Running head: ETHICAL NURSING CARE FOR YOUR LOVED ONE

Ethical Nursing Care for Your Loved One

Davinder Bassi
XXX XXX XXX
NURS 217
Professor X
March 31, 2015
Humber ITAL

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Who would you trust to provide nursing care for your child or your grandparent?
Someone who is extremely competent and infinitely caring most would say. However, another
component considered just as significant, is a nurses moral judgement. Having the knowledge
and skills to perform a nursing task must also be accompanied by ethical values: knowing when
and why it is appropriate to apply these skills safely and effectively. In the case between the
College of Nurses of Ontario (CNO) and Angelika Zarac, RPN, professional misconduct was
committed (CNO v. Zarac, 2013). This paper discusses details of the case, potential contributing
factors, the decision made by the Discipline Committee, ethical values contravened, followed by
suggestions to prevent this situation from recurring.
On January 17, 2013 Angelika Zarac admitted to the following allegations at her
discipline hearing: administering a medication, Voltaren, which was not prescribed to a longterm care (LTC) resident; inappropriately restraining a hospital client having an acquired brain
injury (ABI); and improperly using an incontinence product resulting in the ABI patient to bleed
from his penis(CNO v. Zarac, 2013) . She also did not document administering Voltaren,
implementing restraints or unsafe incontinence care (CNO v. Zarac, 2013). Lastly, she took home
a patients CD of wound images in the perineum area and skin folds from the hospital chart
(CNO v. Zarac, 2013). Each allegation is considered very serious, resulting in Angelikas
termination at both facilities (CNO v. Zarac, 2013).
The panel heard multiple offences of professional misconduct throughout this hearing.
Angelika failed to meet the CNOs standards of practice of the profession by contravening the
Nursing Act, 1991(CNO, Legislation, 2014; CNO v. Zarac, 2013). She administered a
medication without an order, she failed to be honest with the resident regarding the name of the
medication she dispensed, she inappropriately and unsafely restrained a patient with a bed sheet,
she failed to obtain consent prior to restraining, she inappropriately provided toileting care
causing harm, she failed to document any of these nursing acts as required by CNO, she

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breached patient confidentiality and personal health information laws by removing a CD for
personal use, and she confessed to acting disgracefully, dishonourably and unprofessionally
(CNO, Professional Misconduct, 2014; CNO Professional Standards, 2009; CNO v. Zarac,
2013).
It is, however, possible there may have been intrinsic or extrinsic factors contributing to
these incidents from the nurse or the environment. Although Angelika admitted to the allegations
voluntarily and unequivocally, she received her nursing certificate in 1974, thus, has had 34
years of experience prior to her first incident in 2008 (CNO v. Zarac, 2013). The night she
administered the Voltaren without an order, Angelika may have been exhausted simply because
of her age. Depending on her rotation she may have been sleep-deprived, had other waking
residents needing her attention, or had administrative duties for being in charge. Unfortunately, it
has been documented that sleep-deprived nurses cause 56% more patient care errors on night
shifts (Johnson, Jung, Song, Brown, Weaver, & Richards, 2014). Another contributing factor
may have stemmed from fatigue due to multiple jobs or a stressful personal life, since the
misconduct occurred during the evening shift on a floor with long-term medically complex
patients. Here, the unfamiliar environment may have also been a factor because Angelika had
only been employed for less than 30 days. She would not have built up a rapport with many staff
as yet. She may have also required additional orientation. Perhaps the unit had budget
constraints, and was not able to provide unregulated care professionals (UCPs) to assist with
patients. Given sufficient staff and support, Angelika could have made more appropriate, safe
and ethical decisions when caring for her patients.
In Angelikas case, the Discipline Committee ordered her penalty to include a verbal
reprimand, a two-month suspension of her nursing license, review of applicable CNO and
privacy documents, attend two meetings with a nursing expert, develop a learning plan, and
notify future employers of this decision for 12 months once her suspension ends (CNO v. Zarac,

