles and responsibilities for nurses in a 

preceptor role and can be applied to mentors as well. 

Nurses in these roles are responsible for providing 

supervision, coaching and feedback to the learner. They 

must also be aware of the learner’s abilities and maintain 

client safety throughout the learning process. 

Mutual respect 

Both Huron and MacDonald have taken on the 

mentoring role by teaching newer nurses. Doing so 

has provided them with opportunities to review their 

own practice, reflect on their previous experiences and 

education, and examine processes they may not have 

considered before. 

“Before teaching someone, I reflect on what I was taught 

in nursing school, and by teammates and mentors, as well 

as the hospital’s policies and procedures,” explains Huron. 

“I also try to have an explanation as to why things are 

done a certain way. Knowing the why is just as important 

as knowing the how.” 

Mentor-learner relationships are most effective when 

they are based on trust and an appreciation of the other 

person’s knowledge and experience. “As a mentor, you 

must convey confidence in your grasp of the material 

you are presenting or the procedure you are teaching 

while also demonstrating respect for the learner’s previous 

knowledge,” says MacDonald. 

Remaining flexible and attuned to the learner’s needs is 

also important. “Mentors need to recognize that different 

people have different learning styles, as well as different 

paces at which they’ll pick up something new,” says 

Adams. 

Huron feels that nurses shouldn’t consider mentoring 

as just another job requirement. “Nurses who preceptor 

or mentor should have a desire to educate and inspire,” 

she says. “Good mentors don’t just tell someone what to 

do — they help learners find solutions that work for them 

and that they’ll be able to follow through on.” 

Shaping careers 

MacDonald, who wasn’t sure she wanted to continue 

with nursing after finishing her undergraduate degree, 

knows firsthand how a career can be positively shaped by 

mentoring. 

“Mentorship from those I worked with inspired me 

to move forward with my nursing career,” she recalls. 

“During my first year out of nursing school, I was asked to 

apply for a clinical resource nurse role. I was apprehensive 

about taking on a position requiring me to be a mentor 

and educator to nurses who had been practising longer 

than me. However, the organization wanted someone who 

could think critically and teach others.” 

MacDonald stayed in the role for three years and credits 

the mentoring she received from other clinical resource 

nurses, as well as her interactions with front-line nurses, 

for her professional growth during that time. 

New nurses, new knowledge 

The typical picture of a mentor is of a nurse who has 

many years of experience and who passes that knowledge 

to those who are beginning their careers. However, with 

the advent of new technologies, this picture has changed. 

Recently graduated nurses who have learned about the 


Karen Adams, RN, mentors students at Northumberland Hills Hospital in Cobourg. 

latest technologies in school can be in positions to mentor 

senior colleagues who may be unfamiliar with newer 

devices. 

For example, Huron and MacDonald’s hospital recently 

implemented electronic health records (EHRs). According 

to Huron, newer nurses at the facility sometimes act 

as “unofficial tech support” for the long-time staff 

who, before the introduction of the EHRs, had fewer 

opportunities to use computers. 

“The EHRs meant nurses had to start using computers 

for all aspects of their jobs—documentation, medication 

administration, discharge planning, even payroll and 

scheduling,” she explains. “Many of our recent nursing 

graduates had used EHRs during their programs and 

placements. Having these tech-savvy nurses around to help 

them figure out the EHRs gave the senior nurses a sense of 

comfort.” According to Huron, this also gave the facility’s 

newer nurses “a chance to shine.” 

Workplaces can demonstrate how much they value 

nurses’ knowledge by giving them opportunities to 

mentor. Being asked to act as a mentor by an employer 

is “the ultimate compliment,” says Adams, because it is 

an acknowledgement of leadership ability. “It shows that 

your manager believes your skills and experience are worth 

Photo: Swavek 

passing on to someone else,” she explains. “Recently, I 

finished mentoring a student who said that she felt ‘much 

more prepared to be a real nurse after this placement.’ It 

felt good to hear that.” 

“Good mentors don’t 

just tell someone what 

to do. They help 

learners find solutions 

that work for them.” 

Through mentoring and being mentored, nurses develop 

a greater sense of teamwork and collegiality, and build 

confidence in their own knowledge and skills. Says 

Huron: “If you learn from the best, you have no choice 

but to become one of the best.” S 

Have a comment about this article? 

Send an email to editor@cnomail.org. 


Feature 


Get with the program! 

The College regularly receives questions about its Quality 

Assurance (QA) Program. Here are the most commonly 

asked questions and answers. For more information on the 

program, visit www.cno.org/qa. 

I have been selected for Practice 

Assessment. How long does it take 

to complete the multiple-choice 

objective tests? 

You have one hour to complete each test using the online 

QA Program. You have to complete one test for each 

selected practice document. If you are a Nurse Practitioner 

(NP), then you also have to complete a test for the Nurse 

Practitioner practice document. 

You can start each test any time, but once you start you 

have to finish it within one hour. You can’t stop or pause 

the test. The College has online resources to help you 

prepare, including a sample test. 

How does the College select the two 

practice documents for the program? 

The QA team starts by consulting with College experts 

and Advisory Group members to determine current 

nursing issues, trends in practice settings and learning 

needs. The team uses this feedback to choose the practice 

documents. 

Once a document is selected, the team starts the rigorous 

process of developing a related multiple-choice objective 

test that is valid and reliable. The goal is eventually to 

offer all of the practice documents and allow nurses to 

choose the publications that are most relevant to their 

practice. 


Feature 

I don’t think the selected practice 

documents apply to my practice setting. 

How can I create learning goals from 

these documents? 

College practice documents apply to all nurses, regardless 

of their roles, job descriptions or areas of practice. 

However, not all behavioural indicators apply to you at all 

times. For example, the indicator in the Documentation, 

Revised 2008 practice document related to “documenting 

advice, care or services provided to an individual within a 

group, groups, communities or populations” won’t apply 

if you don’t provide care to groups. It is expected that you 

review the relevant document and choose the indicators 

that do apply to your practice. 

Some indicators, such as “accessing only information for 

which the nurse has a professional need to provide care” 

apply to all nurses, regardless of role or practice setting. 

Before you start developing your learning goals, reflect 

on your practice and consider how a practice document 

applies to you, and in what context. 

Why must NPs participate in a rigorous 

QA Program? Why can’t I use my 

continuing education hours to show my 

continuing competence for QA? 

Research shows that continuing competence is better 

gauged when a nurse participates in a variety of assessments, 

such as objective tests, and Chart Review and Interview, 

than if the nurse completes only one assessment or 

continuing education hours. 

Will my Practice Assessment results be 

sent to my employer? 

No. The QA process is completely confidential. 

If I fail the objective tests, will I lose 

my registration? 

No. QA is a facilitative process. If you fail the test(s), then 

you still have an opportunity to demonstrate that you can 

meet the competencies related to the practice document 

by completing a follow-up activity. For example, you may 

be asked to submit a case example from your practice that 

applies the competencies related to that practice document. 

If you are unsuccessful completing that, you will have to 

complete continuing education or remedial activities. S 

The QA Program 

Lifelong learning is essential to continuing 

competence and public protection. This is 

the principle that the College’s QA Program 

is based on. 

