GP 3 - Safe Disclosure (Whistleblower) Policy
| Policy Number: | GP 3 | Approve Date: | June 2025 |
| Review Frequency: | Triennial | *May be reviewed earlier as required | |
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- Safe Disclosure “Whistleblowing”
1.1. The College of Registered Nurses of Alberta’s (CRNA’s) Council is dedicated to the principles of strong corporate governance, combined with the highest ethical standards in all its activities. The reputation for honesty and integrity is reflected in the way the CRNA conducts its business. The CRNA commits to acting immediately when it receives a disclosure of a concern and expects that all the CRNA community (Council members, Council Committee Members and Employees) share in this commitment.
1.2. The CRNA aims to protect the integrity of its organization, and any individual(s) acting to support that aim, by exposing any suspected wrongdoing within the CRNA through this policy. Due to the involvement of employees in the CRNA’s operations, they are often in the best position to observe and disclose any abuse of trust. In keeping with the CRNA’s commitment to accountability and transparency, this policy provides protection for such “whistleblowers” by enabling safe disclosure and prohibiting reprisals against them.
1.3. The CRNA seeks to support an organizational environment where any individual(s) who observes or has knowledge of a possible abuse of authority and/or violation of policy is empowered to disclose their concerns with this policy. The CRNA encourages members of its community to disclose circumstances that may put the organization at risk for wrongdoing (e.g., lack of appropriate oversight mechanism, absence of checks and balances, etc.)
1.4. This policy protects any individual(s) who submits a disclosure, in good faith, or participates in an investigation, from any retaliation. - Purpose
2.1. This policy is a control to further safeguard the integrity of the CRNA, utilizing transparent and accessible processes for receiving and acting on any disclosure of suspected wrongdoing.
2.2. This policy encourages and enables individual(s) to disclose concerns within the CRNA, rather than seeking resolution outside the College. Accordingly, the CRNA does not permit retaliation of any kind against any individual for concerns submitted that are made in good faith. It is important that individual(s) feel safe to disclose a concern.
2.3. This policy enables members of the CRNA community to disclose concerns about the behaviours or actions of members of the CRNA community. Guidance about how to disclose a concern is outlined in section 8 (Disclosing a concern). - Objectivity, Fair Process and Confidentiality
3.1. The CRNA will treat all individuals involved in disclosures or investigations fairly, consistently and objectively, regardless of their position or tenure. Disclosures and investigations will be handled with objectivity, confidentiality and sensitivity. Details will be shared only with those who have a legitimate need to know. While every effort will be made to maintain the whistleblower's anonymity and confidentiality, it cannot be guaranteed as other parties might ascertain their identity and/or it may be necessary to disclose identifying information as part of an investigation.
- No Retaliation
4.1. The CRNA prohibits any consequence or retaliation against any individual(s) who discloses a concern under this policy if they:
• disclose the information in good faith;
• believe it to be substantially true;
• do not act maliciously or make false allegations; and
• do not seek any personal or financial gain.
4.2. The CRNA encourages any individual(s) who witnesses or experiences retaliatory behavior in response to such disclosures to report this behavior as you would report a concern see section 8).
4.3. There may be consequences for disclosures made for reasons beyond what could be considered “good faith,” for example, if the individual is aware that the disclosed information is false or is made with intent to harm another.
- Scope
5.1. This policy applies to all members of Council, Council Committees and the CEO & Registrar. Any individual in the CRNA Community has the right to disclose a concern and have the protections provided to them through this policy. This policy is not intended to serve as a method for dealing with employee matters that do not involve the CEO, nor as a method for appealing any regulatory decision made by CRNA staff or committees.
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Roles and Responsibilities
• Determine that the disclosure falls under the scope of this policy (see sections 5.1 9.1 and appendix A) and if it is within FAC’s scope:
6.1. Chair of Finance and Audit Committee (FAC Chair) or, as appropriate, an alternate Councillor selected by FAC or Council:
- Call a meeting of the FAC to assess and determine next steps.
• Where the disclosure does not fall within the scope of this policy, redirect it to the CEO & Registrar via the third party.
• Communicate the progress or outcomes of a disclosure with Council and others as appropriate (recognizing that Council must maintain objectivity in the event Council members had to be involved in a regulatory appeal in connection with a disclosure).
• Enable and reinforce the principles of objectivity, fair process and confidentiality.
