Running head: ETHICS, MISCONDUCT & CNO

An Examination of Ethical Values, Professional Misconduct, and the CNO

Natasha English
Humber College
NURS217
November 10th, 2015

Running head: ETHICS, MISCONDUCT & CNO

In the nursing profession, nurses are expected to conduct themselves and provide care in
a manner that is in line with ethical guidelines set by a governing body. In Ontario, these
guidelines are set by the College of Nurses of Ontario, also referred to as the CNO. When nurses
do not act in accordance with these guidelines, they are committing professional misconduct,
which is defined as an act or omission that is in breach of these accepted ethical and
professional standards of conduct (College of Nurses of Ontario, 2014). One example of
professional misconduct was committed by a male nurse, who shall be referred to as DKR. He
was employed in a rehabilitation and psychiatric care facility, where he was working as a
registered practical nurse. During his employment he committed two acts of professional
misconduct: sexually abusing a client and not respecting the boundaries of the therapeutic nurseclient relationship. At the time of the incident, the client was diagnosed with borderline
personality disorder, and had attempted suicide multiple occasions. The client was at home
during the day, but returned to the unit during the night. DKR only worked night shifts and the
two developed a bond that went beyond the therapeutic nurse-client relationship. It began with a
note given to him by the client which contained her phone number. The two began speaking, and
progressed to sending sexually suggestive and explicit e-mails to each other. DKR ended up
sexually abusing the client by having sex with her during her time on the unit and after her
discharge. There were no other individuals involved in this act, and DKR was the sole person
responsible. It is possible that the policies of the unit were a contributing factor because while
the nurses act as a team, one nurse is in charge of the same patients to promote continuity of care.
This means that a nurse gets to know their patients better than other patients on the unit, and had
increased contract with those specific patients on a daily basis. Also, only one nurse completes a
check of patients during the evening. Once the misconduct had been discovered and reported, the

Running head: ETHICS, MISCONDUCT & CNO

hearing took place. The committee decided that DKR had in fact breached the therapeutic nurseclient relationship, and that he had sexually abused the client. I agree with the decision of the
committee because it was very clear that he engaged in sexual intercourse, inappropriate
touching, and sexual remarks (College of Nurses of Ontario, 2014). In addition, the nurse made it
very clear to the client that he knew he could lose his license, thereby knowing he was
committing professional misconduct and sexual abuse. He was not lacking in his education as he
was aware, and voiced to the client, of the boundaries. There were multiple ethical values that
were violated, and this paper will explore and examine how the nurse violated them. It will also
look at possible strategies to limit the amount of sexual abuse that occurs in the nursing field.
The CNO Practice Standard document on ethics lists several values which are important
to uphold in society and in the nursing profession. These values are client well-being, client
choice, privacy and confidentiality, respect for life, maintaining commitments, truthfulness, and
fairness (CNO, 2009). In this case of misconduct, there were multiple ethical values breached.
The first one is client well-being. According to the CNO (2009), client well-being is,
facilitating the clients health and welfare, and preventing or removing harm. Mental illness is
the reason why patients are admitted to a psychiatric facility, therefore a large part of their care
and well-being has to do with their mind. DKR breached the client well being by beginning a
sexual relationship with her. Campbell, Yonge, & Austin (2005) discuss the negative effect that a
sexual relationship between a health care provider and a patient can have. The number one effect
that they discuss is that it can damage the self esteem of the patient, and also lower the patients
ability to place trust in others. Sexual relations are sensitive and intimate acts. Unfortunately, she
voiced a concern that she felt as though he was just using her for sex, and that was not what she
was looking for. When a nurse is in charge of a clients well being that includes the well being of

Running head: ETHICS, MISCONDUCT & CNO

their mental status, and not just physically. By starting a sexual relationship with the client, DKR
risked putting the patients mental well being further.
The second value that was breached is maintaining commitments. The CNO (2009)
describes maintaining commitments as keeping promises, being honest and meeting implicit
or explicit obligations toward their clients, themselves, each other, the nursing profession, other
members of the health care team and quality practice settings. These commitments are separated
into distinct categories: commitment to clients, oneself, nursing colleagues, the nursing
profession, the health care team, and quality practice settings. DKR did not maintain his
commitments to several of these groups. The first one is not maintaining commitments to his
client, as this requires a nurse to act in the best interest of the client, provide safe care in an
effective and ethical manner, and refrain from abandoning, abusing, or neglecting patients. Since
sexual relationships are considered sexual abuse and unethical, he violated the commitment to
his patient. Secondly, he did not maintain the commitment to himself. By maintaining a
commitment to oneself means going recognizing and acting in line with their beliefs, but still
providing care ethically. DKR knew he should not have been entering into a relationship with the
patient, however he ignored this and went with the clients wishes. It would have been the best
option to assess the situation, bring it to the charge nurse and have the patient reassigned, even if
he still had the urge to have sexual relations with her. Lastly he did not keep his commitment to
the nursing profession. Maintaining this commitment means nurses must uphold the standards
of the profession. Committing sexual abuse goes against the standards, therefore he failed at
maintaining this part of the ethical standard.
The third value that was breached was fairness. Fairness is defined by the CNO (2009) as
allocating health care resources on the basis of objective health-related factors. When DKR

