nurses.ab.

ca

Protection of Patients from

Sexual Abuse and Sexual
Misconduct Standards
December 2022
Effective March 31, 2023

11120 178 Street, Edmonton AB, T5S 1P2 1 (800) 252-9392 [email protected]
 Standards

Approved by the College of Registered Nurses of Alberta (CRNA) Council, December 2022,
effective March 31, 2023.

The College and Association of Registered Nurses of Alberta (CARNA) is operating as the
College of Registered Nurses of Alberta (CRNA).

Use of this document is permitted for the purposes of education, research, private study or
reference. Ensure you are using the current version of this document by visiting our website.

College of Registered Nurses of Alberta

11120 – 178 Street
Edmonton, AB T5S 1P2

Phone: 780.451.0043 (in Edmonton) or 1.800.252.9392 (Canada-wide)

Fax: 780.452.3276
Email: [email protected]
Website: nurses.ab.ca

2
 Standards

Table of Contents

Purpose.....................................................................................................................................................................................................4

Defining Sexual Abuse and Sexual Misconduct........................................................................................................4

Sexual Abuse....................................................................................................................................................................................4

Sexual Misconduct...................................................................................................................................................................... 5

Defining a Patient............................................................................................................................................................................. 5

When an individual is not considered to be a patient.................................................................................... 6

A sexual relationship after termination of the nurse-patient relationship................................ 6

When the nurse provides episodic care.................................................................................................................... 7

When a sexual relationship with a former patient is NEVER considered appropriate....... 8

Standards for the Protection of Patients from Sexual Abuse and Sexual Misconduct......... 8

Standard 1: Therapeutic and Professional Boundaries................................................................................ 9

Standard 2: Self-reporting by Nurses....................................................................................................................... 10

Standard 3: Reporting a Registrant of a Regulated Profession.......................................................... 10

Glossary..................................................................................................................................................................................................12

References........................................................................................................................................................................................... 14

3
 Standards

The Protection of Patients from Sexual Abuse and Sexual Misconduct Standards are
developed and approved as outlined in Section 133.1 of the Health Professions Act (HPA, 2000).
These standards outline the expectations for the nurse1 in the therapeutic and professional
relationship with the patient, and help ensure patient safety and trust by maintaining
appropriate relationships. These standards are grounded in the Canadian Nurses Association’s
Code of Ethics for Registered Nurses (2017), and the directions, concepts and principles are
aligned with the following College of Registered Nurses of Alberta (CRNA) documents:

 Practice Standards for Registrants (2023)

 Professional Boundaries: Guidelines for the Nurse-Client Relationship (2022)

Purpose
The purpose of these standards is to outline the minimum expectations for the nurse and
their relationship with a patient in order to strengthen the protection of patients from
sexual abuse and sexual misconduct by nurses. The HPA (2000) does not make a distinction
between workplace or ‘after hours’ settings when referring to a nurse-patient relationship.
The obligation of maintaining professional boundaries lies with the nurse, not the patient.

Defining Sexual Abuse and Sexual

Misconduct
Sexual Abuse
Sexual abuse is defined as the threatened, attempted or actual conduct of the nurse towards
a patient that is of a sexual nature (HPA, 2000). It includes any of the following conduct:

i. sexual intercourse between the nurse and a patient of that nurse;

ii. genital to genital, genital to anal, oral to genital, or oral to anal contact between
the nurse and a patient of that nurse;
iii. masturbation of the nurse by, or in the presence of, a patient of that nurse;
iv. masturbation of the nurse’s patient by that nurse;
v. encouraging the nurse’s patient to masturbate in the presence of that nurse;
vi. touching of a sexual nature of a patient’s genitals, anus, breasts or buttocks by the nurse.
(HPA, 2000)

A finding of sexual abuse by the hearing tribunal against the nurse mandates cancellation of
their practice permit.

1
Words or phrases displayed in bold capitals upon first mention are defined in the glossary.

4
 Standards

Sexual Misconduct
Sexual misconduct means

“any incident or repeated incidents of objectionable or unwelcome

conduct, behaviour or remarks of a sexual nature by a regulated member
towards a patient that the regulated member knows or ought reasonably
to know will or would cause offence or humiliation to the patient or
adversely affect the patient’s health and well-being but does not include
sexual abuse”.
(HPA, 2000, s 1[1][nn.2])

A finding of sexual misconduct by the hearing tribunal against the nurse mandates a
minimum of a suspension of their practice permit, with the possibility of cancellation of their
practice permit.