6.2. Finance and Audit Committee (the Committee) or, as appropriate, an alternate Committee as selected by Council:
• Conduct an initial validation of the disclosure received.
• Action and/or dismiss disclosures as appropriate.
• Select an individual from among the Committee or Council to oversee the investigation (investigation liaison).
• Where there is evidence of wronging, bring recommendation(s) to Leadership Review and Governance Committee (LRGC) and/or Council, as appropriate.
• Does not act as an appeal body for any regulatory decision.
6.3. Investigation Liaison (appointed by the Committee):
• In collaboration with the third-party service, plans and executes an investigation.
• Acts as a liaison between the third-party service and the CRNA to support a timely and effective investigation.
• Keep the Committee informed of the progress of any investigation.
• Engage members of Council, management, staff and/or CRNA legal counsel, as appropriate, in the investigation.
• Provide an investigation report and recommendation(s) for consideration by the Committee.
6.4. Leadership Review and Governance Committee (LRGC):
• Where there is a finding of wrongdoing by the CEO, recommend to Council and carry out and/or monitor any disciplinary action.
6.5. Council:
• Where there is a finding of wrongdoing by a Council or Committee member, carry out and/or monitor any disciplinary action.
6.6. Councillors:
• Where there is a finding of wrongdoing by a Council or Committee member, carry out and/or monitor any disciplinary action.
6.7. Third-party (the organization contracted to assist FAC through the receipt and resolution of a disclosure). As directed by FAC and/or the Investigation Liaison:
• Receive and validate disclosures.
• Provide guidance or recommendations through the validation and determining next steps following the receipt of a disclosure, as requested.
• Conduct investigations.
• As directed by Council, monitor and report on disciplinary actions
6.8. Chief Executive Officer (CEO) & Registrar or other senior leadership team members:
• Provide access to employees or resources as required to support an investigation.
• Accountable for decision making and remediation or resolution where an employee has been cited in a disclosure where wrongdoing has been confirmed.
6.9. Corporate Secretary or designated individual will provide support through:
• Coordinating meetings and/or interviews.
• Providing administrative support, coordinating, and/or obtaining legal advice, as necessary.
• Taking meeting minutes
• Ensuring completion of Committee and Council record-keeping processes.
6.10. SFO & Executive Director, People, Planning and Performance Measurement:
• Ensure investigations follow and align with all human resources-related processes as appropriate. - What is a Concern?
7.1. Members of the CRNA community have a responsibility to disclose any concerns of suspected wrongdoing. Concerns of suspected wrongdoing may include discrimination, harassment, abuse of authority, bullying, breach of trust, confidentiality, fiduciary duty and/or the integrity of financial reporting or systems.
- Disclosing a Concern
8.1. Any individual(s) may submit a disclosure, in good faith, regarding any event within the scope of this policy. All such disclosures shall be submitted through Alias Solutions, Inc. intake process through:
Online submission form
or by calling: 1-833-834-1029 - Acting on a Disclosure
9.1. Accountability for responding to and acting on a disclosure is outlined in Appendix A.9.2. The FAC Chair confirms if the disclosure falls within the scope of this policy.
9.3. If the disclosure falls, or it is not clear that it falls, within the scope of this policy, the FAC Chair shall call a meeting of the Committee for the purpose of reviewing a disclosure and determine next steps or actions to be taken. This meeting shall be called:
• Immediately, where the subject matter of the disclosure indicates:
- A serious or imminent risk to public health or the organization;
- A high or imminent risk of evidence being lost or destroyed;
- A high or imminent risk of reprisal for the discloser; and/or
- The alleged wrongdoing has not occurred and there is an opportunity to intervene before it does.
Notwithstanding the foregoing, the FAC chair may take interim measure(s), as deemed appropriate, prior to the Committee meeting to address any imminent risk identified above, only to the extent that such interim measure(s) is deemed necessary to address such imminent risk prior to the Committee meeting.• Within 14 days where the risk to public health, the organization or the disclosure is not imminent.
9.4. At this meeting, the Committee will determine action or next steps to be taken including and not limited to the following:
• Dismissal prior to investigation may be acceptable if one or more of the following are true:
- Has already been or is being appropriately investigated.
- Does not meet the threshold of wrongdoing as defined in the policy. (See 7.0 What is a Concern in the policy)
- Investigation would serve no useful purpose or could not be reasonably addressed given the length of time that has passed between the date of the wrongdoing and the date of disclosure.