You show your commitment to continued 

competence by reflecting on your practice, 

and setting and achieving learning goals. 

The College supports you throughout this 

process by providing resources and tools 

including blank Practice Reflection and 

Learning Goal forms, sample Learning Goal 

forms, and a guide to developing your 

learning goals and Learning Plan. 

There are three components to the 

QA Program: 

■ Self-Assessment, which includes reflecting 

on your practice, and developing and 

maintaining learning goals in relation to 

the two practice documents the College 

selects annually 

■ Practice Assessment 

■ Peer Assessment 

All nurses participate in Self-Assessment; only 

nurses who are randomly selected complete 

Practice Assessment, which includes Peer 

Assessment. 

“Overall, nurses do well in the QA Program,” 

says Allison Patrick, RN, Manager of 

Quality Assurance. “The majority of nurses 

successfully complete the Practice Assessment 

component of QA.” 


15

Feature 

The Best of 

cno.org 

You already know that www.cno.org is the place to go when you 

want to renew your membership, update your contact information 

or learn more about how the College protects the public. But did 

you know the College’s website also has a number of tools and 

services designed specifically to help you with questions about 

your practice? Here are five sections to watch at www.cno.org. 

1. Ask Practice 

www.cno.org/ask 

Every day, nurses encounter situations that put their 

knowledge of practice standards to the test. Some of 

these situations are easy to figure out, but for those 

instances when the answers aren’t always clear, Ask 

Practice can help. 

Ask Practice features questions and answers about a 

variety of practice-related issues. The questions come 

from actual nurses, and the answers are written by expert nurses at the College. And if the 

information you’re looking for isn’t there, you can reach a Practice Liaison to ask your own 

question. Practice support is just a few clicks away. 


Feature 

2. Teleconferences 

www.cno.org/teleconferences 

If nursing is about anything, it’s collaboration. That’s why 

the College hosts free teleconferences that bring together 

nurses, nursing students, administrators and employers to 

share ideas and discuss topics of interest to the profession. 

Past sessions have included social media, conflict 

resolution, practice changes for Nurse Practitioners and 

(a perennial favourite) a 

student’s introduction to 

self-regulation. In this 

section, you can sign up 

for a future session or 

peruse documents from 

past teleconferences. 

3. Learning Modules 

www.cno.org/modules 

Learning is important, but it doesn’t always happen in 

a textbook. That’s why the College has created a series 

of interactive learning modules to help nurses better 

understand the practice documents. Covering a range 

of topics from ethics and consent to medication and 

the nurse-client relationship, nurses can experience the 

learning modules at their own pace and on their own 

schedule. Plus: quizzes! 

4. Practice Consultations 

www.cno.org/consult 

For those times when your organization needs a team-oriented 

approach to deal with the practice challenges that compromise 

client care, practice consultations can help. A consultation with a 

practice consultant can help your organization identify the issue, 

develop a plan for addressing the issue and establish criteria to 

determine if the goals have been met. Just fill out the form at www. 

cno.org/consult. A Practice Consultant will get in touch with you 

and…well, that’s all there is to it. Simple. 

5. Online QA Program 

www.cno.org/QA 

The College’s online Quality Assurance (QA) Program 

gives nurses convenient 24/7 access to their QA Program 

documents. After you log in as a member of the College, 

you can fill out, save and print your Practice Reflection 

form and Learning Plan, access your Learning Plan 

from any computer, and track and update your Learning 

Plan over time. It’s a snap to use, which is a good 

thing — because when it comes to lifelong learning, every 

moment counts. 


17

Feature 

Struggling 

with Electronic 

Documentation? 

Here’s how and when to advocate. 

When a facility introduces a new technology, such as an 

electronic documentation system, it can take time for 

users to adjust to the change. Switching from paper-based 

to electronic documentation often requires nurses to alter 

their routines. Even if you are comfortable using computer 

technology, you will still need time to learn how the 

new system works, and adjust to changes in policies and 

processes. 

College standards for documenting also apply to 

electronic documentation. If nurses find it difficult 

to adjust to the new technology, or if it is not userfriendly, 

then they will have a harder time balancing 

documentation requirements with providing the best 

possible client care. 

As regulated health care professionals, nurses have a role 

to play in improving their practice settings. Part of that 

role is advocating for documentation systems and policies 

that increase their ability to provide quality nursing care 

and meet the College’s standards on documentation. 

“In this context, advocating means talking about the issue 

with the right people, with the aim of finding a solution,” 

says Anthony Derro, Registered Nurse (RN), Practice 

Consultant. “It involves communicating in a manner that 

helps decision-makers take action to support the ultimate 

goal of providing the best possible care to clients.” 

Advocacy is typically used to initiate the change 

needed to solve a problem. However, once technology is 

implemented, it can be harder and costlier to change. This 

is why nurses should advocate for their own involvement 

in choosing, implementing and evaluating new electronic 

documentation systems. “It helps to get the early input of 

the nurses who will use the system,” Derro says. 

If nurses still have problems with a system after it is 

implemented, then they should advocate for more training, 

improvements to the system or changes to policies. “There 

should be no conflict between what the electronic system 

allows nurses to do and what the College’s standards on 

documentation require,” says Lori Adler, RN, Manager 

of Practice Standards. “If there are conflicts, they should 

advocate for changes.” 

How to advocate 

How can you advocate for improvements to electronic 

documentation technology? The key is knowing how to 

present the issue without alienating the people who are 

able to provide a solution. “Nurses should have a plan 

for how to approach those who are equipped to execute 

change such as managers, information technology staff, 

and educators or training staff,” says Adler. 

First, discuss the issue with colleagues to see if others 


Feature 

have similar problems with the system. Focus discussions 

on identifying both the issues and your needs, and 

consider possible options to resolve the problems. Then, 

talk to your managers and nurse leaders, presenting your 

recommendations and implementation plans. 

For example, if computers are in an inconvenient 

location, making it difficult to document right away, you 

could suggest placing wireless computers on wheeled carts 

that can be transported to clients’ bedsides. Or you could 

look for inefficiencies in existing documentation policies. 

For example, you could recommend documenting routine 

assessments using revised charting-by-exception policies. 

It is part relationship management and part problemsolving,” 

explains Derro. “Taking this approach to 

advocacy means it’s not enough to identify and discuss the 

problems. Be prepared to suggest solutions.” 

Nurse managers, administrators and educators also have 

a responsibility to advocate, especially during the selection 

and implementation of a documentation system, because 

their positions of leadership can help influence decisionmakers. 

“They should think proactively,” says Adler. 

“While presenting decision-makers with suggestions of 

systems to implement, they also need to prepare plans for 

potential mishaps such as system outages or data loss.” 

Advocating from the point of view of client care is an 

important part of the therapeutic nurse-client relationship. 

“The best interest of the client should be the central 

goal,” says Adler. “You will be more likely to convince 

decision-makers if you can demonstrate how the proposed 

changes will promote clear documentation, privacy 

and confidentiality of client information, and enhance 

communication about client care.” S 

Advocating 

By advocating, nurses use their influence as 

knowledgeable members of the health care 

team to help improve systems such as electronic 

documentation, while maintaining client needs as 

the highest priority. 