Defining a Patient
In these standards, ‘patient’ refers to the individual to whom the nurse provides a health
service (HPA, 2000). Factors, which may contribute to the determination of whether an
individual is considered the nurse’s patient, include

 the nurse has provided a health service for the patient;

 the nurse has contributed to a health record or file for the patient; or
 the patient has consented to a health service provided by the nurse.

In a nurse-patient relationship, the nurse has power over the patient due to the professional
position of the nurse and their access to, and awareness of, private information of the patient.
The nurse must always consider the risk of any power imbalance before entering into a sexual
relationship with a former patient. This power imbalance can vary on a continuum, based on
several factors, including

 the duration of the nurse-patient relationship;

 the sensitivity of private information the nurse has access to; and
 the vulnerability of the patient.

5
 Standards

When an individual is not considered to be a

patient
An individual receiving health services from the nurse is not considered to be a ‘patient’ as
defined in the HPA (2000) with respect to sexual abuse or sexual misconduct if the nurse
is their spouse, adult interdependent partner, or if they are in an ongoing, pre-existing
sexual relationship with the nurse.

The nurse shall not provide health services to a spouse, adult interdependent partner, or
individual with whom they are in an ongoing, pre-existing sexual relationship unless all of the
following factors are met:

 the health service provided by the nurse to the individual is due to an emergency or is
minor in nature
 the nurse has taken reasonable steps to transfer the individual’s care or there is no
reasonable opportunity to transfer care

The nurse who provides health-care services to a spouse, adult interdependent partner, or
individual with whom they have an ongoing, pre-existing sexual relationship outside of these
factors may be found by a hearing tribunal to have engaged in unprofessional conduct.
After making a finding of unprofessional conduct, a hearing tribunal can impose a range of
sanctions, including suspension or cancellation of registration and practice permit.

A sexual relationship after termination of the

nurse-patient relationship
The HPA (2000) prohibits sexual relationships between the nurse and a patient. Therefore, the
nurse must ensure the nurse-patient therapeutic and professional relationship is terminated
before engaging in a sexual relationship with a former patient and must comply with the
timeframes addressed below.

For the purposes of the sexual abuse provisions in the HPA (2000), an individual may still be
considered a ‘patient’ after the termination of the therapeutic and professional relationship.
An individual is considered to be a ‘patient’ for the purposes of the sexual abuse provisions
for a one-year period after the date of the last clinical encounter, where a health service
was provided by the nurse. As a result, the nurse must not engage in the type of sexual acts
described in the definition of sexual abuse with such an individual for a minimum of one year
after the last clinical encounter.

Sexual conduct may still be considered inappropriate after the one-year period has elapsed
depending on all the circumstances. In determining whether a sexual relationship between
the nurse and a former patient after the one-year period is inappropriate, the factors to be
considered include

6
 Standards

1. whether there is a risk of a continuing power imbalance;

2. the length of time that has passed since the last clinical encounter;

3. whether the nurse-patient therapeutic and professional relationship existed for a lengthy
period of time;

4. the nature of the care provided:

a. whether a former patient who was provided care is likely to require the nurse’s care
again in the future, and

b. the type, intensity, and duration of the nursing care; and

5. the vulnerability of the patient during the course of the therapeutic relationship:

a. how mature and vulnerable the former patient is, and

b. whether the former patient has impaired decision-making.

Beyond the one-year period, sexual conduct with a former patient that is considered
inappropriate given all the circumstances, is not considered to be sexual abuse.

However, such conduct may be considered to be unprofessional conduct by a hearing

tribunal. After making a finding of unprofessional conduct, a hearing tribunal can impose a
range of sanctions, including suspension or cancellation of registration and practice permit.

When the nurse provides episodic care

The nurse may provide episodic care to a patient when there is no expectation of continuing
care, and there is no expectation of the continuation of the therapeutic and professional
relationship. The nurse providing episodic care to a patient must

 collect and document any relevant history;

 assess and provide nursing interventions as appropriate;
 inform the patient that the nurse will not provide continuing care beyond addressing the
patient’s defined health-care need;
 document this clinical encounter on the patient’s health record so the primary provider
can access the documentation.

For the purposes of the sexual abuse and sexual misconduct provisions, a nurse- patient
relationship is formed during the provision of episodic care. Therefore, the nurse who

7
 Standards

engages in the type of activity described in the definition of sexual abuse or sexual
misconduct while providing episodic care will be considered to have committed sexual abuse
or sexual misconduct.

