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Blackwell, Sandralee

Sandralee Blackwell 7309941

PUBLISHED JUNE 2002

Discipline Committee Of The College Of Nurses Of Ontario

FULL-TEXT DECISION

Note: This is the full text of the decision of the Discipline Committee in this matter. Any information identifying clients, witnesses or facilities has been removed [ ]. The member’s name is omitted if allegations have been dismissed or if the results are not placed on the public portion of the Register.

Panel:

ELIZABETH BAKER, RNEC   Chairperson
SANDY BREWER, RN   Member
CHRISTNE BARBER, RPN   Member
TOM CLIFFORD   Public Representative
KAY WETHERALL   Public Representative

BETWEEN

COLLEGE OF NURSES OF ONTARIO   Michelle Fuerst for College of Nurses of Ontario
- and -    
SANDRALEE BLACKWELL
#73-0994-1
  WILLIAM DICK for SANDRALEE BLACKWELL
     
    Heard: JULY 31, 2001

REASONS FOR DECISION

This matter came on for hearing before a panel of the Discipline Committee on July 31, 2001 at the College of Nurses of Ontario at Toronto.

The Allegations

The allegations against Sandralee Blackwell as stated in the Notice of Hearing (Exhibit #1) dated June 27, 2001, are as follows:

  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 from September 19, 1993 through to and including March 1, 1997 at [geographical location 1]; and/or [geographical location 2] and/or [geographical location 3] and/or elsewhere in the Province of Ontario, you contravened a standard of practice of the profession or failed to meet the standards of practice of the profession with respect to the following incidents:
    1. You maintained a friendship with [Client “A”], a patient at [facility A] and later at [facility B]; and/or
    2. You visited [Client “A”], a patient at [facility A] and later at [facility B]; and/or
    3. You loaned money to [Client “A”], a patient at [facility A] and later [facility B]; and/or
    4. You conducted banking transactions on the bank account of [Client “A”], a patient at [facility A] and later at [facility B].
  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(37) of Ontario Regulation 799/93, in that from September 19, 1993 through to and including March 1, 1997 at [geographical location 1], and/or [geographical location 2], and/or [geographical location 3], and/or elsewhere in the Province of Ontario, you engaged in conduct or performed an act, relevant to the practice of nursing, that, having regard to all the circumstances, would reasonably be regarded by members as disgraceful, dishonourable or unprofessional with respect to the following incidents:
    1. You maintained a friendship with [Client “A”], a patient at [facility A] and later at [facility B]; and/or
    2. You visited [Client “A”], a patient at [facility A] and later at [facility B]; and/or
    3. You loaned money to [Client “A”], a patient at [facility A] and later [facility B]; and/or
    4. You conducted banking transactions on the bank account of [Client “A”], a patient at [facility A] and later at [facility B].

Counsel for the College advised the panel that the Member denies having contact with [Client “A”] at [facility A] as alleged in paragraphs #1(b) and #2(b) of the Notice of Hearing and that the College will not be pursuing this issue.

Member’s Plea

Sandralee M. Blackwell admitted the allegations set out in paragraphs numbered one and two in the Notice of Hearing with the exceptions previously noted. The panel conducted a plea inquiry and was satisfied that the Member’s admission was voluntary, informed and unequivocal.

Agreed Statement of Facts

Counsel for the College advised the panel that agreement had been reached on the facts and introduced an Agreed Statement of Facts which provided as follows:

The Member and the Facility

  1. Ms Blackwell is a Registered Nurse who graduated from nursing school in 1972. She obtained a Diploma in Mental Health Nursing in 1988 and a Certificate in Psychosocial Rehabilitation in 1996.
  2. Ms Blackwell has worked in the forensic mental health setting at [facility A]continuously since 1984.
  3. [Facility A] has two separate divisions: the maximum-security facility, [the Division], and a regional mental health hospital. Ms Blackwell worked at [the Division] from April 1, 1984 to January 4, 1993. Since 1993, Ms Blackwell has worked at the regional hospital at [facility A].

The Client

  1. The client, [Client “A”], is a male individual who was being held [information pertaining to client deleted] at [the Division] [information pertaining to client deleted]. He had been diagnosed as having:
    • Dysthymic Disorder; and
    • Personality Disorder, mixed with Antisocial and Borderline Features.
  2. [Client “A”] has a history of being a manipulative individual who develops sexual obsessions about female staff with whom he feels entitled to have personal relationships. In the past, [Client “A”] has responded to the termination of relationships with female staff by acting in a self-destructive manner.

