GP 2: Conflict of Interest Protocol
| Policy Number: |
2 |
Approve Date: |
March 2025 |
| Review Frequency: |
Triennial |
*May be reviewed earlier as required |
Members of Council and committees of the College, both regulatory and governance, are in a position of protecting and maintaining a high degree of public trust and accountability. In this capacity, members of Council and committees are expected at all times to act in the best interest of the public. Council and committee members must take care to avoid situations in which their personal and other interests and obligations are (or may be perceived to be) in conflict with those of the public.
1. Conflicts of interest
1.1. A conflict of interest may be actual or potential, real or perceived, direct or indirect. A conflict of interest exists where:
1.1.1. reasonable person knowing the relevant facts would conclude that the exercise of the Council’s or committee member’s judgment was likely to have been influenced by the personal interest of the Council or committee member or by the interest of a related person or a related corporation of that Council or committee member;
1.1.2. a reasonable person knowing the relevant facts would perceive that the exercise of the Council’s or committee member’s judgment was likely to have been influenced by the personal interest of the Council or committee member or by the interest of a related person or a related corporation of that Council or committee member;
1.1.3. the Council member is a person who holds a position with another organization such that:
1.1.3.1. a reasonable person knowing the relevant facts would conclude that the exercise of the Council member’s judgment was likely to have been influenced by that Council member’s responsibilities or duties to that other organization; or
1.1.3.2. a reasonable person knowing the relevant facts would perceive that the exercise of the Council member’s judgment was likely to have been influenced by that Council member’s responsibilities or duties to that other organization;
2. Deemed conflicts of interest
2.1. As per Bylaw 2, a prospective or current Council or committee member shall be deemed to have a conflict of interest and shall be ineligible for nomination or must resign from Council and all the College committees if he or she:
2.1.1. is elected to federal, provincial or municipal public office;
2.1.2. occupies a senior position (Executive Director or higher) with the provincial Ministry of Health or Health Canada;
2.1.3. is a member or officer of a Health Authority Board;
2.1.4. as their primary responsibility in the course of their employment represents a health authority or any other nursing employer in collective bargaining or in proceedings under a collective bargaining agreement with registrants;
2.1.5. is an officer or senior employee of a professional association or a labour union that represents members of a regulated health profession;
2.1.6. as their primary responsibility in the course of their employment negotiates or sets fees charged by registrants for professional services or guidelines on fees charged by registrants for professional services on behalf of registrants; or is employed by the College; or
2.1.7. is employed by the College.
3. Initial disclosure of conflicts of interest
3.1. Each Council and committee member shall, prior to commencing to serve as a Council or committee member, provide to the Chair a list of all of the organizations for which he or she serves (including professional associations and unions) and in respect of which it is reasonably conceivable that a conflict of interest could arise, including the position they occupy and the details of the nature of the duties the individual has with that organization.
3.2. Each Council and committee member shall thereafter advise the Chair of any changes to the information provided in 4(a) within a reasonable time of the change taking place.
3.3. The Chair will take issues identified in 4(a) or 4(b) forward to Council for discussion.
4. Bias, including reasonable apprehension of bias:
4.1. Bias exists where there is actual bias or a reasonable apprehension of bias.
5. Bias in regulatory proceedings
5.1. Bias on the part of a regulatory committee member or Council member exercising an adjudicative function exists where the committee member or Council member has a stereotype, prejudice, deeply held belief, association, relationship, interest or activity that is incompatible with his or her responsibilities as an impartial decision-maker.
5.2. Reasonable apprehension of bias on the part of a regulatory committee member or Council member exercising an adjudicative function exists where a reasonable person, well informed of the facts, might reasonably conclude that the committee member's decision was not impartial nor based solely on the evidence or information received, but rather influenced by the existence of personal extraneous factors which may include but are not limited to:
5.2.1. the committee member's or Council member's connection with the issue(s) or the decision(s) to be made; or
5.2.2. the committee member’s or Council member's connection with a person or persons involved in the proceeding, including the person who is the subject of the hearing or meeting or any person whose evidence or information is presented at the hearing or meeting.
