STANDARD OF MAINTAINING PROFESSIONAL BOUNDARIES AND PREVENTING SEXUAL ABUSE
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Approved by the College of Registered Psychiatric Nurses of Alberta (CRPNA) Provincial Council, March 2019. Permission to reproduce this document is granted. Please recognize CRPNA.
College of Registered Psychiatric Nurses of Alberta (CRPNA)
Suite 201, 9711 – 45 Avenue
Edmonton, AB T6E 5V8
Phone: (780) 434-7666
Fax: (780) 436-4165
Email: [email protected]
Website: www.crpna.ab.ca
The Standards of Psychiatric Nursing Practice are the minimum acceptable level of performance required of the Registered Psychiatric Nurse. The Standards of Psychiatric Nursing Practice articulate the legal and professional obligations of the Registered Psychiatric Nurse; they apply to all practice settings, domains of practice, and roles regardless of an individual RPN’s educational preparation or professional experience. It is the professional responsibility of the Registered Psychiatric Nurse to know, understand and adhere to the Standards of Psychiatric Nursing Practice. Failure to meet the Standards constitutes unprofessional conduct as defined in the Health Professions Act.
Indicators illustrate how to meet each Standard of Psychiatric Nursing Practice. The indicators are representative but not comprehensive for each Standard. Specific indicators vary with the situation and
context within the psychiatric nurses’ role. It is the professional responsibility of the Registered Psychiatric Nurse to articulate how they meet the Standards.
This is an additional Standard of Practice that outlines the expectations for the psychiatric nurse in maintaining the therapeutic and professional boundaries with the patient/client in preventing sexual abuse.
PURPOSE
The purpose of this standard is to outline expectations for the Registered Psychiatric Nurse and their relationship with a patient/client in order to strengthen the protection of patients/clients from sexual abuse and sexual misconduct by Registered Psychiatric Nurses for the purposes of a complaint of unprofessional conduct in relation to Sexual Abuse or Sexual Misconduct under the Health Professions Act.
This document provides clarity and direction on:
- defining patient, for the purposes of this document and to maintain consistency with other College documents, client will be used interchangeably and is synonymous with patient;
- setting and maintaining boundaries for the therapeutic relationship;
- identifying and dealing effectively with unacceptable and/or abusive behaviour in registered psychiatric nurse-client relationships; and
- using professional judgment when establishing, maintaining and terminating a therapeutic
Definition of Patient/Client
For the purposes of this document and to maintain consistency with other College documents, client will be used interchangeably and is synonymous with patient.
An individual is a client when there is a health care service interaction:
- that includes psychotherapeutic interventions between an individual and a registered psychiatric nurse, or
- the registered psychiatric nurse has contributed to a client health record or chart for that individual, or
- the individual has consented to receive a health care service recommended by the registered psychiatric nurse, or
- the registered psychiatric nurse has issued billings or received payment in connection with a health care service provided to that individual, or
- the registered psychiatric nurse prescribed a drug for which a prescription is needed, to that individual
Definition of Sexual Abuse and Sexual Misconduct
Sexual Abuse
Sexual Abuse is defined in section 1(1)(nn.1) of the Health Professions Act as the threatened, attempted or actual conduct of a regulated health professional towards a patient/client that is of a sexual nature and includes any of the following conduct:
- sexual intercourse between the registered psychiatric nurse and a client of that registered psychiatric nurse
- genital to genital, genital to anal, oral to genital, or oral to anal contact between the registered psychiatric nurse and a client of the registered psychiatric nurse
- masturbation of the registered psychiatric nurse by, or in the presence of, a client of that registered psychiatric nurse
- masturbation of the registered psychiatric nurse’s client by that registered psychiatric nurse
- encouraging the registered psychiatric nurse’s client to masturbate in the presence of the registered psychiatric nurse
- touching of a sexual nature of a client’s genitals, anus, breasts, or buttocks by the registered psychiatric nurse
Sexual Misconduct
Sexual Misconduct is defined in section 1(1)(nn.2) of the Health Professions Act as any incident or repeated incidents of objectionable or unwelcome conduct, behavior or remarks of a sexual nature by a regulated member towards a patient/client that the regulated member knows or ought reasonably to know will or would cause offense or humiliation to the patient/client or adversely affect the patient’s/client’s health and well-being but does not include sexual abuse.
Sexual Nature
Sexual nature is defined in section 1(1)(nn.3) of the Health Professions Act as not including any conduct, behaviour or remarks that are appropriate to the service provided.
Sexual Relationship with a Former Client - NEVER Appropriate when a Psychotherapeutic Treatment has been provided
It is NEVER considered appropriate to have a sexual or romantic relationship with a former client if the registered psychiatric nurse provided the client with psychotherapeutic treatment. The negative consequences and power imbalances of this type of relationship with a registered psychiatric nurse who provided psychotherapeutic treatment can be long term. Under the Health Professions Act, regardless of the amount of time that has lapsed since the psychotherapeutic relationship ended, a sexual or romantic relationship would constitute Sexual Abuse as defined in the Health Professions Act.