The Member’s Relationship with [Client “A”]

  1. While employed at [the Division], Ms Blackwell became [Client “A’s”] primary nurse in 1988 or 1989. She had weekly psychotherapy sessions with [Client “A”] from 1989 until October 1992, when Ms Blackwell requested and received a transfer to another unit at [the Division].
  2. Ms Blackwell later admitted to her employer that her request to transfer was directly related to an attempt to distance herself from [Client “A”] because she was concerned about her developing personal relationship with [Client “A”]. Ms Blackwell was reprimanded by her employer for her failure to report the boundary issue promptly.
  3. Ms Blackwell provided no further nursing care to [Client “A”] after October 1992.
  4. In November 1992, Ms Blackwell’s husband began to visit [Client “A”] on a bi-weekly basis and developed a personal relationship with [Client “A”]. In an assessment interview with the facility’s social worker in May 1993, [Mr. B] acknowledged that in the fall of 1992, he had found a love letter from [Client “A”] to Ms Blackwell in Ms Blackwell’s purse. After a discussion with Ms Blackwell about her relationship with and advocacy for [Client “A”], Mr. [B] decided to initiate a relationship with [Client “A”].
  5. In January 1993, Ms Blackwell transferred to the regional hospital at [facility A].
  6. In April 1993, Ms Blackwell wrote a letter to the Criminal Code Review Board on behalf of [Client “A”], in which she stated that as of July 1992, she and [Client “A”] had a friendship. She also stated that she and her husband were willing to educate and assist [Client “A”] in his transition back to the community.
  7. Ms Blackwell and her husband discussed adopting [Client “A”].
  8. In April 1994, the Complaints Committee of the College of Nurses reviewed a complaint regarding Ms Blackwell’s personal relationship with [Client “A”]. The Committee issued a reminder to Ms Blackwell that in the future, she must ensure that she maintains appropriate therapeutic and professional boundaries in the nurse-client relationship. The Committee also expressed concern that Ms Blackwell had allowed her husband to become involved with [Client “A”].
  9. In August 1995, [Client “A”] was transferred to [facility B], a medium security institution located in [geographical location 3], Ontario.
  10. Ms Blackwell’s husband applied and became an approved person for [Client “A”] at [geographical location 3] in the fall of 1995. An approved person is a person approved by the hospital administration to supervise a client on outings onto hospital grounds or into the community.
  11. Ms Blackwell accompanied her husband on visits to [Client “A”] and arranged some of the visits. She continued her friendship with [Client “A”] on visits to the facility and outings in the community, although always in the presence of her husband.
  12. In 1993, Ms Blackwell opened a bank account for [Client “A”]. [Client “A”] gave Ms Blackwell signed withdrawal slips. Over a three and one half year period, Ms Blackwell made the following banking transactions on that account:
 * November 18/93 deposit to [Client “A’s”] account $20.00
 * May 6/93 deposit to [Client “A’s”] account $50.00
 * June 18/93 deposit to [Client “A’s”] account $30.00
 * July 7/93 deposit to [Client “A’s”] account $150.00
 * July 21/93 deposit to [Client “A’s”] account $25.00
 * August 6/93 deposit to [Client “A’s”] account $185.00
 * August 26/93 deposit to [Client “A’s”] account $40.00
 * September/93 withdrawal from [Client “A’s”] account $70.00
 * October 5/93 deposit to [Client “A’s”] account $90.00
 * October 25/93 deposit to [Client “A’s”] account $32.00
 * November 2/93 deposit to [Client “A’s”] account $192.00
 * November 4/93 deposit to [Client “A’s”] account $10.00
 * December 2/93 deposit to [Client “A’s”] account $50.00
 * December 7/93 deposit to [Client “A’s”] account $76.00
 * May 2/94 deposit to [Client “A’s”] account $2000.00
 * June 6/94 withdrawal from [Client “A’s”] account $65.00
 * July 2/94 deposit to [Client “A’s”] account $112.00
 * October 28/94 withdrawal from [Client “A’s”] account $300.00
 * December 15/94 transfer from Ms Blackwell’s account to [Client “A’s”] account $300.00
 * January 12/95 deposit to [Client “A’s”] account $80.00
 * January 27/95 withdrawal from [Client “A’s”] account $300.00
 * February 2/95 deposit to [Client “A’s”] account $410.00
 * February 3/95 deposit to [Client “A’s”] account $25.00
 * February 16/95 withdrawal from [Client “A’s”] account $30.00
 * May 15/95 transfer from Ms Blackwell’s account to [Client “A’s”] account $50.00
 * June 15/95 transfer from Ms Blackwell’s account to [Client “A’s”] account $50.00
 * June 29/95 deposit to [Client “A’s”] account $50.00
 * July 11/95 deposit to [Client “A’s”] account $57.00
 * February 15/96 deposit to [Client “A’s”] account $50.00
 * February 24/96 deposit to [Client “A’s”] account $50.00
 * February 24/96 transfer from Ms Blackwell’s account to [Client “A’s”] account $50.00
 * December 12/95 withdrawal from [Client “A’s”] account $30.00
 * January 12/96 deposit to [Client “A’s”] account $50.00
 * July 4/96 deposit to [Client “A’s”] account $7000
  1. In addition to depositing money directly into [Client “A’s”] bank account, since 1994, Ms Blackwell and her husband purchased for [Client “A”] or provided [Client “A”] with funds to purchase two computers and educational courses.
  2. In July 1996, Ms Blackwell and her husband sold their cottage and gave [Client “A”] $5000.00 of the proceeds.
  3. In 1997, following the termination of their relationship with [Client “A”] due to a disagreement, [Client “A”] alleged that he had had a sexual relationship with Ms Blackwell. Ms Blackwell denies having any sexual relationship with [Client “A”].
  4. In 1998, [Client “A”] was involuntarily transferred back to the maximum-security facility at [geographical location 1]. Ms Blackwell’s husband wrote a letter in support of that transfer, in opposition to [Client “A”].