The individual is not considered to be a patient after the completion of the episodic care.
However, sexual conduct at any time after the conclusion of episodic care may still be
considered inappropriate if there is a risk of an ongoing power imbalance. The factors
outlined in the section ‘A sexual relationship after termination of the nurse-patient
relationship’ must be considered.

Sexual conduct within the one-year time period or after the one-year time period with a
former patient who has received episodic care that is considered inappropriate given all
the circumstances is not considered to be sexual abuse. However, such conduct may be
considered by a hearing tribunal to be unprofessional conduct under the HPA (2000). After
making a finding of unprofessional conduct, a hearing tribunal can impose a range of
sanctions, including suspensions and cancellation of registration and practice permit.

When a sexual relationship with a former patient

is NEVER considered appropriate
There are circumstances when it is NEVER considered appropriate for the nurse to engage
in a sexual relationship with a former patient. The nurse must NOT engage in a sexual
relationship if the nurse provided the patient with psychotherapeutic treatment.

In these circumstances, a sexual relationship between the nurse and a former patient would
constitute sexual abuse as defined in the HPA (2000), and a hearing tribunal will impose
cancellation of registration and practice permit.

Standards for the Protection of

Patients from Sexual Abuse and
Sexual Misconduct
These standards for the protection of patients from sexual abuse and sexual misconduct,
identify the minimum expectations of CRNA registrants. The criteria describe how registrants
must meet each standard and are not listed in order of importance.

8
 Standards

Standard 1: Therapeutic and Professional

Boundaries
The nurse must maintain therapeutic and professional boundaries in all interactions with
the patient in the provision of professional services.

Professional boundaries keep the nurse-patient relationship safe and respected. A patient
trusts the nurse to set and maintain limits that respect the patient as a person in need of care
and the nurse as a person providing the care (CRNA, 2022). Establishing boundaries addresses
the power differential and sets limits to the nurse-patient relationship (CRNA, 2022). Violations
of these boundaries that betray the therapeutic relationship is a breach of trust.

A boundary violation occurs when the nurse abuses their authority over the patient, causing
confusion and may result in distress for the client. Sexual relations between the nurse and
a patient are unethical and abusive, and are considered a serious breach of trust (College of
Physicians and Surgeons of Ontario, n.d.).

Criteria

The nurse must

1.1 take responsibility for maintaining therapeutic and professional boundaries;

1.2 not sexualize any interaction with a patient;

1.3 avoid requesting details of a patient’s sexual or personal history unless the information
is pertinent to the patient’s care (College of Physicians and Surgeons of Alberta [CPSA],
2019);

1.4 inform a patient if they are providing episodic care;

1.5 refrain from socializing or communicating with a patient for the purpose of pursuing a
sexual relationship (CPSA, 2019);

1.6 refrain from entering into a sexual relationship with a patient or any person with whom
a patient has a significant interdependent relationship (i.e., parent, guardian, child, or
significant other) (CPSA, 2019);

1.7 must not engage in a sexual relationship at any future point with any patient where the
nurse-patient relationship was psychotherapeutic;

1.8 seek impartial advice and refrain from any relationship with the individual if there is any
doubt that the individual is still their patient; and

1.9 acknowledge that the nurse-patient relationship remains a professional relationship for
a minimum of one year following the last clinical encounter.

9
 Standards

Standard 2: Self-reporting by Nurses

Nurses are required to self-report to the registrar of all relevant regulatory bodies they are
associated with, as soon as reasonably possible, any finding of unprofessional conduct
against them.

Nurses may be registered in more than one regulatory college within Alberta, or across other
jurisdictions. In these cases, the nurse is obligated to report any finding of unprofessional
conduct against them to all regulatory colleges with which they are registered.

Criteria

The nurse must report, in writing to the registrar, as soon as reasonably possible

2.1 a decision of finding of unprofessional conduct from another regulatory college in

Alberta that nurse is registered with, and provide a copy of that decision to any other
regulatory college they are registered with;

2.2 any finding of unprofessional conduct from regulatory colleges of similar professions in
other jurisdictions making similar findings, and provide a copy of that decision, if any, to
the registrar;

2.3 any finding of professional negligence made against the nurse to the registrar, as soon
as reasonably possible, after the finding has been made; and

2.4 any charges and convictions under the Criminal Code (RSC 1985, c C-46) after April 1,
2019.