VOLUNTEER 

a 

COMMITTEE 

Use your knowledge 

member! 

of nursing practice to make decisions 

that protect the public and are fair to nurses 

and applicants. 

Learn more about the committees and volunteer 

at www.cno.org/commapply. 

Apply online from March 1 

to April 6, 2012. 

This is your chance to put yourself in nursing regulation. 

to be 


19

Quiz 

Quiz questions are 

based on queries 

to the College; real 

names have not 

been used. 

The therapeutic 

relationship is 

based on trust, 

respect, empathy 

and professional 

intimacy, 

and requires 

appropriate use 

of the power 

inherent in the care 

provider’s role. 

Take the Quiz: 

Therapeutic nurse-client 

relationship 

1 

Sarah is the director of nursing care at 

a nursing home in a small community. 

Recently, Al, a long-time friend of one of the 

staff nurses, Teitur, was admitted to the home. 

Sarah doesn’t think Teitur should provide care 

to Al, so she assigns Al’s care to another staff 

nurse. When Teitur learns he won’t be Al’s 

nurse, he rushes to see Sarah, insisting he can 

provide better care to Al because he has known 

him for years. 

Should Teitur provide nursing care to his friend? 

Yes Teitur knows what Al likes and doesn’t 

like. 

No It’s hard to be objective when caring for 

a friend, and another nurse is available to 

care for Al. 

3 

Lily is an RPN in the paediatric unit. One 

of her clients, Jack, has been on the unit for 

several months, and Lily has noticed how much 

he loves reading. Lily wonders if it would be 

appropriate to buy Jack her favourite children’s 

book for his upcoming birthday. But when Lily 

asks another nurse about her idea, the colleague 

tells her that giving a client a present could be 

considered boundary-crossing. 

If Lily gives Jack a gift, does it cross a 

boundary? 

Yes Gift-giving may cross a boundary in the 

nurse-client relationship. 

No The birthday present will give Jack a lot 

of joy, and they can read the book together. 

2 

Cliff is an NP who practises in a primary 

health care clinic. He helps maintain 

the clinic’s Facebook page, which provides 

information on the clinic’s location, hours and 

services. Cliff also has a personal Facebook 

page that he uses to share photos of his new 

baby with his family and friends. Today, a 

client visited this personal Facebook page and 

sent Cliff a “friend” request. 

Should Cliff allow a client to be a friend on 

Facebook? 

Yes It’s OK as long as he does not discuss 

health care. 

No A friendship would violate the therapeutic 

relationship. 

4 

Tara, an RN in a nursing home, sees a 

nursing colleague hitting a client. She 

intervenes and stops the abuse. Tara questions 

her colleague, who says she was tired and 

frustrated, but that it will never happen again. 

She asks Tara not to tell the nurse manager. 

Should Tara report the client abuse to her 

manager? 

Yes Tara needs to report the client abuse. 

No Tara intervened and her colleague 

promised it will not happen again. 

Answers on page 25 


News you can use 

continued from page 9 

reasonable accommodations can be 

made while protecting public safety. 

The requirements outlined in the RSAs 

document, which Council approved last 

December, are in keeping with other 

Canadian nursing regulatory bodies. To 

see the document, visit www.cno.org/ 

docs. S 

New national forum 

for nursing standards 

Last year, the College and 11 other 

regulatory bodies formed the Canadian 

Council of Registered Nurse Regulators. 

The Council promotes best practices, 

harmonizes approaches to nursing 

regulation, monitors trends, identifies 

issues related to nursing regulation 

and undertakes projects that promote 

excellence in professional nursing 

regulation. 

The Council recently incorporated 

to become a national forum and 

unified voice on matters related to 

interprovincial, national and international 

regulatory matters. Recently, the Ordre 

des infirmières et infirmiers du Québec 

(OIIQ) voted to upgrade the educational 

requirement for RN registration to a 

baccalaureate degree. The Council has 

offered to support the OIIQ as it takes 

this resolution forward for approval by 

the Quebec government. This change 

aligns Quebec’s educational requirements 

with the rest of Canada’s, supports 

interprovincial labour mobility for nurses 

and helps ensure that Quebec residents 

receive quality nursing care. 

For more information on the Council’s 

activities, visit www.cno.org. S 

news You can use 

QA 

Go online 

to the2012 

Watch the tutorial and learn how 

to create, save and review your learning goals 

in one secure place. 

Program 

Go to www.cno.org/qa for all your QA tools and 

resources, including FAQs, sample learning goals and 

a webcast. 



web publishing


web publishing

CONTRIBUTE TO 

NURSING REGULATION 

Join an Outreach 

ADVISORY 

Group 

The College will be looking for nurses to participate 

in its Advisory Groups. 

Each group focuses on regulatory issues based on 

practice sectors. 

Visit www.cno.org/outreach for details as they 

become available in May/June. 


web publishing

Quiz 

Quiz answers from page 20 

1 

No A nurse should not provide paid nursing care 

to friends or family members unless no other care 

provider is available. Sarah correctly assigned Al’s care to 

another nurse. 

If another nurse was not available to care for Al, then 

Teitur would have to consider several factors before caring 

for his friend. He would have to reflect on the need to 

maintain professionalism and objectivity, and whether 

his personal relationship with Al would interfere with the 

care of his other clients. Teitur would need to be vigilant 

about maintaining the boundaries between professional 

and personal roles, and about informing Al of those 

boundaries. 

By continually clarifying his role in the therapeutic 

relationship, Teitur could relieve any discomfort Al might 

feel about receiving nursing care from a friend. If Teitur 

ever does provide nursing care to Al, then he should 

develop and follow a plan of care to help him maintain 

professionalism and objectivity in the therapeutic nurseclient 

relationship. 

2 

No When a therapeutic nurse-client relationship 

exists, a nurse should not enter into a friendship or 

other personal relationship with the client. Accepting 

a request to be a friend on Facebook for a personal 

relationship is the same principle. The focus of the nurseclient 

relationship must remain professional at all times. 

Nurses are responsible for setting and maintaining 

appropriate boundaries in the therapeutic relationship and 

helping clients understand when their requests are beyond 

the limits of that relationship. Cliff needs to clarify with 

the client that they have a therapeutic relationship— not a 

social or personal relationship. Cliff could suggest that the 

client consider joining the clinic’s Facebook page. 

3 

Yes In this instance, giving a birthday present 

to Jack would cross a boundary because it has the 

potential to change the dynamics of the therapeutic 

relationship. Jack’s parents may feel indebted to Lily, and 

feel that they the need to reciprocate by buying Lily a 

gift. Also, there is potential for upsetting other clients 

who didn’t receive a present on their birthdays. Lily could 

be perceived as treating Jack differently than her other 

clients. 

Because Lily was unclear whether giving a birthday gift 

crossed a boundary in the therapeutic relationship, she 

was correct to consult with a colleague. The Therapeutic 

Nurse-Client Relationship, Revised 2006 practice 

document identifies warning signs for boundary-crossing. 

