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COVID-19: Practice resources
This page provides answers to many COVID-19-related practice questions we have received. Please use the search function to locate other information that may be relevant to you, or browse the Standards & Learning section of this website. In addition, CNO’s Practice Support staff can help with your nursing practice-related inquires.
Ontario has moved to a regional approach and maintaining the provincial shutdown under the Emergency Management and Civil Protection Act.
Regions will transition from the shutdown measures to a revised COVID-19 Response Framework: Keeping Ontario Safe and Open.
See the provincial status on COVID-19 for current updates and information.
COVID-19 update: Standard of care and nurses’ accountabilities
CNO acknowledges that it is an unprecedented time in health care. We understand that you are stressed and may be concerned about being able to maintain standards of nursing practice. We want to assure you that the standard of care is always considered in context. The standard of care can evolve with the dynamic nature of the pandemic, including that resources may become scarce or absent.
Working within a quickly evolving environment can be challenging and distressing. In this situation, it will be important to make reasonable efforts to comply with any direction from the Chief Medical Officer of Health and your workplace policies and procedures pertaining to COVID-19 management. While CNO will continue to receive complaints and reports during the COVID-19 pandemic, we will assess all information with consideration to the circumstances in which nurses are working.
All nurses are accountable to …
- Role model and follow public health directives that keep patients safe.
- Take action when patient care may be compromised. This includes identifying strategies to prepare for, reduce and resolve situations that may leave patients without the nursing services they need.
- Practice according to CNO's standards and guidelines during the pandemic. However, if there is conflict between the Ontario government reopening response and a CNO practice standard or guideline, then you should follow the government’s order while in effect.
- Self-reflect to ensure you are providing safe and quality care to patients.
- Determine learning needs and actively updating knowledge and skills to maintain continued competence.
If you have questions about your accountabilities when caring for patients affected with COVID-19, please complete and submit a practice support form.
- Nurses supporting public health measures
- Virus respiratory kit (Nasopharyngeal) specimen collection instructions
- Public Health Ontario COVID-19 Health Care resource
- Regulation changes to support COVID-19 vaccine administration
To help contain the risk of exposure to COVID-19, The Ministry of Health encourages limiting the number of in-person health care visits. In addition, some services provided by nurses will need to comply with the Ontario government’s COVID-19 Response Framework.
To determine whether you are permitted to provide a nursing service during the pandemic, first use best clinical evidence to consider if you can safely provide the service remotely (online, by telephone, or other virtual means). Consider:
- the risks and benefits to the patient of providing in-person services, and if the benefits outweigh the risks
- the prevalence and incidence of COVID-19 in your geographical area and how providing in-person services may affect COVID-19 spread and regional health care capacity as a whole.
If you are unable to provide the service remotely, you next need to assess if it is a health service that is done to treat, manage, mitigate, or improve the condition of a patient with a documented diagnosis. Therefore all nurses providing services for cosmetic purposes only, must comply with the requirements from the ministry related to personal care services.
If you determine that in-person visits are necessary and the service complies with the COVID-19 Response Framework, you must adhere to the requirements and guiding principles in Directive #2 for Health Care Providers. You should also:
- apply the “Hierarchy of Hazard Controls” (COVID-19 Operational Requirements: Health Sector Restart) in your practice setting in order to protect patients from harm
- if removal of face masks is required for the service, determine the precautions taken to reduce and prevent risk of exposure and transmission of infection. To ensure you are able to protect yourself, colleagues and patients from harm, refer to pages 3-13 of the COVID-19 Operational Requirements: Health Sector Restart.
As nurses, your primary accountability is to patients. When deciding whether to provide care in a particular situation, exercise your professional judgment and follow an ethical decision-making process.
When deciding whether to refuse an assignment or discontinue nursing services, you are accountable to:
- Assess the potential for harm to yourself and your patients, considering the circumstances and your practice setting. This includes completing a point-of-care risk assessment and stating any personal health concerns you have.
- Use a variety of evidence-based sources to inform your decision making. Consider the best available information, including guidance from Public Health Ontario as well as a consultation with your colleagues and health care team.
- Communicate your concerns to your employer. You must communicate to your employer that you are considering refusing an assignment and why, and you must consider your employer’s response. If, after doing so, you choose to refuse the assignment, ensure that another caregiver is available, or allow a reasonable opportunity for alternate services/replacement to be found.
- Document your decision-making process, actions and decision.
More information to consider in your decision-making process:
The decision-making process to resolve this ethical dilemma is outlined in more detail in the practice guideline, Refusing Assignments and Discontinuing Nursing Services. Note that during the COVID-19 pandemic, aspects of this guideline do not apply because other orders under the Reopening Ontario (A Flexible Response to COVID-19) Act, 2020 may override the practice guideline.
Nurses are accountable for knowing about and understanding these changes and the impact they have on nursing practice. See the Ministry of Health's web page to know which orders and directives are currently in effect.
If CNO receives concerns about your decision to refuse an assignment:
Be assured that we always assess the standard of care in context. We understand that the standard of care can evolve with the nature of the pandemic, including that resources, such as PPE, may be scarce or absent.
We will consider the circumstances in which you are/were working during the COVID-19 pandemic when we assess all information about the concern. This includes any documentation you make about advocating for resources and your ethical decision-making process.
- As a nurse, you must ensure you have the knowledge, skill and judgment, and the appropriate authority before performing any activity or procedure.