Expert Opinion

  1. The College obtained the expert opinion of [Expert A] RN, who is the Administrative Director – Addiction & Forensic Programs at [a hospital]. If he testified, he would provide the following opinion about Ms. Blackwell’s conduct.

    Breach of the standards of practice

    The Member breached the standards of practice by engaging in a friendship with the client, visiting with the client, loaning money to the client and conducting banking transactions for the client. This conduct violated the boundaries of the nurse client relationship.

    Friendship

    • The friendship was initiated while the Member was in a direct nurse-client relationship with the client and all of the Member’s later conduct flows from the fact of the friendship initiated in 1992.
    • Although the Member did not provide any further direct care to the client after October 1992, her husband did begin to visit the client at the facility on a personal basis in the fall of 1992. The husband’s involvement with the client cannot be divorced from the Member’s conduct since all contact between her husband and the client resulted from her friendship with the client. In effect, the husband was a substitute for the Member during the year from October 1992 onward.
    • These behaviours clearly confused the boundaries between a professional relationship and a personal friendship. There is also some indication that the client perceived the relationship to be one of a romantic nature in that he sent the Member a love letter and after the termination of the relationship, he claimed that the relationship had in fact been sexual.

    Visiting the client

    • It is a breach of the standards that the Member continued the friendship and visited the client at the new facility. When the client transferred to a new facility, and particularly where there had already been a previous crossing of the therapeutic boundary, it was a very good opportunity for the nurse to encourage the client to develop therapeutic relationships with other health care professionals at the new facility. Instead, the Member continued her relationship with the client.

    Loaning and/or giving money to the client

    • The Member breached the standards of practice by loaning and/or giving money to the client.
    • Nurses should use their professional judgement in giving gifts to clients. It is important for the nurse to consider how the client will perceive the gift. The client may consider that a special relationship is occurring which is different than that with any other client; he may feel uncomfortable about the nurse’s intentions in giving the gift; and he may feel concerned about having to pay the money back.
    • In this situation, the gifts were sizeable, including two computers and educational courses, plus a cash amount of $5000.00. The giving of these gifts creates an extremely unequal balance in the relationship between the nurse and the client and would confuse the relationship further for the client.

    Conducting banking transactions

    • The Member’s involvement in the client’s banking is a breach of the standards of practice. There is no indication that the client had been declared financially incompetent. The nurse would be expected to assist the client to manage his own financial affairs, rather than to take over his financial affairs.