- Is considered vexatious and in bad faith.
• Transfer the matter to the CEO as the Committee has determined the disclosure:
- Cites only an employee(s) who is not the CEO & Registrar.
- Is the consequence of regulatory decision.
• Immediate resolution in the form of an alternative dispute resolution (ADR).
• Engage or consult with CRNA legal counsel, law enforcement, or other expertise as appropriate.
• Determine provisional or interim measures, if any, to be implemented pending resolution.
• Investigate the matter to determine if wrongdoing has occurred.
• Or any other measure that the Committee deems appropriate and/or necessary. - Investigate a Disclosure
10.1. If the Committee decides to investigate a disclosure, they shall appoint an individual from the Committee, who is not the Chair, to manage the investigation (investigation liaison). In making such determination, Committee may consult with the Council Chair or another member of Council.
10.2. The investigation liaison will lead the investigation through:
• Providing the third party with guidance and support through an investigation.
• Inform the Committee of progress of any investigation.
• Seek direction from the Committee as appropriate.
• Seek legal advice from CRNA legal counsel, as appropriate.
• At the conclusion of an investigation, provide an investigation report and recommendations for the Committee’s consideration. - Remediation or Resolution and Monitoring
11.1. The Committee and the individuals involved may choose to resolve a matter through an alternative dispute resolution which may not require Council or LRGC oversight.
11.2. Where the investigation report concludes there is no evidence or findings of wrongdoing, the Committee may dismiss the matter without further action.
11.3. The Committee may recommend any remedial or disciplinary action to the LRGC or Council, as appropriate.
11.4. Remedial and/or disciplinary action for findings of wrongdoing may involve a range of actions from a formal written reprimand to termination of employment or removal from Council and/or Committee.
11.5. Remedial and disciplinary action for findings of wrongdoing by a staff member who is not the CEO & Registrar fall under the scope of the operational policies.
11.6. The Committee, LRGC or Council may involve a third party to assist with monitoring any discipline imposed upon an individual. - Communication
12.1. The Committee may restrict communication about a disclosure if sharing it with the broader Council risks compromising objectivity, fair process or confidentiality.
12.2. The FAC Chair ensures action of all communications of findings and outcomes of any disclosure within the scope of this policy. - Reporting
13.1. The Committee, through its quarterly report to Council, shall report, at minimum annually, to Council on this policy and their activities under it. - Retaining Records
14.1. Meeting minutes, actions, investigations, reporting and decision making regarding any disclosures are a record of Council and the CRNA and shall be retained as outlined by the College’s Record Management policies.
14.2. The Corporate Secretary shall retain records regarding disclosures submitted under this policy and actioned by the Committee regardless of validity or findings of wrongdoing and these shall be kept in accordance with the CRNA's record retention policy and applicable law.
14.3. Records or directions may be provided to the SFO & Executive Director, People, Planning and Performance Measurement, to be actioned or retained in an individual(s) employee record, as appropriate. - Amendments
15.1. The Committee will review the policy, at minimum, tri-annually and bring forward suggested revisions to Council. The Committee may choose to review the policy for improvements following the resolution of a disclosure.
- Safe Disclosure “Whistleblowing”
Appendix A
- Oversight of a Disclosure
1.1. Responsibility for responding to and acting on a disclosure is outlined below:
• The CEO & Registrar is responsible for acting on and investigating all disclosures or concerns submitted under the policy where the cited individual(s) is an employee of the CRNA and not the CEO & Registrar. If appropriate, the CEO may escalate a disclosure to the Committee to address the matter to reinforce transparency and objectivity of an investigation. The CEO retains accountability for decision making and remediation or resolution in these matters.
• In the case where the CEO & Registrar, a member of Council, or a member of a Regulatory Committee is cited in the disclosure, the Committee is responsible for overseeing any investigation and making recommendations for remediation. If a disclosure also cites CRNA staff in addition to the CEO and/or a member(s) of Council or a Committee, the Committee may treat the disclosure as a single event. (subject to 11.4 for remediation and/or discipline of a staff member.)
• The Committee is not an appeal body for any regulatory decision. In the event a disclosure is the consequence of regulatory decision, the disclosure shall be forwarded to the CEO & Registrar for actioning by the appropriate individual or committee.