6. Bias in governance proceedings
There is reasonable apprehension of bias in the context of a meeting of Council or a governance committee which does not involve an adjudicative decision if a reasonable person, well-informed of the facts, might reasonably conclude that the Council or committee member's decision was not one impartially made in the best interests of the College, but rather influenced by the existence of personal extraneous factors which may include but are not limited to the committee member's or Council member's connection with the issue(s) or the decision(s) to be made.
7. Regulatory versus governance functions
7.1. Regulatory functions are carried out by:
a) Registration Committee
b) Registration Review Committee
c) Hearing Tribunal
d) Complaint Review Committee
e) Competence Committee
f) Appeals Committee
7.2. Governance functions are carried out by:
a) Standing committees
b) Ad hoc committees
c) Sub-committees of Council
d) Council, when not exercising its regulatory authority
7.3. Conflict in regulatory functions
When regulatory functions are being carried out, the interests of the public are to be considered. When an issue arises to do with impartiality, bias or perceived apprehension of bias, the members of the committee are expected to act in accordance with the rules of natural justice and the provisions of the Health Professions Act. Regulatory committees owe their duty to uphold the regulatory provisions of the Health Professions Act. The decisions of the committee exercising its regulatory role can be reviewed by a higher regulatory authority – not the registrants or Council. These functions are carried out in a manner that upholds proper nursing standards and the provisions of the Health Professions Act and Registered Nurses Profession Regulation in accordance with law.
7.4. Conflict in governance functions
When governance functions are being carried out, the interests of the public are to be considered. It is expected that all members of the committees exercising their governance functions will bring various viewpoints, including those that are controversial, to discussions. However, the expectation is that all members of these committees must, according to the College’s mandate, consider the public trust that they hold and the public interest in their deliberations.
7.5. A member of a regulatory committee who is elected to Council shall resign his/her position on the committee.
8. Principles
8.1. Members of the College Council and committees shall comply with the following principles:
8.1.1. Clarity of role – Council and committee members shall be cognizant of the differing roles and responsibilities that they have as both members of Council and committees and as members of the public. Members shall recognize that each of these roles carries with it different obligations and loyalties which may be in conflict. Members shall not knowingly take advantage of, or benefit from, information obtained during their official College duties and responsibilities and that is not generally available to the public.
8.1.2. Accountability and disclosure – Members of Council and committees are accountable to the public for the exercise of their duties and responsibilities and shall disclose any circumstances wherein a potential conflict of interest could arise.
8.1.3. Prudence and judgment – In the exercise of their functions, Council and committee members shall exercise due caution and judgment in order to avoid situations which may give rise to a conflict of interest between their College responsibilities and possible personal interest or gain.
9. Final decision making
9.1. Regulatory functions – When an issue arises to do with bias, real or perceived, the final decision will be made by the regulatory committee hearing the matter. This decision is final and binding on the members of the regulatory committee. If the issue of bias is raised by an individual who has a right of appeal in the matter that is under consideration, this issue may be raised on appeal.
9.2. Governance functions – When an issue arises related to the actual, potential, or perceived conflict of interest of a Council or committee member, the majority decision of Council or the committee becomes the official position of all members of Council or the committee. This decision is final and binding and shall not be questioned or reviewed in any court.
10. College conflict of interest procedures
10.1. At the beginning of each Council and committee meeting, Council or committee members will be asked to declare any conflict or potential conflict of interest related to the items for discussion at the meeting. Council or committee members shall declare any such conflicts or potential conflicts of interest or bias at the commencement of the meeting, or as soon thereafter as the individual becomes aware of them.
10.2. All incoming committee or Council members will sign the Council Members’ Code of Conduct Agreement indicating that they have read and understood this Conflict of Interest Protocol (Protocol), that they do not have or anticipate having a conflict of interest and that they agree to disclose any future conflict or potential conflict to the Chair, CEO & Registrar or committee Chair.
11. Acknowledged conflict
11.1. When a member of Council or a committee is aware of their own conflict of interest, the following guidelines will be followed:
11.1.1. Regulatory committees
11.1.2. The conflict of interest or the issue of bias shall be disclosed at the time it is recognized. Should this be prior to a meeting, a replacement member may be found for the regulatory committee, to ensure quorum.
11.1.3. Should the issue be discovered at the time of the meeting of the regulatory committee, the person who believes that he or she may be biased or in conflict will identify this as soon as the issue is realized.