A Sexual Relationship after Termination of the Registered Psychiatric Nurse-Client Relationship
The Health Professions Act prohibits sexual relationships between the registered psychiatric nurse and a client. Therefore, the registered psychiatric nurse must ensure the registered psychiatric nurse-client therapeutic and professional relationship is terminated before engaging in a sexual relationship with a former client and must comply with the timeframes addressed below.
For the purposes of the Sexual Abuse provisions in the Health Professions Act, an individual may still be considered a client after the termination of the therapeutic and professional relationship. An individual is considered to be a client for the purposes of the Sexual Abuse provisions for a minimum of one-year following the last clinical encounter with the registered psychiatric nurse.
Sexual relationships with former clients may still be considered inappropriate after the one-year period has elapsed. Sexual conduct with a former client is inappropriate if there is more than a minimal risk of a continuing power imbalance. A non-exhaustive list of factors in determining whether there is more than a minimal risk of a continuing power imbalance is as follows (in this list the patient/client is referred to as the “individual”):
- Whether the individual understands the inherent power imbalance that typically exists in a registered psychiatric nurse-client relationship.
- Whether sufficient time has passed since the end of the registered psychiatric nurse-client relationship, given the nature and extent of the registered psychiatric nurse-client
- The nature of the individual’s clinical
- The type of care provided by the registered psychiatric
- Whether the individual has confided close personal or sexual information to the registered psychiatric
- The length and intensity of the former registered psychiatric nurse-client
- Whether this is a situation where there is a likelihood of transference.
- The vulnerability of the individual including a consideration of whether the individual is a member of a vulnerable population such as, for example: those who have diminished capacity, those who are economically disadvantaged, those suffering from addictions and the homeless.
A Sexual relationship with a former client is never appropriate if psychotherapeutic treatment was provided by the registered psychiatric nurse.
When an Individual is not considered a Client/Patient
For the purposes of the Sexual Abuse provisions under the Health Professions Act, a person receiving health care treatment from the registered psychiatric nurse is not considered to be a client/patient if the registered psychiatric nurse is their spouse, adult interdependent partner or if they are in an ongoing pre- existing sexual relationship with the registered psychiatric nurse.
However, the registered psychiatric nurse shall not provide health care treatment to a spouse, adult interdependent partner or person with whom they are in an ongoing pre-existing sexual relationship unless the following conditions are met:
- the individual is receiving professional health care services in an emergency situation;
- the registered psychiatric nurse has taken reasonable steps to transfer the individuals care, or there is no reasonable opportunity to transfer care to another qualified health care
Episodic Care
For the purposes of the sexual abuse and sexual misconduct provisions, a registered psychiatric nurse-client relationship is formed when a registered psychiatric nurse provides “Episodic Care”. However, the registered psychiatric nurse-client relationship does not extend beyond the conclusion of the episodic care. The individual is considered a client during the episodic care. Therefore, a registered psychiatric nurse who 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, as the case may be.
Sexual conduct between a registered psychiatric nurse and a former client after the completion of episodic care may still be considered to be inappropriate. This conduct is considered to be inappropriate if there is more than a minimal risk of a continuing power imbalance. A non-exhaustive list of factors in determining whether there is more than a minimal risk of a continuing power imbalance is set out in the section entitled “A Sexual Relationship after Termination of the Registered Psychiatric Nurse-Client Relationship.”
However, such conduct may be considered by a Hearing Tribunal to be unprofessional conduct under the Health Professions Act. 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.
A Registered Psychiatric Nurse is responsible for establishing and maintaining professional therapeutic boundaries, and prevents sexual abuse in the therapeutic registered psychiatric nurse-client relationship and protects the client from harm in the provision of professional health services.