It also offers guidance on when it is appropriate to give a 

gift to a client and how to give a gift so it doesn’t violate 

the therapeutic relationship. Nurses need to reflect 

continually on their relationships with their clients and 

seek assistance from colleagues, managers or members 

of the health care team when they have questions about 

crossing boundaries, especially when it involves selfdisclosure, 

or giving or receiving gifts from clients. 

4 

Yes Tara must report the physical abuse to her 

manager. Nurses protect clients from harm by 

ensuring that abuse is prevented or stopped and reported. 

If a nurse witnesses another nurse or member of the 

health care team abusing a client, then the nurse must 

take action. In all cases of client abuse, nurses need to 

follow up on the incident with a report to the employer 

or authority responsible for the health care provider, such 

as a nursing agency. College research shows that when 

someone intervenes in an incident of abuse, the abuse 

stops. Tara must also inform the client of their right to 

contact the police and the College. 

For more information, see the Therapeutic Nurse- 

Client Relationship, Revised 2006 practice document and 

the College’s abuse prevention program, One is One Too 

Many, at www.cno.org/docs. 

Council meetings 

The draft minutes of the March Council meeting 

will be posted at www.cno.org/agendas in early 

April. 

Council meetings are open to the public. To 

attend, contact Jenna Hofbauer, Council Affairs 

Coordinator, at 416 928-0900, ext. 7566; 

1 800 387-5526, ext. 7566 (toll-free in Ontario); or 

jhofbauer@cnomail.org. 

Upcoming meetings: 

June 7, 2012 

For more information on Council, visit 

www.cno.org/council. 


25

You 

Asked 

Us 

Consulting with 

nurses 

The lockbox 

provision 

Authority to 

initiate IVs 

Recommending 

OTC medications 

Q 

I’m an RN in the general 

medicine unit of an acute 

care hospital. I used to practise in 

a neurosurgical unit. Today, one 

of my nursing colleagues, Rachel, 

asked me to perform spinal cord 

testing for a client who was admitted 

postoperatively after spinal cord 

surgery. Our unit does not normally 

admit clients with spinal cord injuries, 

so Rachel doesn’t feel competent to 

provide some aspects of care for this 

client. If I perform this assessment, 

am I accountable for following up 

with findings? 

A 

In this consultation, Rachel is 

asking to transfer an aspect of 

care (the spinal cord testing) to you. 

If you agree to accept this additional 

aspect of the client’s care, then you 

are accountable for providing that 

care safely and ethically. 

You must work with Rachel to 

determine who will be responsible for 

the various components of client care. 

Although Rachel does not have the 

competence to perform spinal cord 

testing, she can still take action on 

the findings. 

In this situation, Rachel has 

requested a consultation in which 

you are the consultant. Consultations 

result in one of three outcomes: 

1) The nurse requesting the 

consultation receives advice from 

the consultant and continues to 

care for the client. 

2) The nurse transfers an aspect of 

client care to the consultant. 

3) The nurse transfers all of the care 

to the consultant. 

Rachel will need to assess whether 

the findings of the spinal cord testing 

show new client care needs that are 

beyond her competence level. If they 

are, Rachel will need to determine 

who the most appropriate care 

provider is to consult with or transfer 

care to. 

If, for example, the spinal cord 

testing findings are normal, then 

Rachel may not require any further 

assistance. If the findings require a 

change to the client’s plan of care that 

is within Rachel’s level of competence, 

she may assume responsibility for the 

follow-up. However, if the spinal cord 

testing you perform reveals that the 

client needs nursing interventions that 

are beyond Rachel’s competence, then 

she may need to transfer an aspect 

or all of the care to another care 

provider. This situation offers Rachel 

the opportunity to reflect on her 

practice and develop a plan to address 

her learning needs. 

Q 

My client doesn’t want to share 

part of his personal health 

information with the other members 

of the health care team. Am I required 

to keep this information from my 

team? 

A 

Yes, you must withhold the 

information from the health 

care team. The client has the right 

to refuse to share part of his personal 

health information with other health 

care providers. This right is referred 

to as the lockbox provision. 

It is the client’s decision to 

withhold information from other 

care providers. However, you can 

still examine the implications of this 

choice with him. By discussing the 

possible consequences of not releasing 

the information, you will help the 

client make an informed decision. 


you asked us 

If, for example, the client decides 

not to share part of his health 

information with the attending 

physician, but you consider the 

information necessary for the 

provision of care, you must tell the 

physician that the client has withheld 

relevant information. The physician 

can then explore the matter with the 

client. 

Check if your organization has 

a policy for documenting locked 

information. If there isn’t one, take 

action to protect the confidentiality 

of the locked information, with 

the Documentation, Revised 2008 

practice document in mind. You 

should also advocate for a policy that 

explains the documentation of locked 

information. 

For more information, refer to the 

Confidentiality and Privacy — Personal 

Health Information practice document 

at www.cno.org/docs. 

Q 

I’m an RN practising at 

a wellness clinic where 

naturopaths offer clients intravenous 

(IV) chelation therapy. The clinic 

protocol is to have the RN start the 

IV and the naturopath administer the 

chelation treatment. There is no order 

in place for a nurse to insert IVs. As an 

RN, am I permitted to initiate an IV for 

this therapy? 

A 

No. RNs have the authority to 

initiate venipuncture only when 

delaying venipuncture would likely 

be harmful to the client, such as in 

an emergency. Chelation therapy 

at the wellness clinic is a routine 

treatment, so you are not permitted 

to initiate an IV in this situation. 

Initiation means a nurse 

independently decides that a 

controlled act procedure is required 

and then performs the procedure 

without an order. The Authorizing 

Mechanisms practice document 

lists the procedures that RNs and 

RPNs can initiate, and outlines the 

conditions necessary for performing 

them. 

If a nurse requires an order to 

perform a controlled act procedure, 

then the Nursing Act, 1991 specifies 

five health care practitioners a nurse 

can accept an order from, including 

NPs and physicians. You cannot 

accept an order for a controlled act 

procedure from naturopaths because 

they are not listed in the Act. 

To facilitate the authority for IV 

insertion, the wellness clinic team 

members could work together to 

create a directive that is authorized 

by an NP or a physician. For more 

information on directives, download 

the Authorizing Mechanisms and 

Directives practice documents at 

www.cno.org/docs. 

Q 

As a public health nurse in a 

high school, students ask me 

about nicotine replacement therapies 

to help with smoking cessation. I 

don’t supply these medications, but 

I’m considering recommending that 

students buy them at a pharmacy. Can 

I recommend nicotine replacement 

therapy to adolescents who want to 

stop smoking? 

A 

Nicotine replacement 

therapy is an over-thecounter 

(OTC) medication. A 

nurse is solely accountable for 

recommending an OTC medication 

to a client and for any outcomes 

of that recommendation. Before 

recommending an OTC medication, 

you must know the client’s situation, 

condition and medication profile. 

You must also have knowledge of the 

drug. 

There is no minimum age for 

consenting to treatment. Use your 

professional judgment to determine 

whether the student can understand 

and appreciate the information, and 

make an informed decision. 