    Disgraceful, dishonourable and unprofessional conduct

    The Member engaged in conduct that members of the profession would consider unprofessional for the following reasons:

    • The Member initiated the friendship with the client while she was in a primary nurse-client relationship providing direct care to the client;
    • The Member conducted the client’s banking and controlled his financial interactions where there was no indication that the client was financially incompetent.
    • It is the responsibility of the Member to maintain and respect the professional boundaries of the nurse-client relationship. Despite strong feedback from her employer and from the Complaints Committee of CNO, the Member did not reflect upon her situation and take responsibility for the clarification and maintenance of the appropriate boundaries in the relationship. The Member appears to have ignored the information and instead continued the relationship. A reasonable nurse would have reflected upon the situation and would have terminated the relationship after this feedback.
    • The relationship between the client and the Member did not seem to focus upon the needs of the client. Instead, it seemed that the Member was getting some of her needs met through the relationship. It does not matter whether the Member’s intentions were positive or negative, the Member’s behaviour blurred the professional boundaries of the relationship and had the potential to cause confusion to the client.
    • The Member’s behaviour in involving her husband with the client was unprofessional, especially in light of the feedback given by the Complaints Committee.
    • Based upon the Member’s role as professional caregiver, she was aware that the client would require long term care in light of his Criminal Code disposition. The fact that a client is incarcerated in a forensic facility for a long period of time predisposes the client to confusion about relationships with his health care professionals. In addition, the Member was aware that the client had a history of obsessive and manipulative behaviour, including having sexual fantasies about and relationships with other female health care providers. The Member should have used her professional judgement to discern that the client was at risk for confusing relationships, thus requiring the Member to be very clear about the professional boundaries. It is in fact one of the major nursing interventions with this type of client that the nurse communicates clearly and carries out a professional relationship with the client.

Allegation 1(a), (b), (c) and (d) – Failure to meet the standards of practice

  1. Ms Blackwell admits that she has committed an act or acts of professional misconduct as set out in allegations 1(a)(with the exception previously noted), (b), (c) and (d) in the Notice of Hearing in that she contravened or failed to meet the standards of practice of the profession in that she:
    1. maintained a friendship with [Client “A], while he was a client at [geographical location 3]; and
    2. visited [Client “A” while he was a client at [geographical location 3]; and
    3. loaned money to [Client “A”] while he was a client at [geographical location 1] and later at [geographical location 3]; and
    4. conducted banking transactions on the bank account of [Client “A”] while he was a client at [geographical location 1] and later at [geographical location 3].

Allegation 2(a), (b), (c) and (d) – Unprofessional conduct

  1. Ms Blackwell admits that she has committed an act or acts of professional misconduct as set out in allegations 2(a) (with the exception previously noted), 2(b), 2(c) and 2(d) in that she engaged in conduct or performed an act, relevant to the practice of nursing that, having regard to all of the circumstances would reasonably be regarded by members of the profession as unprofessional conduct in that with respect to [Client “A”] while he was a client at [geographical location 1] and later at [geographical location 3], she:
    1. maintained a friendship with [Client “A”], while he was a client at [geographical location 3] and
    2. visited [Client “A”] while he was a client at [geographical location 3]; and
    3. loaned money to [Client “A”] while he was a client at [geographical location 1] and later at [geographical location 3]; and
    4. conducted banking transactions on the bank account of [Client “A”] while he was a client at [geographical location 1] and later at [geographical location 3].

Decision

The panel has considered the Agreed Statement of Facts and finds that the facts support a finding of professional misconduct and, in particular, finds that the Member committed an act of professional misconduct as alleged in paragraphs one and two of the Notice of Hearing in that the Member:

  1. maintained a friendship with [Client “A”], a patient at [facility A] and later at [facility B]; and
  2. visited [Client “A”], a patient at [facility B]; and
  3. loaned money to [Client “A”], while he was a patient at [facility A] and later [facility B]; and
  4. conducted banking transactions on the bank account of [Client “A”], a patient at [facility A] and later at [facility B].