11.1.4. The committee will ask all parties if the issue that has been raised is seen as a problem.
11.1.5. If all parties are satisfied that the individual can consider the matter impartially, the member of the regulatory committee can remain and participate in the business of the committee.
11.1.6. If any party to the proceedings takes issue with the member continuing, the member in question of the regulatory committee may voluntarily withdraw.
11.1.7. If voluntary withdrawal is not done, the member in question of the regulatory committee will be asked to leave while the regulatory committee considers the matter.
11.1.8. The regulatory committee will issue its decision in the matter.
11.1.9. The decision of the regulatory committee is final and binding on the member of the committee who is alleged to have the conflict.
11.1.10. If a regulatory appeal mechanism is available, any other parties to the matter may appeal based on the issue of bias or perceived bias.
11.1.11. The issue will be recorded in the minutes or in the legal transcript of the proceedings.
11.2. Governance committees
11.2.1. The conflict of interest shall be disclosed orally or in writing to the Chair, CEO & Registrar, or committee Chair.
11.2.2. The person with a bias or in conflict must refrain from attempting to exert personal influence in connection with the issue being discussed or decided.
11.2.3. Possible solutions may include withdrawal from specific discussions and decisions or resignation from a committee or Council.
11.2.4. The person with a bias or in conflict may be recalled by the Chair to answer questions pertinent to either the issue or the bias or conflict.
11.2.5. The minutes will reflect bias or conflict disclosure and whether the member withdrew from the meeting.
12. Potential conflict
12.1. When a member of Council or a committee becomes aware of their own or another’s potential bias or conflict of interest:
12.1.1. Regulatory functions
12.1.1.1. The management of a potential conflict, i.e., a perceived apprehension of bias, is the same as an acknowledged conflict, the issue of a perception or potential bias is now under consideration.
12.1.1.2. If the person who is alleged to have the potential conflict or bias is not present when the issue is raised, that person shall be informed in writing of the matter.
12.1.2. Governance functions
12.1.2.1. The potential bias or conflict of interest shall be disclosed to the Chair, CEO & Registrar or committee Chair. When in doubt, the person in potential conflict shall place the circumstances before Council or the committee.
12.1.2.2. The person in potential conflict must refrain from attempting to exert personal influence in connection with the issue being discussed or decided.
12.1.2.3. Possible solutions may include withdrawal from specific discussion and decisions or resignation from Council or a committee.
12.1.2.4. The person in potential bias or conflict may be recalled by the Chair to answer questions pertinent to either the issue or the bias or conflict.
12.1.2.5. Council or committee shall decide whether a bias or conflict is deemed to exist.
12.1.2.6. The minutes will reflect potential bias or conflict disclosure and whether the member withdrew from the meeting.
13. Disputed conflict
13.1. When a member of Council or a committee becomes aware of another's conflict of interest or bias and the existence of the conflict is in dispute, the following steps will occur:
13.1.1. Regulatory functions
The procedure for disputed conflicts on issues of bias, real or perceived, is the same as for acknowledged and potential conflicts for regulatory committees.
13.1.2. Governance functions
Step I
13.1.2.1. Council or the committee member alleged to have a bias or conflict of interest shall be informed either in writing or orally of the alleged issue and the identity of the complaining party.
13.1.2.2. The person against whom the complaint was made may request the complaint in writing.
13.1.2.3. The person in disputed bias or conflict must refrain from attempting to exert personal influence in connection with the issue being discussed or decided.
13.1.2.4. Possible solutions may include withdrawal from specific discussions and decisions or resignation from a committee or Council. If not resolved, the matter proceeds to Step II.
Step II
13.1.2.5. The member who is alleged to have a bias or conflict of interest shall be allowed to present personal views of the alleged violation.
13.1.2.6. The complaining person and the respondent member shall absent themselves from any vote on whether a bias or conflict of interest exists and/or the appropriate censure.
13.1.2.7. The complaining person and the respondent member may be recalled to answer questions pertinent to the issue, the bias or conflict.
13.1.2.8. Resolution of the issue will be determined by the governance committee involved.
13.1.2.9. The minutes will reflect bias or conflict disclosure and whether the member withdrew from the meeting.
14. General
14.1. The Protocol shall be reviewed and revised on a triennial basis or sooner as needed.