Because OTC medications do 

not require a prescription, they are 

not included in the controlled act of 

prescribing. Consequently, a nurse 

can recommend an OTC medication 

and/or administer it without an 

order. However, legislation or 

organizational policy might require 

an order from an authorized 

prescriber in a particular practice 

setting. Check with the school 

board to determine its expectations 

for nurses recommending OTC 

medications. 

For more information on this, refer 

to the Complementary Therapies and 

Medication, Revised 2008 practice 

documents at www.cno.org/docs. S 

All College documents can be found at 

www.cno.org/publications. 

Have a question about applying the 

College’s practice standards? Send an 

email to the Practice Support Line at 

ppd@cnomail.org. Or, call 

416 928-0900, ext. 6397; or toll-free in 

Ontario at 1 800 387-5526, ext. 6397. 


Reflect on Professional Conduct 

The College responds to concerns received from the public, 

employers and other sources through its complaints and 

reports processes. The goal is to enhance the quality of nursing 

care and ensure public protection by reinforcing the College’s 

standards of practice, and providing nurses with opportunities 

to reflect on and improve their practice. 

This column is intended to help nurses understand and reflect 

on commonly raised concerns, as well as the College’s overall 

approach to resolving those concerns. 

The scenarios are examples based on actual complaints or 

reports. All names, locations and identifying characteristics 

have been changed to protect confidentiality. 

Advocating for Clients 

The complaint 

The College received a letter of complaint from Martin, 

who was admitted to his local hospital to treat a severe 

allergic reaction. The hospital assigned Angela, an RN, 

to provide nursing care. On Martin’s first day as an 

in-patient, Angela administered adrenalin by an incorrect 

route, which caused an adverse reaction. According to 

Martin, when Angela’s shift ended, she informed him of 

the mistake and apologized. 

In his letter to the College, Martin made a complaint 

about Angela’s medication error and her failure to take 

appropriate action. He stated that even after recognizing 

her mistake, Angela did not assess him or ensure that he 

was monitored. Martin believed that Angela should have 

taken action and followed up on his care when she learned 

of the error, even though her shift had ended and his care 

was transferred to a different nurse. 

The College responds 

After reviewing the results of the complaint investigation, 

the Inquiries, Complaints and Reports Committee 

expressed concern about Angela’s medication administration 

and her failure to take appropriate action after realizing her 

mistake. 

The committee decided that public protection would 

be served best by using a remedial approach. This would 

involve an expert who would help Angela engage in 

facilitated reflection. To do this, the committee required 

Angela to complete a specified continuing education or 


Reflect on Professional Conduct 

Questions: 

■ 

■ 

How could Angela have addressed Martin’s needs when she learned 

of the medication error? 

How do you advocate for clients in your practice setting? 

remediation program addressing the issues in Martin’s 

complaint. The program would help Angela improve her 

professional, therapeutic nursing practice by showing her 

how to take appropriate action in similar circumstances. 

The program required Angela to review the College’s 

Medication, Revised 2008, Therapeutic Nurse-Client 

Relationship, Revised 2006 and Professional Standards, 

Revised 2002 practice documents; complete a reflective 

questionnaire after reviewing the standards; complete the 

College’s online learning modules based on the standards; 

and meet with a regulatory expert approved by the College 

to discuss the incidents, applicable nursing standards, and 

the insight and learning gained from practice reflection. 

The committee required Angela to appear for an oral 

caution to express its concerns about her practice. It 

also referred her to the Professional Standards and the 

Therapeutic Nurse-Client Relationship practice documents, 

which discuss the requirements for nurses to meet the 

needs of clients. 

The member responds 

Angela said that she became aware of her medication error 

at the end of her shift. She explained that she decided not 

to assess or monitor Martin because he did not appear to 

be experiencing any negative effects from the medication. 

Angela believed that she was not required to take further 

action because her shift had ended and Martin was going 

to be cared for by another nurse. 

In her reflective questionnaire, Angela regretted not 

making Martin’s needs a priority. When reviewing the 

relevant practice standards, she understood that her 

professional obligation is to provide client-centred care to 

all clients. She stated that when she learned of her mistake, 

she should have taken action by assessing Martin and 

arranging for him to be monitored for adverse reactions. 

Angela reflected that she was not focused on the client’s 

well-being, and that her conduct was inconsistent with 

the principles of the Medication, Therapeutic Nurse-Client 

Relationship and Professional Standards documents. 

Angela maintained that she was committed to providing 

excellent care in accordance with the College’s standards. 

She said she appreciated the opportunity to learn from the 

complaint and improve her nursing practice. 

Reflecting on the complaint 

Ensuring client well-being is every nurse’s obligation. For 

this reason, nurses are required to take action to ensure 

clients’ needs are met. 

In this case, Angela did not report her medication 

error or follow up on Martin’s care because she did 

not observe an adverse reaction and she was no longer 

providing nursing care to him that day. However, as a 

nurse, her foremost responsibility is to provide, facilitate, 

advocate and promote the best possible care for clients. 

Even though Angela’s shift had ended, she was aware that 

Martin’s safety and well-being had been compromised as a 

result of an error. Her professional obligation was to take 

appropriate action to address Martin’s immediate health 

care needs. S 



web publishing


web publishing

The following 

decisions and reasons 

of the Discipline 

Committee form 

part of the College’s 

Summarized 

Discipline Decisions 

Annual Report and are 

published as a requirement of 

the Regulated Health Professions 

Act, 1991. By publishing these 

decisions, the College educates 

nurses and informs the public 

about what constitutes 

professional misconduct and 

incompetence. These decisions 

also provide direction to RNs, 

RPNs and NPs on practice 

standards and professional 

behaviour, if they find 

themselves in similar situations. 

The name of the Member who 

is the subject of the hearing 

may or may not be included, 

as required by law. Information 

revealing the names of witnesses 

and clients has been removed. 

For copies of full decisions, 

visit the website at 

www.cno.org/decisions, or 

contact Bill Clarke at 

1 800 387-5526, ext. 7590 (tollfree 

in Ontario) or 416 928-0900, 

ext. 7590. 

Caron Campbell 

9707068 

Allegations and plea 

The College alleged that the Member 

misappropriated taxi chits from her 

workplace. 

The Member admitted the 

allegations, and the College and 

the Member submitted a written 

statement to the Panel in which they 

agreed to the following facts. 

Agreed facts 

The Member worked as a patient care 

manager in a hospital’s emergency 

department. In this role, she was 

responsible for maintaining a budget, 

which included tracking taxi chits for 

the emergency department. During an 

unrelated investigation into emergency 

department expenses, it was discovered 

that the Member had used taxi chits 

for unauthorized personal purposes 

for approximately six months. She also 

provided chits to her child for personal 

use. The Member signed the chits 

using a number of different names. 

The Member’s misuse of taxi chits 

totalled approximately $5,500. 

Finding 

The Panel found that the facts 

supported a finding of professional 

misconduct as alleged. The Panel 

found the Member’s behaviour to be 

dishonourable and unprofessional. 

