Do mental health struggles excuse professional misconduct? Tribunal clarifies
The Civil and Administrative Tribunal of New South Wales recently dealt with a case involving a registered nurse who engaged in inappropriate relationships with vulnerable mental health patients.
This case highlighted the critical importance of maintaining professional boundaries in healthcare settings, particularly when working with vulnerable individuals.
The Tribunal's decision emphasised the serious consequences for healthcare professionals who breach these boundaries, even if they are experiencing personal difficulties themselves.
Background of the case
The case centred around a registered nurse who worked in the Adult Mental Health Unit and Psychiatric Emergency Care Centre of a hospital. The nurse had been registered since 2010 and had experience in acute mental health settings. She completed her Bachelor of Nursing in 2018 and became a registered nurse in June 2019.
The complaints against the nurse arose from allegations that she failed to maintain appropriate professional and personal boundaries with two patients. Specifically, she was accused of engaging in a sexual relationship with one patient and a friendship with another.
The Health Care Complaints Commission applied to the Tribunal for disciplinary findings and orders against the nurse under the Health Practitioner Regulation National Law (NSW). The complaint was initially made by the Mental Health Drug & Alcohol Services in September 2021.
Complaints against the healthcare worker
The Commission's application included four main complaints:
- Unsatisfactory professional conduct due to engaging in conduct significantly below the standard expected of a practitioner with equivalent training or experience.
- Unsatisfactory professional conduct for improper and unethical behaviour.
- Professional misconduct of a sufficiently serious nature to justify suspension or cancellation of registration.
- Impairment that detrimentally affects the nurse's capacity to practise nursing.
The nurse admitted to all complaints and particulars set out in the Commission's application.
Nurse’s inappropriate relationships with patients
The nurse's misconduct involved two patients, referred to as Patient A and Patient B. Both were vulnerable mental health patients with complex needs.
Patient A was a 28-year-old female with a history of post-traumatic stress disorder, borderline personality disorder, and anorexia. She was considered a high-risk inpatient requiring one-on-one care due to suicide or self-harm risks. The nurse first met Patient A in December 2020 when she was an inpatient.
With Patient A, the nurse engaged in a sexual relationship shortly after the patient's discharge from the hospital in August 2021. She also made inappropriate comments, gave gifts, and maintained extensive communication outside of professional boundaries.
The nurse sent 3,842 SMS messages and made 76 calls to Patient A between August 1 and September 17, 2021.
Patient B was a 47-year-old female with bipolar affective disorder and a history of acute relapses of mania. The nurse formed an inappropriate friendship with Patient B, including social visits and group messaging, after the patient's discharge.
"The practitioner's conduct in failing to maintain appropriate professional boundaries by engaging in inappropriate frequency of social communication with Patient A fell significantly below the standard reasonably expected of a practitioner with equivalent training or experience," the Tribunal noted.
Professional misconduct and false information
The Tribunal found that the nurse's conduct amounted to professional misconduct. This was based on the seriousness of the boundary violations and the vulnerability of the patients involved.
Additionally, the nurse provided false information to her employer and the Nursing and Midwifery Council during initial investigations. She initially denied having any personal relationship with Patient A outside of the professional nursing context. In interviews on September 10 and December 13, 2021, and at a hearing on December 20, 2021, the nurse denied or minimised her contact with Patient A.
The Tribunal emphasised the importance of honesty in disciplinary proceedings:
"Engaging with one's professional regulator and all forms of disciplinary inquiry with diligence and honesty are fundamental requirements of any professional."
Impairment and mental health considerations
The nurse was diagnosed with Major Depressive Disorder, which the Tribunal accepted as an impairment under the National Law. She had been a voluntary inpatient at a hospital for depression on three occasions between November 2021 and May 2022.
However, the Tribunal noted that there was insufficient evidence to conclude that this impairment was present at the time of the misconduct with Patients A and B.
The nurse's psychiatrist stated that the onset of her major depressive disorder in 2021 was after the boundary violation and was related to having her nursing registration suspended.
The nurse's mental health struggles were considered in the context of the disciplinary proceedings, but did not excuse her professional misconduct.
The Tribunal’s decision
The Tribunal ultimately decided to cancel the nurse's registration with a non-review period of two years. This decision was based on several factors:
- The seriousness of the boundary violations with vulnerable patients.
- The nurse's initial lack of honesty during investigations.
- Concerns about the nurse's insight into the harm caused to patients.
- The need to protect the public and maintain professional standards
The Tribunal explained its reasoning:
"Maintenance of professional boundaries is an essential element in nursing, particularly mental health nursing, and [the nurse] does not appear to have an understanding of this. To the contrary, [the nurse's] conduct demonstrated a blatant disregard for those professional boundaries and a lack of understanding or concern as to the particular vulnerability of those patients."
In concluding, the Tribunal emphasised the protective function of its decision:
"Overall, we consider a period of two years will give [the nurse] an appropriate amount of time to get the help she needs and gain insight into the effect of her conduct."
This case serves as a stark reminder of the critical importance of maintaining professional boundaries in healthcare settings, particularly when working with vulnerable patients. It also highlights the serious consequences for healthcare professionals who breach these boundaries, even if they are experiencing personal difficulties themselves.