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2013). This penalty seems fair as there will be accountability to the nursing expert whom
Angelika must also discuss potential consequences of her misconduct and strategies for
preventing the misconduct from recurring. Moreover, Angelika accepted responsibility and is
willing to improve herself when she admitted all allegations to be true, as evidenced by not using
counsel. Her loss of income, additional education, accompanied by remorse is sufficient to
rehabilitate a willing participant.
There were numerous ethical values contravened in this case, however, I will focus on
two. The first and foremost, is that of client well-being (CNO, Ethics, 2009). This value is
fundamental to nursing and therefore, a priority to follow as it refers to providing nursing care,
which promotes the clients health or removes them from harm (CNO, Ethics, 2009). Angelika
could have greatly harmed her resident when she administered Voltaren without an order. She
was not authorized to initiate the controlled act and she may not have been able to manage
potential negative outcomes (CNO, Authorizing Mechanisms, 2014; CNO, Directives, 2014). By
not contacting the physician first, she did not follow the decision tree for medication
administration and gave the resident suboptimal medical care (CNO, Medication, 2014). After
performing this controlled act, the absence of documentation or verbal communication broke the
continuity of care, placing the resident at risk. The clients needs, Angelikas intervention, and
the outcomes were not evaluated so transfer of knowledge did not occur (CNO, Documentation,
2009). Potential negative outcomes could have been an allergic or adverse drug reaction or a
drug interaction with any prescribed medications. The ethical value of client well-being was,
again, not considered when Angelika initiated a restraint on the hospital patient without
following proper protocols. As restraints are known to increase falls, confusion and decubitus
ulcers, using them placed the clients safety at risk (CNO, Restraints, 2009). Since there was no
documentation provided, Angelika failed to show evidence of attempts to understand the clients

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behaviour, did not collaborate with other team members to reduce the need for a restraint, did not
use the least restrictive restraint available, nor did she discuss options or risks with the substitute
decision-maker so that an informed decision could be made (CNO, Consent, 2009; CNO,
Restraints, 2009). The ethical value was contravened when Angelika restrained a patient with an
ABI, who was unable to speak. She used a bed sheet tied tightly to the bedrails, placed him in
two patient gowns, the second one upside-down with the his legs through the arm holes (straps
tied tightly), and unfortunately, left him bleeding with a cut to his penis following an improper
change in his incontinence product (CNO v. Zarac, 2013). Client well-being was also breached
when she took home a patients CD of wound images, no longer keeping it confidential and
secure (CNO, Confidentiality and Privacy Personal Health Information, 2009).
Another ethical value that Angelika violated was that of maintaining her commitment
towards clients, herself, nursing colleagues, other healthcare team members, the profession, and
the organization by failing to be honest and not following through with obligations (CNO,
Ethics, 2009). The focus, here, will be on discussing 2 of the 6 commitments in order to provide
rationale for each contravention. In Angelikas case, she failed to keep her commitment to her
clients by not providing safe, effective and ethical care (CNO, Ethics, 2009). This was evident
when she failed to be honest and didnt tell a patient the name of the medication she
administered, she inappropriately and unsafely restrained a client with a bed sheet and gowns,
caused injury to a patients penis, and took home a patients CD containing images of wounds
(CNO v. Zarac, 2013). In each incident, Angelika breached the clients trust, a vital component to
develop a therapeutic nurse-client relationship (CNO, Therapeutic Nurse-Client Relationship,
2013). She also contravened her commitment to her fellow nurses by not working
collaboratively (CNO, Ethics, 2009). Utilizing a variety of communication techniques and
effective interpersonal skills would have built respectful behaviour among colleagues, which in