Submissions on order 

The College and the Member sought 

an oral reprimand and a one-month 

suspension. The Member would 

be required to complete specified 

remediation activities in preparation 

for a series of meetings with a nursing 

expert. For 12 months after returning 

to practice, the Member would be 

required to advise the College of 

her employers, provide employers 

with a copy of the Panel’s decision 

and reasons, and only practise for 

an employer who agreed to advise 

the College if the Member breached 

the standards of practice of the 

profession. The Member would be 

required to pay a fine to the Minister 

of Finance in the amount of $1,000. 

However, if she were to make full 

restitution to the facility, then the 

fine would not be enforced. 

Panel order 

The Panel accepted the joint 

submission as reasonable and in 

the public interest. The Member 

accepted responsibility for her actions 

and cooperated with the College by 

agreeing to the facts and admitting to 

professional misconduct. The penalty 

sends a clear message to the public, 

the Member and the profession that 

this misconduct is considered serious 

in nature and will not be tolerated. 

Scott Ezard 

0103580 



removed medications from his 

employer’s ward stock. 


allegation, and the College and 





Discipline decisions 

Agreed facts 

The Member worked as a staff 

nurse on a surgical unit. The facility 

received 14 medication packages 

that had been recovered from the 

Member’s home including lorazepam, 

oxazepam and trazodone. An 

internal investigation revealed that 

the medications had been taken 

from the PRN medication stock. 

The pharmacy determined that the 

medications had been sent to the 

floor over an 11-month period. 

The Member acknowledged that 

he had taken the medication packages 

home and failed to return them to the 

facility for extended periods of time. If 

the Member were to testify, he would 

say he inadvertently took medication 

packages home sometimes after having 

put them in his pocket on busy shifts. 

He did not consume the medications 

and he did not hide them from his 

spouse. The medications were placed 

in a dresser for safekeeping. When 

the Member and his spouse became 

estranged, his spouse reported to 

the police that the member had the 

medications. The police returned 

them to the facility. 

Finding 





unprofessional. 



an oral reprimand and a two-month 




for a meeting with a nursing expert. 

For 12 months after returning to 

practice, the Member would be 

required to advise the College of his 

employers, provide employers with 

a copy of the Panel’s decision and 

reasons, and only practise for an 

employer who agreed to advise the 

College if the Member breached the 

standards of practice of the profession. 

Panel order 




accepted responsibility for his actions 


agreeing to the facts and admitting 

to professional misconduct. The 

penalty addresses the components 

of remediation, specific and general 

deterrence, and protection of the 

public. 

Kelly Anne Heydens 

8519407 



breached the boundaries of the 

therapeutic nurse-client relationship 

by socializing with the client and 

her family on numerous occasions, 

accepting gifts from the client and 

engaging in self-disclosure with the 

client. 






Agreed facts 

The Member worked as a nurse 

case manager for an organization 

providing assistance to injured clients. 

After an accident in which she 

injured her hand, the client sought 

assistance from the organization. The 

client also had a history of depression 

and post-traumatic stress disorder. 

The Member was assigned as her 

nurse case manager from 2003 to 

2006. In her professional role, the 

Member monitored and assisted the 

client to ensure timely provision of 

health care services, and provided 

rehabilitation counselling. 

The Member socialized with the 

client and her family throughout 

2004. They ate out at restaurants 

together, had meals in each other’s 

homes, celebrated Canada Day 

together, exchanged Christmas gifts 

and visited each other at home. The 

client drew a picture of the Member’s 

house, paid to have it framed and 

presented it to the Member with a set 

of note cards as a gift of appreciation. 

The client also gave the Member a 

watercolour painting. From 2003 to 

2005, the Member revealed details 

about her personal and family life to 

the client. 

Finding 



misconduct as alleged. Given the 

Member’s serious disregard of the 

therapeutic nurse-client relationship 

and the impact on the client, 

the Panel found the Member’s 

behaviour to be dishonourable and 





suspension. The Member would be 

required to complete remediation 

activities in preparation for two 

meetings with a regulatory expert. 



required to advise the College of her 







Panel order 



33






professional misconduct. The penalty 

meets the objectives of specific and 

general deterrence, provides an 

opportunity for rehabilitation and 

remediation, and protects public 

safety. 

Sandra D. Munro #1 

IJ00407 



administered medications earlier than 

ordered and falsely documented that 

they had been administered at the 

correct time. 






Agreed facts 

The Member worked at a long-term 

care facility where she was responsible 

for administering medications to 

residents. At 1830 hrs, the assistant 

director of care conducted an audit 

of the medication cart and the 

medication administration records 

(MARs). She noted that a large 

number of 2100-hr medications were 

missing, and that the Member had 

signed the clients’ MARs as having 

given them their medications at 2100 

hrs. The Member acknowledged that 

she had administered medications 

early to approximately 18 clients and 

falsified her charting. 

Finding 





dishonourable and unprofessional. 







for two meetings with a regulatory 







employer who agreed to provide three 

performance appraisals to the College 

and advise the College if the Member 

breached the standards of practice of 

the profession. 

Panel order 

The Panel accepted the joint submission 

as reasonable and in the public 

interest. The Member accepted 

responsibility for her actions and 

cooperated with the College by 



Sandra D. Munro #2 

IJ00407 


The College alleged that the 

Member failed to redirect the client 

appropriately when he became 

aggressive, pushed the client, 

threatened to hit him, improperly 

restrained him and failed to 

document accurately her interactions 

with him. 






Agreed facts 

The Member worked at a long-term 

care facility on a secure unit for clients 

who wandered and suffered memory 

loss. Client A entered Client B’s room 

and refused to leave. Client A became 

more agitated as the Member and 

a personal support worker (PSW) 

attempted to coax him out of the 

room. A Registered Nurse managed 

to get Client A out of the room by 

telling him there was a phone call 

for him. Some time later, Client A 

had his arms around the Member; he 

wanted the portable phone she was 

holding. She refused to give it to him, 

despite being encouraged by the PSW 

to do so, and a struggle ensued. The 

Member threatened to hit Client A 

and eventually pushed him. Client 

A stumbled across the hall and into 

the fire doors with enough force to 

disengage the magnetic locks. The 

PSW left to get help. 

When she returned with another 

PSW, Client A was on his back on 

the floor, flailing his arms and legs. 

The Member was on top of him, 

with one knee on his chest and the 

other knee on the ground, holding 

him down by his shoulders. A PSW 

asked the Member to get up and 

leave. The Member agreed to leave 

after having been asked three times. 

Later, the Member was found upset 

and crying uncontrollably. When 

asked to document the incident in 

two different locations, she provided 

inaccurate information. She reported 

that Client A had struck out at her 

chest and attempted to corner her 

in Client B’s room. She failed to 

chart that she had pushed him and 

restrained him on the floor using her 

knees and hands. 

Finding 

The Panel noted the Member’s 

previous discipline history in which 

she was found to have committed 



professional misconduct when she 

administered medications earlier 

than ordered and documented untrue 

statements. 




found that the Member physically, 

verbally and emotionally abused 

Client A, and that her behaviour 

was disgraceful, dishonourable and 




an oral reprimand and a three-month 




for two meetings with a nursing 










Panel order 






agreeing to the facts. 