- If you are deployed to an area that you are not familiar with:
- Perform activities you are competent to do. For example, provide basic care to free up nurses with expertise to provide more complex care.
- Find ways to address your learning needs specific to the new practice setting.
- Discuss your competency and expected responsibilities with your employer.
- Seek advice and collaborate with the health care team to uphold safe patient care and work together with other health care experts to improve your patients’ care.
- For more information on orders related to work deployment and staffing, search for “work deployment” under the Ministry of Health resource web page.
NPs issuing medical certificates of death
As a temporary measure during the COVID-19 pandemic, an NPs electronic signature will be accepted on the Medical Certificate of Death. However, it is still recommended that you manually sign the Medical Certificate of Death after it’s printed. Once completed, you will need to provide the funeral director with a printed copy of the document.
Before signing a Medical Certificate of Death, you must read and follow the instructions in the Handbook on Medical Certification of Death. The expectations outlined in the handbook apply in all circumstances, including deaths that have occurred in hospital.
Emailing prescriptions to pharmacists
- Unsecured email, texting and other digital platforms are generally not acceptable ways to send prescriptions.
- Whenever feasible, NPs should use channels such as phone, fax or secure e-prescribing systems.
- If the methods of communication listed above are not available, work with the pharmacist to identify the best way to meet patient needs, such as unsecured email. The pharmacist needs to assure any prescription is valid. Unsecured email cannot be used for drugs listed under the Narcotic Control Regulations. For more information, see information from the Ontario College of Pharmacist and the College of Physicians and Surgeons of Ontario.
- Work with your patients to meet their needs and get informed consent before using unsecured email to send a prescription. If the patient consents to you sending an unsecured prescription email, ensure you are only sending it to the pharmacy of the patient’s choosing. For guidance, see Communicating Personal Health Information by Email from the Information and Privacy Commissioner of Ontario.
Working with Patients with Problematic Substance Use and COVID-19
- For NPs who treat patients with problematic substance use, refer to the Health Canada Substance Use and COVID-19 Toolkit
Health Canada exemptions for prescribing controlled substances
- As part of its response to contain COVID-19, Health Canada is issuing exemptions for prescriptions of controlled substances under the Controlled Drugs and Substances Act.
- NPs can now temporarily issue verbal orders (for example, over the phone) to extend or refill a prescription to a patient under your treatment.
- Health Canada Controlled Drug and Substances Act exemptions
- Health Canada Controlled Drug and Substances Act exemption FAQs
Prescription forgery notifications
- The Ministry of Health has made changes to reporting forged prescriptions during the COVID-19 pandemic.
- If a pharmacist suspects a forgery, they will ask the prescriber to notify the Ministry’s Drug Programs Delivery Branch by email, instead of fax. Otherwise, prescriber responsibilities remain the same.
- For information on the types of PPE to use and when, refer to the chart on page 5 of Public Health Ontario’s PPE recommendations. Monitor this resource regularly, as recommendations may change.
- Assess the patient, situation and the environment for the appropriate use of PPE; not every patient situation may require the same precautions.
- Consider risk of transmission in various areas of your environment (e.g. staff-only areas as well as patient care areas)
- The Ontario Government has outlined the steps health care workers and employers can take to ensure the proper use and supply of PPE. For more information, see Directive #5.
The goal of these orders is to contain and reduce the number of COVID-19 outbreaks in long-term care (LTC) and retirement homes.
The orders apply to:
- LTC and retirement home staff working in other LTC homes, retirement homes or health care facilities.
- Beginning April 22, 2020, nurses can work for only one LTC employer or retirement home employer.
For more information:
- Regulation 146/20: Limiting work to a single long-term care home
- Regulation 158/20: Limiting work to a single retirement home
- Guidance for Long-Term Care Homes and Retirement Homes
- Ministry of Health and Long-Term Care COVID Action Plan: Long-Term Care Homes
During these challenging times, nurses are being asked to do more than ever before. That’s why it is important to remember to keep your own health and well-being a priority too. We know this is easier said than done when working at a rapid pace. The following resources offer mental health support:
- Mental Health Commission of Canada: Free online crisis training for essential workers during COVID-19
- Canadian Mental Health Association: Information, resources and tips for health care workers dealing with COVID-19
- Government of Ontario: Support for health care workers
- CAMH: Mental health and COVID-19 resources for health care workers
- Your employer’s Employee Assistance Program (if applicable).
Nurses providing care through telepractice are accountable for:
- Adhering to the principles outlined in the Telepractice guideline.
- Clearly communicating to patients the details of the care they intend to provide, including communicating the limits of any care provided through telepractice. Virtual care is not a substitute for attending an Emergency Department if urgent care is needed.
- Working with employers and broader health care teams to identify strategies to mitigate risks for delivering virtual care and to identify the best way to meet patient needs.
- Communicating personal health information through appropriate channels, such as the telephone. Unsecured digital platforms, email and texting are generally not acceptable ways to communicate personal health information.
During the pandemic, nurses may be using new technologies to support patient care, and should:
- continue to use their professional judgement while providing virtual care
- inform their patients that a particular method of communication may not be secure (e.g. video conferencing technologies or personal email)
- receive consent before proceeding with care.
For guidance, see Communicating Personal Health Information by Email from the Information and Privacy Commissioner of Ontario.