Running head: ETHICS, MISCONDUCT & CNO

decided to breach the boundaries of the nurse-client relationship, he started to pay more attention
to a single client. Whether or not the attention was nursing related or personal, it translated into
being unfair for the other patients as he was now using his time to pursue a sexual relationship
and not focusing on providing quality nursing care to all of his patients in the same fashion. He
himself can be viewed as a resource that needs to be allocated fairly amongst the clients in the
facility.
Having a sexual and intimate relationship with a patient is a serious ethical violation.
Since education is a powerful tool, it would be beneficial for nurses to have as much knowledge
as possible on relationships with patients. This would help to reduce the risk of being drawn into
undesirable situations. One suggestion to reduce incidences of sexual abuse is to provide nurses
with as much education, through monthly in-services. Smith, Taylor, Keys, & Gornto (1997)
state that some nurses are at risk of violating these boundaries because they do not have the
required knowledge to properly assess the situation. One way that this can be achieved is by
various educational sessions and workshops. There are different topics that can be explored and
focused on to maximize the knowledge that each nurse has. Both Campbell et al., (2005) and
Smith, et al. (1997) believe that education is key to avoiding sexual misconduct. Campbell et al.
(2005) state that nurses should be educated on how to maintain a balance between work and life
outside work. By maintaining this balance, it will avoid the two from mixing and the nurse can
fulfill the personal needs outside of work. This is very important as it can be easy to become
involved heavily in the environment, and if there is no draw from outside of the work life, one
starts to look to fulfill their needs from the environment where they are immersed. Another form
of education is to hold regular professional boundary training which provides or refreshes
knowledge on what boundaries nurses must maintain with their patients. This could be an in-

Running head: ETHICS, MISCONDUCT & CNO

service that happens in the workplace on a monthly basis. A third educational session would
focus on the patient aspect. Campbell et al. (2005) mention that it is important for nurses to
understand the effect of a sexual relationship on their patient. Educating on the negative effects is
important so nurses understand just how much of an impact it can have. Another part of this
educational session would be information on how to handle patient advances, perhaps engaging
in effective role play exercises.
A second strategy to prevent sexual abuse by a nurse would be to have a specific process
set up when a nurse is feeling conflicted about feelings toward a patient. Nurses should be able
to, seek support and consultation to cope with these feelings and to assist with boundary
maintenance (Campbell et al., 2005). Therefore, the type of process would be to have a trained
staff member, such as a charge nurse, or guidance counsellor as part of the staff. The nurse could
set up an appointment to seek guidance by discussing how to deal with the feelings, how its
impacting their nursing practice, and solutions to deal with the ethical dilemma. As long as the
nurse had not committed professional misconduct this would not be a punitive process, and it
would be confidential. Smith et al. (1997) suggest that nurses need to be continually performing
self-assessments and self reflections, so having someone to provide guidance could also provide
them with the tools to effectively perform these tasks.
When DKR completed his education, wrote his registration exam, and took a job as
registered practical nurse, he knew that it was his job to take care of and protect his patients. He
was aware that he had clear, and well documented ethical guidelines to follow and adhere to.
However, he chose to cross the boundary when he decided to blur the lines between satisfying
his personal needs and work. By having sexual intercourse, touching her in sexually suggestive
ways, and speaking in a sexual nature; he committed sexual abuse. To complicate the situation

Running head: ETHICS, MISCONDUCT & CNO

even more, this patient was admitted to a psychiatric ward which means he jeopardized her
mental well being, which was the first violation of ethical standards. By having sexual relations
with his patient, he broke commitments to his patient, himself, the nursing profession, and to
having a quality practice setting. In addition to those ethical values, he also violated the value of
fairness, but committing more time to a specific patient. This means that less time was spend
focusing on the needs of the other patients on the unit. Due to the ethical violations he lost his
licence and can no longer practice as a nurse, which I think is the only appropriate decision the
CNO could have made. When a nurse knowingly commits a serious case of misconduct, they do
not deserve to take care of any other patients, and possibly put them in harms way. Due to the
serious nature of sexual abuse, there needs to be an increase in the effort to stop the behaviour.
Ongoing education is a great way to ensure nurses are informed, and understanding of how to
handle situations like these. It would also be beneficial to have a confidential and non-punitive
process where the nurse can speak to a designated person about any conflicts of interest they are
feeling. DKRs case of professional misconduct is not isolated and these conflicts occur across
Ontario, however by examining it and understanding what went wrong, strategies can be put into
place to ensure the risk of this happening is minimized in the future.

Running head: ETHICS, MISCONDUCT & CNO

References
Campbell, R. J., Yonge, O., & Austin, W. (2005). Intimacy boundaries: Between mental health
nurses & psychiatric patients. Journal of Psychosocial Nursing and Mental Health
Services, 43(5), 32-39.
College of Nurses of Ontario. (2014). Professional conduct, professional misconduct. Retrieved
November 10, 2015, from http://www.cno.org
College of Nurses of Ontario. (2009). Ethics. Retrieved November 4, 2015, from
http://www.cno.org
Smith, L. L., Taylor, B. B., Keys, A. T., & Gornto, S. B. (1997). Nurse-patient boundaries:
Crossing the line. The American Journal of Nursing, 97(12), 26-31.