Stewart John Lethbridge 

IB14578 



sexually and emotionally abused the 

client; exchanged personal email 

messages with the client; asked the 

client to delete their correspondence; 

failed to document that he received 

a handwritten note from the client; 

failed to document his observations, 

interactions and interventions with 

the client over a five-day period; and 

failed to follow the client’s treatment 

plan. 






Agreed facts 

The Member worked as a staff nurse 

in a mental health facility. The 

client had frequent admissions to 

the psychiatric unit over a five-year 

period, spending approximately twothirds 

of that time at the facility. 

A month after the client’s fourth 

admission, the Member’s coordinator 

met with the Member to express 

concerns about the Member’s 

preferential treatment of the client 

and to get the Member’s agreement 

to follow the treatment plan. Three 

months later, the coordinator 

addressed ongoing concerns about 

the Member’s preferential treatment 

of the client and failure to abide by 

the treatment plan. 

The client’s psychologist renewed 

concerns about the Member’s 

boundaries four months later, 

and suggested they were creating 

attachment issues for the client. A 

formal investigation ensued, raising 

a number of concerns. The Member 

spent a substantial amount of time 

with the Client, even when not 

assigned. He did not follow the 

treatment plan and discouraged the 

client from attending therapy. He 

helped the client find an apartment, 

even though this was the job of a 

social worker, and attended at the 

apartment. On his day off, the 

Member attended the funeral of the 

client’s sibling despite having been 

advised by the care team not to 

attend, and failed to document his 

interactions with the client at the 

funeral, such as hugging the client 

and rubbing the client’s back. The 

Member gave the client a poem 

signed FFE (Friends For Ever) and he 

was seen walking down the hall with 

his arm around the client. He also 

received a handwritten note from the 

client and did not document it. 

Approximately eight months later, 

(only one month after the client’s 

last discharge from the facility), the 

Member and the client exchanged a 

series of emails. The Member referred 

to a “naughty pic” he had of the 

client. In another series of emails, the 

Member asked the client to ensure 

that his correspondence with the client 

was deleted. Later, the Member wrote 

comments of a sexual nature. 

Much later, the client complained 

to a psychiatrist of painful 

recollections of a relationship with 

the Member three years earlier, 

and disclosed the emails. When 

initially confronted with the emails, 

the Member denied authorship or 

ownership, and suggested they had 

been sent by someone else with the 

same name. 

Finding 




found the Member’s behaviour to 

be disgraceful, dishonourable and 




an oral reprimand and a five-month 

suspension. The Member would be 

required to complete remediation 

activities in preparation for three 

meetings with a regulatory expert. 



required to advise the College of 

his employers, provide employers 


35

with a copy of the Panel’s decision 

and reasons, and only practise for 

an employer who agreed to advise 



profession. 

Panel order 




accepted responsibility for his actions 




Rose Anne McKenzie 

9602954 



had been found to have committed 

gross negligence by the California 

Board of Registered Nursing with 

respect to the care she provided to a 

post-operative client. 


allegation, and the College and 




Agreed facts 

The Member worked for an agency 

in the U.S. In 2001, she obtained a 

licence from the Board and began 

work at a facility in California. The 

Member left the facility in 2002 and 

eventually returned to Ontario. Her 

Board licence expired in January 

2003 and was not renewed. 

In December 2001, the Client 

underwent elective spinal surgery. 

Post-operative surgical orders 

for the client included Percocet, 

Valium and Ambien. While in the 

post-anaesthesia recovery unit, the 

client experienced severe pain and 

received high doses of opiates and 

benzodiazepines including fentanyl, 

Demerol and Ativan. The Pain 

Service assessed the client and wrote 

orders for morphine via a patientcontrolled 

analgesia pump that 

allowed the client to administer a 

maximum amount per hour, with 

an additional bolus that could be 

administered by the nurse. The 

Pain Service orders required close 

monitoring of the client and Narcan 

administration in the event of 

respiratory depression, and indicated 

that no other narcotics were to be 

given unless ordered by the Pain 

Service. 

The client was transferred to the 

unit at 2000 hrs, at which time the 

Member assumed care for the client. 

The Member transcribed the postoperative 

and Pain Service orders and 

did not question whether both sets of 

orders should be followed or whether 

the Pain Service orders superseded 

the others. She was not told and did 

not ask about the nature or quantity 

of medication that the client had 

received before transfer to the unit. 

Between 2000 and 0100 hrs, the 

Member administered Percocet, 

Valium, Ambien and lorazepam. 

By 0100 hrs, the client had received 

96 mg of morphine: 66 mg selfadministered 

and 30 mg via additional 

boluses. The Member documented 

vital signs at 0200 hrs and noted that 

the client was sleeping but roused at 

0400 and 0500 hrs, and indicated 

there were no neurological deficits. 

The client was not monitored by way 

of an apnea monitor or continuous 

pulse oximetry. 

The Member went into the client’s 

room at 0600 hrs and found the client 

was unrousable, was making loud 

indrawing snoring noises, and had 

cold and clammy skin. The Member 

brought a vital signs machine into 

the client’s room and found that the 

client’s oxygen saturation level was 

46 per cent and his blood pressure 

was 80-90/50. The Member called 

for assistance. Together, the Member 

and another nurse unsuccessfully 

tried to wake up the client before the 

other nurse administered Narcan. 

The Member called the respiratory 

therapist as well as the doctor. 

Oxygen was administered by the 

respiratory therapist, and the client 

was transferred to intensive care 

with a diagnosis of acute respiratory 

failure and shock. After further 

hospitalization, the client was 

ultimately discharged home. He is 

now a quadriplegic with a severe brain 

injury and requires 24-hour care. 

In 2002, the client sued the 

facility, the Member and others for 

the injuries he suffered. The matter 

was settled in 2005 with payments by 

the facility and the Member’s insurer. 

The insurer was legally required to 

report the settlement to the Board, 

which it did in 2005. The Board 

investigated and eventually made 

formal charges against the Member. 

Notice of the investigation and formal 

proceedings were mailed to the 

Member’s last address known to the 

Board. The Member did not reply and 

was considered to be in default, which 

allowed the Board to make findings 

without holding a hearing. In August 

2008, the Board released a default 

decision, finding that the Member 

had committed gross negligence, and 

revoked her licence. 

The Board did not notify the 

College of its decision. The College 

learned of the decision as a result 

of a media article and began an 

investigation. The Member became 

aware of the decision when she was 

notified of the College’s investigation. 

The Member has not taken steps to 

challenge the decision and admits that 

the Board’s decision would be an act 

of professional misconduct in Ontario. 



Finding 



misconduct as alleged. 


The College and the Member jointly 

submitted that the Member should 

appear for an oral reprimand and 

be restricted from providing direct 

nursing care until she has completed 

extensive remediation activities and 

a meeting with a nursing expert. For 

12 months after returning to practice, 

the Member would be required to 

advise the College of her employers, 

provide employers with a copy of the 

Panel’s decision and reasons, and only 

practise for an employer who agreed 

to provide the College with regular 

performance appraisals and advise 



profession. 