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turn, would have promoted positive patient outcomes (CNO, Ethics, 2009). By not trusting her
peers or sharing in their knowledge and expertise, Angelika may not have been aware of her
personal values affecting the decisions she made, thus placing each of the clients in this case at
greater risk of harm (CNO, Ethics, 2009).
Some strategies to help prevent these situations from ever happening again would include
reducing workload, improving working conditions, and increasing education. In 2014,
researchers found that an increase in nurses' workload increases the likelihood of inpatient
hospital deaths, (Aiken, Sloane, Bruyneel, Van den Heede, Griffiths, Busse, Diomidous,
Kinnunen, Kozka, Lesaffre, McHugh, Moreno-Casbas, Rafferty, Schwendimann, Tishelman, van
Achterberg, & Sermeus , 2014, p.1827). With the addition of UCPs, nurses could spend more
time assessing their patients and providing interventions in a timely manner. Angelika would
have had sufficient time to call the physician to get her order for the Voltaren prior to
administering, had assistance with her patient during changing of incontinence products, and
kept him safe as he became more aggressive. Therefore, more staff would be beneficial in that it
would help decrease mortality rates and improve quality of patient care and safety (Aiken et al.,
2014). A second strategy is to improve working conditions by having more resources available
on all shifts, stronger nursing leadership, participation in organization planning, and more
collegial relationships between staff (Cho, Sloane, Kim, Kim, Choi, Yoo & Aiken, 2015). This
would aid in less burnout, improved patient care, leading to increased patient satisfaction and
ultimately, better mortality rates (Cho et al., 2015). Had Angelika sought out her charge nurse for
leadership skills before applying incorrect and unsafe restraints, the patients care could have
been more appropriate. She also may have returned the missing CD to the chart the same night if
leadership had been stronger. Lastly, a third strategy to prevent negative incidents from occurring
is to provide additional education in the form of on-going training. Studies have shown new staff

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take approximately 8 weeks before they can perform all assigned nursing duties (OBrien-Pallas,
Tomblin Murphy, G., Shamian, Li, Kephart, Laschinger, Smadu, McGillis Hall, DAmour,
Gallant, Hayes, Lee, Lee & Liu, 2014). During this transition, more attention, guidance and
support are necessary to empower the new nurse to provide quality patient care. If Angelika
would have had refresher training on appropriate use of incontinence products, how to care for
patients with an ABI, or added weeks of clinical supervision, her patients outcomes could have
been more positive.
Above all, patients are vulnerable and place their trust in a nurse. Angelika Zarac broke
that trust and admitted to allegations of professional misconduct. In summary, she administered a
medication without an order, inappropriately restrained a patient, no consent obtained for the
restraint, provided unsafe incontinence care, breached personal health information, failed to meet
standards of practice of the profession, failed to document interventions and acted in a
dishonourable manner (CNO v. Zarac, 2013). She accepted full responsibility to penalties
considered fair, including loss of license for 2 months. There may have been factors contributing
to this case such as sleep-deprivation, personal lifestyle, or a new work place, however, Angelika
must be responsible for the consequences of her actions (CNO, Professional Standards, 2009).
She contravened many ethical values, but those presented here were contravening client wellbeing, commitment to client and commitment to nursing colleagues. Strategies that may help
prevent these incidents from occurring in the future would be to reduce nursing workload,
improve the work environment, and provide access to on-going education. This would promote
competent, ethical care resulting in improved patient outcomes, the ultimate goal for our loved
ones.
References
Aiken, L., Sloane, D., Bruyneel, L., Van den Heede, K., Griffiths, P., Busse, R., Diomidous, M.,
Kinnunen, J.,Kozka, M., Lesaffre, E., McHugh, M., Moreno-Casbas, M., Rafferty, A.,

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Schwendimann, R., Tishelman, C., van Achterberg, T., & Sermeus, W. (2014). Nurse
staffing and education and hospital mortality in nine European countries: a retrospective
observational study. Lancet, 383, pp. 18241830
Cho, E., Sloane, D. M., Kim, E. Y., Kim, S., Choi, M., Yoo, I. Y. & Aiken, L. H. (2015). Effects
of nurse staffing, work environments, and education on patient mortality: An
observational study. International journal of nursing studies, 52(2), 535-542.
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College of Nurses of Ontario. (2013). Therapeutic Nurse-Client Relationship, Revised 2006.

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Retrieved from http://www.cno.org/Global/docs/prac/41033_Therapeutic.pdf

College of Nurses of Ontario v. Angelika M. Zarac. (2013, January 17). Discipline Decision.
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