Penalty

Counsel for the College advised the panel that a Joint Submission as to Penalty had been agreed upon. The Joint Submission as to Penalty provides as follows:

THE MEMBER AND THE COLLEGE jointly submit that the appropriate penalty in this matter is for the Discipline Committee to make the following order:

  1. Directing the Executive Director to suspend the Member’s certificate of registration for a period of nine months from the date the order becomes final;
  2. Requiring the Member to appear before the panel of the Discipline Committee to be reprimanded, at a date to be arranged, but in any event within three months of the date the order becomes final; and
  3. Directing the Executive Director to impose the following specified terms, conditions and limitations on the Member’s certificate of registration:
    1. The Member shall review and complete the One is One Too Many self-guided workbook and meet with a Practice Consultant to discuss the standards with respect to boundaries of the nurse-client therapeutic relationship within three months of the date the order becomes final.

College Counsel provided the following reasons:

  1. This was a serious form of boundary violations in that it involved an array of improper conduct; it involved a three year intense therapeutic relationship which consisted of weekly psychotherapeutic sessions.
  2. The interaction continued over a significant length of time, September 1993 to March 1997.
  3. The Member maintained a relationship with the client despite being expressly cautioned by her employer and the College of Nurses of Ontario.
  4. This particular client required a nurse to clearly assert and maintain professional boundaries. Defence Counsel identified that the policies at [facility A] had changed as a direct result of this case to decrease the length of time a nurse maintained a primary nursing relationship with one client. Further, while it was clear that boundaries had been violated, there have been changes in the psychiatric field. It was also noted that this particular relationship was an open relationship and that other professional staff was aware that the Member and her husband continued to visit this client.

Finally, Defence Counsel indicated that the Member had always received positive annual reviews although no evidence was provided at the hearing. Nevertheless, Counsel agreed with the nine-month suspension in that this Member had previously received a letter of warning from the College of Nurses of Ontario, regarding boundaries in therapeutic relationships but continued to allow trying to please others to cloud her judgement.

Penalty Decision

The panel accepted the Joint Submission as to Penalty and made the following order:

  1. Directing the Executive Director to suspend the Member’s certificate of registration for a period of nine months from the date the order becomes final;
  2. Requiring the Member to appear before the panel of the Discipline Committee to be reprimanded, at a date to be arranged, but in any event within three months of the date the order becomes final; and
  3. Directing the Executive Director to impose the following specified terms, conditions and limitations on the Member’s certificate of registration:
    1. The Member shall review and complete the One is One Too Many self-guided workbook and meet with a Practice Consultant to discuss the standards with respect to boundaries of the nurse-client therapeutic relationship within three months of the date the order becomes final.

The panel concluded that the proposed penalty is reasonable and in the public interest.

This Member has an additional Diploma in Mental Health Nursing and extensive experience in psychiatric nursing. She worked in a forensic mental health setting for a number of years. In light of these factors she ought to have been aware of the risks of becoming over-involved and manipulated by clients. This particular client had a history of being manipulative and of developing sexual obsessions with female staff with whom he feels entitled to have personal relationships. In addition this client has previously responded to the termination of relationships with female staff by acting in a self-destructive manner. Despite knowing this, the Member failed to establish and maintain boundaries. Finally, it must be noted that the client’s therapeutic needs were not served by the relationship and in fact it was detrimental to his mental condition.

Despite a caution from the Member’s employer and a cautionary letter from the College of Nurses of Ontario, the Member not only continued the relationship but also did not discourage her husband’s involvement with the client. The Guidelines for Professional Behavior in Therapeutic Relationships were published in 1995 by the College of Nurses. They contained very explicit direction regarding observing boundaries in therapeutic relationships. This was during the time that the relationship was taking place.

The Member has co-operated with the College and, by agreeing to the facts and a proposed penalty, has accepted responsibility for her actions and has avoided unnecessary expense to the College.

This Panel must send a very clear message to other members of the profession that this type of conduct will not be tolerated. The Panel also agreed that the penalty was appropriate in that it fulfills the objective of remediation in the Member’s future practice.

I, Elizabeth Baker, RNEC, sign this decision and reasons for the decision as Chairperson of this Discipline Panel and on behalf of the members of the Discipline Panel as listed below:

Elizabeth Baker, RNEC
Sandy Brewer, RN
Christine Barber, RPN
Kay Wetherall, Public Member
Tom Clifford, Public Member

Page mise à jour le septembre 28, 2010