Standard 3: Reporting a Registrant of a

Regulated Profession
If a nurse has reasonable grounds to believe that the conduct of any registrant of
any regulated profession constitutes sexual abuse or sexual misconduct, that nurse
must report the conduct of that member to the complaints director of the appropriate
regulatory college.

Every nurse has the responsibility to take reasonable steps to ensure the safety, security, and
well-being of a patient (Protection for Persons in Care Act, 2009).

10
 Standards

Criteria

The nurse must

3.1 while acting within their professional capacity, if they have reasonable grounds to
believe that a registrant of any regulated profession has conducted themselves in a
manner that constitutes sexual abuse or sexual misconduct, report this behaviour to
the complaints director of that regulatory college with which they are registered.

11
 Standards

Glossary
Adult interdependent partner – The relationship between two persons who are adult
interdependent partners of each other; formerly referred to as ‘common-law’. The three
ways people can become adult interdependent partners are: cohabit for 3 years; cohabit
and have a child together; or enter into an adult interdependent partner agreement (Adult
Interdependent Relationships Act, 2002).

Episodic care – A single clinical encounter with the patient for a defined health-care need,
where neither the nurse nor the patient has the expectation of continuing care and the
therapeutic and professional relationship.

Health service – “A service provided to people

(i) to protect, promote or maintain their health,

(ii) to prevent illness,

(iii) to diagnose, treat or rehabilitate, or

(iv) to take care of the health needs of the ill, disabled, injured, or dying”
(HPA, 2000, s 1[1][p]).

Nurse – Refers to registrants of the CRNA, including registered nurses (RNs), graduate nurses,
certified graduate nurses, nurse practitioners (NPs), graduate nurse practitioners, and RN or
NP courtesy registrants on the CRNA registry.

Nurse-patient relationship – A relationship established and maintained by the nurse

through therapeutic interactions, which enable the nurse to provide safe, competent, and
ethical care.

Power – The power of the nurse comes from the professional position and the access to the
private knowledge about the client.

Professional service(s) – A service that comes within the practice of a regulated profession
(HPA, 2000, s 1[1][ff]).

Psychotherapeutic – Planned and structured psychological, psychosocial, and/or

interpersonal interventions influencing a behaviour, mood, and/or emotional reactions to
different stimuli (College of Nurses of Ontario, 2006).

Reasonable grounds – Enough credible evidence to lead an ordinary person to prudent

judgment of the suspicions and belief that they hold.

Sexual nature – Does not include any conduct, behaviour or remarks that are appropriate to
the service provided (HPA, 2000).

Sexualize – To make sexual: endow with a sexual character or cast (Merriam-Webster, n.d.).

12
 Standards

Spouse – A person to whom one is married.

Vulnerability – Susceptibility to health problems, harm or neglect that could either be

caused or influenced by physical, psychological, or sociological factors; is situational based on
an individual’s experiences (Heaslip & Ryden, 2013).

13
 Standards

References
Adult Interdependent Relationships Act, SA 2002, c A-4.5.

Canadian Nurses Association. (2017). Code of ethics for registered nurses. https://www.cna-
aiic.ca/en/nursing/regulated-nursing-in-canada/nursing-ethics

College of Nurses of Ontario. (2006). Therapeutic nurse-client relationship. https://www.cno.

org/globalassets/docs/prac/41033_therapeutic.pdf

College of Physicians and Surgeons of Alberta. (2019). Standards of practice: Boundary

violations: Sexual. https://cpsa.ca/wp-content/uploads/2020/05/Boundary-Violations-
Sexual.pdf

College of Physicians and Surgeons of Ontario. (n.d.). Advice to the profession: Maintaining
appropriate boundaries. https://www.cpso.on.ca/Physicians/Policies-Guidance/Policies/
Boundary-Violations/Advice-to-the-Profession-Maintaining-Appropriate-B

College of Registered Nurses of Alberta. (2022). Professional boundaries: Guidelines for the
nurse-client relationship.

College of Registered Nurses of Alberta. (2023). Practice standards for registrants.

Criminal Code, RSC 1985, c C-46.

Health Professions Act, RSA 2000, c H-7.

Heaslip, V., & Ryden, J. (Eds.). (2013). Understanding vulnerability: A nursing and healthcare
approach. Wiley-Blackwell.

Merriam-Webster. (n.d.). Sexualize. In Merriam-Webster.com dictionary. Retrieved July 27,

2022, from https://www.merriam-webster.com/dictionary/sexualize

Protection for Persons in Care Act, SA 2009, c P-29.1.

14