Indicators:
A Registered Psychiatric Nurse:
a) establishes boundaries for the therapeutic relationship and or psychotherapeutic interventions;
b) informs the client that information will be shared with the health care team and also who makes up the health care team;
c) informs a client if they are providing episodic care;
d) refrains from self-disclosure unless it meets a specific, identified therapeutic client need;
e) sets and maintains the appropriate boundaries within the relationship, and helps clients understand when their requests are beyond the limits of the registered psychiatric nurses therapeutic relationship;
f) develops and follows a comprehensive care plan with the client and health care team that aims to meet the client’s needs;
g) ensures that any approach or activity that could be perceived as a boundary crossing is included in the care plan developed by the health care team (i.e. in a mental health clinic meeting a client and having a coffee may be an appropriate strategy that all health care team members will use when counselling that client);
h) recognizes that there may be an increased need for vigilance in maintaining professionalism and boundaries in certain practice settings such as a client’s home or the community;
i) is aware of the warning signs that the professional boundaries of the therapeutic relationship may be in jeopardy (i.e. inappropriate requests from the client, gifts from the client, spending free time with the client, favoring one client’s care at the expense of other clients) and take action to immediately re-establish the professional therapeutic relationship;
j) maintains appropriate boundaries between professional and personal relationships if one must treat a family member or spouse in an emergent situation;
k) continually clarifies her/his role in the therapeutic relationship, especially in situations in which the client may become unclear about the boundaries or limits of the relationship;
l) does not sexualize any interaction with a client;
m) intervenes and reports, when appropriate, incidents of verbal and non-verbal behaviours that demonstrate disrespect for the client;
n) intervenes and reports a regulated member of any regulated profession to the applicable College any behaviours or remarks toward a client that may reasonably be perceived by the registered psychiatric nurse and/or others to be sexually suggestive, exploitive and/or sexually abusive;
o) does not engage in behaviours or activities with a client or make remarks that may reasonably be perceived by other health care professionals and/or others to be romantic, sexually suggestive, exploitive and/or sexually abusive;
p) does not engage with the client in watching any pornography or encouraging the client in performing any pornographic behavior;
q) does not engage in any behavior, activity or verbal remarks of a sexual nature that would cause offence or humiliation to the client or adversely affect the clients health and well-being;
r) does not enter into a close personal, intimate or sexual relationship with a client or a former client to whom they have provided psychotherapeutic treatment;
s) does not socialize or communicate with a client for the purpose of pursuing a sexual relationship;
t) refrains from entering into a sexual relationship with a client or any person with whom a client has a significant interdependent relationship (i.e. parent, guardian, child, or significant other) (CPSA, 2018);
u) seeks impartial advice and refrains from any relationship with the individual if there is any doubt that the individual is still their client; and
v) acknowledges that the registered psychiatric nurse-client relationship remains a professional relationship for a minimum of one-year following the last clinical encounter. (Refer to the non- exhaustive list of factors to determine if a sexual relationship with a former patient/client is ever appropriate, as found on page 4).
Adult Interdependent Partner Agreement: is the relationship between two persons who are adult interdependent partners with 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, 2014).
Boundaries: boundaries are limits that protect the space between the professional’s power and the client’s vulnerability. Boundaries define and separate professional roles from other roles. Boundaries are the limits that allow a safe connection between a professional and a client and are always based on the client’s needs (Peterson. M. 1992). It is the nurse’s responsibility to maintain professional boundaries.
Client: (synonymous with patient) individual, groups, families, and communities.
Episodic Care: a single clinical encounter with the patient for a defined health care need, where neither the nurse nor the patient have the expectation of continuing care and the therapeutic and professional relationship. The nurse is required to document this clinical encounter on the patient’s health record.
Health Service: a service provided to people to protect, promote or maintain their health; to prevent illness; to diagnose, treat or rehabilitate; or to take care of the health needs of the ill, disabled, injured or dying (Health Professions Act, 2018).
Power Imbalance: the power of the psychiatric nurse comes from the professional position and the access to the private knowledge about the client
Psychotherapeutic: planned and structured psychological, psychosocial, and/or interpersonal interventions influencing a behavior, mood, and/or emotional reactions to different stimuli (College of Nurses of Ontario, 2006).
Registered Psychiatric Nurse: refers to regulated members of CRPNA, including psychiatric nurses, and those on the temporary and courtesy registers.
Sexualize: to make sexual: endow with a sexual character or cast (Webster, 2018).
Therapeutic relationship: An interpersonal process that is purposeful, goal directed and focused on achieving outcomes in the best interest of the client.
Transference:The client’s experience of feelings toward the psychiatric nurse that were originally held toward significant others in his or her life (Halter, 2014)
Adult Interdependent Relationships Act, S.A, 2002, c. A-4.5
College of Registered Psychiatric Nurses of Alberta Code of Ethics & Standards of Psychiatric Nursing Practice – September 2013.
College and Association of Registered Nurses of Alberta. (2011). Professional boundaries for registered nurses: Guidelines for the nurse-client relationship. Edmonton, AB: Author.
College of Nurses of Ontario. (2006). Therapeutic nurse-client relationship. Toronto, ON: Author.
College of Physicians and Surgeons of Alberta. (2018). Standards of practice: Boundary violations. Edmonton, AB: Author.
College of Physicians and Surgeons of Ontario (2018). Maintaining appropriate boundaries and preventing sexual abuse. Toronto, ON: Author.
Criminal Code, R.S.C. 1985, c. C-46
Health Professions Act, R.S.A. 2000, c. H-7
Sexualize. (2018). Merriam-Webster. Retrieved from https://www.merriamwebster.com/dictionary/sexualize
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