Management didn't like nurse's method during crisis, but no evidence of written guidelines
The termination of a nurse’s employment for the way she administered medication to a violent child was excessive given the lack of proper guidelines and the lack of harm incurred by the patient, an Ontario arbitrator has ruled.
The worker was a nurse at Royal Victoria Hospital in Barrie, Ont., since 2007. Her entire nursing career, since 1998, was in the emergency department (ED) and she had no discipline on her record. She also taught nursing since 2002 and wrote a textbook on medication administration.
On April 16, 2022, the worker was assigned to “medical directives,” which involved assessing patients after triage. A mother brought her seven-year-old child into the emergency department with “manic behaviour” and the child was physically violent towards hospital staff.
The worker tried to calm the child by offering him a popsicle and she requested a child and youth worker to do perform a mental health assessment, as per standard protocol. She moved the child and his mother to another area for a doctor’s assessment, where another nurse took charge of the patient.
Medication for violent patient
A short time later, the worker found the child in his room screaming and yelling with the child and youth worker telling him to behave. A doctor arrived and ordered medications for the child, but he stated kicking the walls and screaming. The other nurse asked the worker for help in administering the medications and they found the mother crying outside the room, unwilling to go inside while the child was in that state.
The child was violent to the extent that four security guards had to pin him down. The worker asked the guards to let the child go, but when they did the child started kicking so they held him down again. The worker tried to calm the child down but was unsuccessful.
The other nurse retrieved the medication, which was designed to dissolve under the tongue. She squeezed the child’s cheeks to open his mouth and placed the pill inside, then put her hand under his chin to keep his mouth closed. The child calmed down briefly, but then started trying to jump off the bed, so the guards continued to hold him.
The worker and the other nurse considered administering the second medication, which was stronger, by injection, but they would have had to forcibly remove the child’s pants and inject it into a tense muscle. Since children are usually afraid of injections, they thought it best to administer it orally.
The worker clenched his jaw shut, making it difficult to open his mouth by pinching his cheeks, so the worker pinched his nose to open his mouth. She popped the drug in his mouth and he tried to spit it out, so she cupped her hand over his mouth. According to the worker, she didn’t apply any pressure and she didn’t block his nose so he could continue to breathe. The child soon calmed down and asked for his mother. The worker explained to the mother how she had pinched the child’s nose to deliver the medication orally, and the mother said she had sometimes done the same. Later, the worker apologized to the worker for trying to hurt her.
Workplace investigation
The child and youth worker was unsettled by the incident, as she thought that she heard the child say in a muffled voice that he couldn’t breathe while the worker’s hand was over his mouth. It seemed to her that the worker’s hand was over the child’s mouth “for an eternity,” but according to the worker it was 10 seconds.
One of the security guards agreed that it was 10 seconds, but he was still disturbed by the worker holding her hand over the child’s mouth. He reported the incident to his manager, although he said that the worker had administered the first pill with the other nurse administering the second.
The manager of the ED investigated, interviewing the worker, the other nurse, the security guard, and the child and youth worker. The worker explained how she pinched the child’s nose to open his mouth and that she had used that method before. The other nurse agreed with the worker’s account, but said she felt attacked and no longer administered medication orally to children.
She reviewed the results of the investigation with the operations director of the ED, the operations director for professional practices, and other managerial team members, and they agreed that the worker had committed “unwarranted physical abuse on the child” that warranted dismissal. The operations director for professional practices felt that forcing the child to take the medications orally was unsafe and contrary to the standards of the provincial College of Nurses – a nurse must exercise the proper skill and competency to deliver the medication and the medication must be delivered safely.
The operations director for the ED emailed the team to reconsider whether dismissal was appropriate, as she felt that the “chaos and attempting to get control of the patient” was a difficult situation and, while not best practice, she could see similar situations happening in the moment. She also expressed concern that the accounts of the incident indicated that the worker’s hand was in front of the child’s mouth, they chose to use pills because a needle would be scarier for the child, his nose wasn’t blocked, and the level of violence the child was exhibiting.
Termination of employment
However, the management team decided to terminate the worker’s employment on June 2 for “abusive behaviour towards a patient” in contravention of the hospital’s code of conduct, policy for consent, policy for least restraint, and the standards of practice and care from the College of Nurses.
The other nurse wasn’t dismissed, but instead was required to complete an advanced learning plan.
The nurses’ union grieved the worker’s dismissal as without cause.
The arbitrator found that it was clear that the worker administered at least one of the medications by pinching the child’s nose and holding his mouth closed for up to 10 seconds, noting that it happened in a highly stressful environment and was aimed at safely delivering necessary treatment. In addition, both the worker and the other nurse reasonably believed that the mother consented to whatever reasonable treatment would bring her child under control, despite the fact such consent wasn’t charted, the arbitrator said.
The arbitrator noted the absence of clear, written guidelines addressing how oral medications should be administered to unco-operative children in policies and standards relied upon by the hospital in the termination letter, finding that the nurses’ decision to use oral rather than intramuscular injection was reasonable under the circumstances. There was no evidence that the child couldn’t breathe or was in any danger, and they were able to successfully calm him down after administering the medication, said the arbitrator, noting that the ED’s operations director expressed to the management team how it was possible that others could have done the same thing.
“[The worker and the other nurse] used their best judgment based on their years of experience to administer the medication in the least invasive and obtrusive manner possible,” said the arbitrator.
No just cause
The arbitrator determined that the hospital didn’t have cause for dismissal and therefore violated the collective agreement. The hospital was ordered to reinstate the worker to the same position with compensation for lost wages. The arbitrator dismissed the worker’s claim for aggravated damages, as there was no evidence of bad faith or discrimination in the hospital’s implementation of discipline.