A number of factors were 

considered in reaching the proposed 

order, including the fact that the 

conduct appears to have been an 

isolated incident, that it occurred 

almost 10 years ago and that the 

Member has undergone multiple 

instances of professional development 

since that time. The extended period 

of time between the incident and these 

proceedings was beyond the control 

of the College and the Member, who 

had no knowledge of the regulatory 

proceedings in California. There has 

been significant publicity about this 

case, which has also had a deterrent 

effect on the Member and the 

profession as a whole. 

Panel order 




cooperated with the College, 

made an insightful and remorseful 

statement to the Panel, and by 


professional misconduct has accepted 

responsibility for her actions. 

Julie Pouget 

9706144 



worked on several occasions in an 

unfit condition, slept while on duty 

and failed to keep records regarding 

three clients as required. 






Agreed facts 

The Member worked through two 

different agencies that placed her at 

an organization and a facility. At the 

organization, the Member reported 

for work in an unfit condition on six 

occasions between 2005 and 2007. 

Her speech was slurred, her eyes 

droopy and her gait was staggered. 

The Member stated that she was tired 

or had low blood sugar levels. More 

than once she met with managers 

who stressed that she must report to 

work in an appropriate condition. 

At the facility, the Member 

reported for duty in an unfit 

condition; she was tired and 

unsteady on her feet, and presented 

with slurred speech. She failed to 

document that Client A had been 

administered medications, that 

Client B’s dressing was saturated with 

drainage from weeping sores on her 

legs, and that Client C’s soaker pad 

had a bit of blood on it from scabs 

on Client C’s arm. The Member did 

some charting, but it was illegible 

and unclear. She was also found 

sleeping in Client A’s room more 

than once during the shift. The 

Member attributed her appearance 

and behaviour to exhaustion and 

difficulty coping with stresses in her 

personal life. 

There is no evidence that the 

Member suffers from a substance use 

disorder. 

Finding 





unprofessional. She did not exercise 

good judgment and she lacked insight 

into her ability to practise safely. 


The College and the Member 

sought an oral reprimand and a twomonth 

suspension. The Member 

would be required to complete 

specified remediation activities in 

preparation for two meetings with a 

nursing expert. For 12 months after 

returning to practice, the Member 

would not be permitted to practise 

independently in the community, 

and would be required to advise the 

College of her employers, provide 

employers with a copy of the Panel’s 

decision and reasons, and only 

practise for an employer who agreed 

to advise the College if the Member 

breached the standards of practice of 

the profession. 

Panel order 









37

The College welcomes letters commending outstanding 

nursing care. Please send original signed letters from clients 

or family members. Facilities or agencies can also forward 

original signed letters, along with a copy of the author’s 

letter and the author’s permission to publish. Letters may 

In Praise 

of Nurses 

be edited for publication. 

Going the extra mile 

We would like to express our heartfelt 

thanks for the wonderful care our 

mother, Dot Preston, received at 

Valleyview Home in St. Thomas 

before passing away. For almost five 

years at Valleyview, we always knew 

she was in good hands with people 

who truly loved her and appreciated 

her spirit. 

Our mother was energetic and fun, 

but dementia led to some difficult 

moments. Still, we never heard a 

cross word from the nurses. They 

always made her feel better with 

hugs, which she loved. 

As we sat by her bedside during 

her last few days, many nurses who 

had cared for our mother came to 

say goodbye and tell us nice stories 

about her. These stories confirmed 

something we’ve always known—our 

Mom was an amazing woman. Even 

dementia couldn’t stop her beautiful 

qualities from shining through. The 

nurses enjoyed her humour, treating 

her with the utmost respect. 

On her last day, a nurse sat with 

her stroking her hand so she wouldn’t 

be alone until we arrived. This meant 

so much to us. We were touched to 

see the level of care provided by such 

compassionate people. They never 

complained or had any harsh words 

for the residents. 

The employees of CP Place at 

Valleyview Home were Mom’s 

guardian angels. Many of them 

came to the funeral or sent flowers, 

which meant a lot to us. They really 

went the extra mile in caring for our 

mother. 

Dot’s children – Anne Day, Penny 

Preston and Bob Preston 

Compassionate professionals 

I was diagnosed with a brain stem 

tumour and underwent an operation 

at Hôtel-Dieu Grace Hospital in 

Windsor. After three weeks in the 

intensive care unit, I was transferred 

to eighth floor east neurology where I 

stayed for almost three months. 

I want to recognize all of the 

nurses who cared for me, but 

especially those in the neurology unit. 

They became a second family to me. 

Their care, compassion, concern and 

friendship meant so much to me and 

my family. I cannot say enough about 

their dedication, professionalism and 

friendship. I will never forget how 

they made my hospital stay more 

comfortable after I went through a 

life-altering experience. I hope they 

get the recognition they deserve. 

Sincerely, 

June Couvillion 

Send your letters to: 

InPraiseOfNurses@cnomail.org or 






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41

“A nurse demonstrates the standard 

by creating plans of care that 

address client needs, preferences, 

wishes and hopes.” 

– from Professional Standards 

The Standard of Care. 

Photo: Melanie Gordon 

At Joseph Brant Memorial Hospital in 

Burlington, you can call Cheryl Bower, NP, the GAITEkeeper. 

GAITE stands for Geriatric Assessment and 

Intervention Team in the Emergency, which Bower leads. 

When clients over age 70 enter the emergency 

department, the triage nurse screens them for memory 

impairment, use of more than five medications, falls or 

mobility issues, a visit to the ED within the past 30 days 

or a hospitalization within the past 90 days, and concerns 

about coping at home. If any two of these factors are in 

evidence, Bower is alerted. 

GAITE requires Bower to draw on a vast body of 

knowledge — from pharmacology to literature on seniors 

living in isolation. She performs holistic assessments of 

clients, provides evidence-based care plans, and educates 

seniors and their families. Her assessments can be twoand-a-half 

hours long, and involve a nurse, social worker, 

physiotherapist, occupational therapist and Community 

Care Access Centre case manager, as needed. “It all 

threads together,” says Bower. 

In her position, Bower integrates the best available 

research, resources and clinical expertise. For example, if 

a client has had a fall, Bower conducts a physical exam to 

examine gait abnormalities, arthritic changes, pain, blood 

pressure, medications and vision. A cognitive assessment 

can include the Montreal Cognitive Assessment test, 

or screening for depression or confusion. A functional 

assessment explores the client’s daily living; for example, 

do they use mobility aids or have support at home? By 

investigating possible precursors to a fall, Bower can 

develop an appropriate plan and make recommendations 

to the client’s primary physician. 

Recently, an 87-year-old client arrived in the ED with 

syncopal episodes. Bower discovered that the client had 

significant chronic pain. By starting the client on a new 

pain management regimen and addressing related effects 

of the pain (such as hyponatremia, depression, and 

appetite and weight loss), Bower helped him reduce his 

pain, continue to live independently at home and have a 

better quality of life. 

Bower sees herself as improving the transfer of geriatric 

knowledge at the point of care. “The goal is to keep people 

at home longer, safer, healthier and independent,” she says. S 

At the College, the phrase “the standard of care” is more than a 

tag line for the logo; it’s about setting the bar for safe, effective 

and ethical nursing care through the practice standards and 

guidelines. This page features nurses who have raised the bar 

on the standard of care they provide their clients. 



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