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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.
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 …
- Take action when patient safety may be compromised. This includes identifying strategies to prepare for, reduce and resolve situations that may leave patients without the nursing services they need.
- Role model and follow public health directives that keep patients safe.
- Self-reflect, determine learning needs and actively updating knowledge and skills to maintain continued competence.
- 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.
If you have questions about your accountabilities when caring for patients affected with COVID-19, please complete and submit a practice support form.
The Ministry of Health has created an exemption in the Laboratory and Specimen Collection Centre Licensing Act, 1990 to allow any person to perform a COVID-19 point-of-care test. Anyone performing a test must follow the product label instructions and/or receive training to make sure they administer the test correctly.
Examples of point-of-care tests include, nasal or throat swabs or nasopharyngeal swabs. Nasopharyngeal swabs fall under the controlled act of putting an instrument, hand or finger beyond the nasal passages where they normally narrow. Not everyone is authorized to perform this controlled act.
Nurse Practitioners (NPs) are authorized to perform and order nasopharyngeal swabs. Registered Nurses (RN) and Registered Practical Nurses (RPN) will need an order or medical directive from an authorized provider (i.e. physician or NP) to perform nasopharyngeal swabs or any other point-of-care test that involves a controlled act. RNs and RPNs can also delegate this controlled act if they have an order.
Changes have not been made to the Regulated Health Professionals Act, 1991, to address the authority needed to perform the controlled act component of these point-of-care tests.
- COVID-19 Provincial Testing Guidance
- COVID-19 Guidance: Considerations for Antigen Point-of-Care Testing
- COVID-19 Quick Reference Public Health Guidance on Testing and Clearance
- COVID-19 Guidance: Considerations for Privately Initiated Testing
- Point-of-Care Testing Use Case Guidance
- Rapid Antigen Testing FAQ
- Appendix 9: Management of Individuals with Point-of-Care Results
The COVID-19 pandemic is constantly evolving, and nurses need to monitor and adapt to changes in the health care environment. Regulated health professionals, including nurses, are permitted to provide services in lockdown and other ‘zone’ designated areas as established by provincial legislation, regulations, and guidance.
Nurses must consider whether any of the services they provide, or that are provided as part of their practice setting, need to be temporarily restricted in accordance with the provincial direction. If a nurse provides services in a clinic providing personal care services, they must comply with any restrictions set out by the provincial zone designations. We encourage nurses to refer to the provincial legislation, regulations, and guidance for additional information.
It is important for all nurses to follow Ministry of Health guidance (see Directive # 2) when determining which nursing services they can provide to help reduce the risk of exposure to COVID-19. Based on the best available evidence, consider:
- Whether you can safely provide the service remotely (online, by telephone, or other virtual means)
- 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
- Whether your workplace meets safety measures identified by the province Enhancing Public Health and Workplace Safety Measures in the Provincewide Shutdown
It is up to public health authorities to determine if an individual is violating specific legislation, regulations, and/or public health directives related to and during the pandemic.
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.
We recognize nurses are being asked to do more, including working overtime or covering extra shifts. Nurses may be concerned that declining work could be considered abandonment.
First, it is important to remember how CNO defines abandonment.
Abandonment occurs when a nurse has accepted an assignment and discontinues care without:
- the patient requesting the discontinuation.
- arranging a suitable alternative or replacement service; or
- allowing a reasonable opportunity for alternative or replacement services to be provided.
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.
For additional information please see:
- Refusing Assignments and Discontinuing Nursing Services. practice guideline. 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
- Ask Practice FAQ: Risking fatigue by working long hours
- 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
Starting Feb. 26, 2021, the Ministry of Government and Consumer Services expanded the use of the electronic Medical Certificate of Death (eMCOD) to include physicians and NPs providing palliative care outside of a hospital setting (e.g., patient’s place of residence, hospice, long-term care home).
This is not mandatory but NPs and physicians have the option to use the eMCOD to electronically securely complete, certify and submit the form directly to the funeral home.
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
- Generally, unsecured email, texting and other digital platforms are 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, which may include 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 COVID-19 Pandemic is constantly evolving, requiring frequent regulatory changes to the the Emergency Management and Civil Protection Act.
Below are some key changes that may impact your practice. Work with your employer to determine which emergency orders may apply to your practice.
Visit the Ontario Ministry of Health website for a complete list of orders, directives and other resources.
Redeployment for Local Health Integration Networks and Ontario Health
Effective Friday, April 9, 2021 until Friday, April 23, 2021, local health integration networks and Ontario health are authorized to deploy staff to respond to, prevent an alleviate the COVID-19 outbreak.
This regulation change supports the redeployment of health care professionals and other workers currently working in Ontario Health and Home and Community Care Support services organizations to hospitals.
For more information:
Transferring Hospital Patients Without Consent
Effective Friday, April 9, 2021 until Friday, April 23, 2021, hospitals can transfer patients without consent to alternate hospital sites (if necessary).
This regulation will provide hospitals with greater flexibility to transfer patients to alternate hospital sites in situations where hospital’s resources are at significant risk of becoming overwhelmed.
For more information:
- Regulation 272/21: Transfer of Hospital Patients
- See the Ontario Hospitals Association FAQ on the transfer of patients due to major surge during covid-19 developed in partnership with Ontario Health
- See the Ontario Hospitals Association’s website for information on Patient Transfers
Limiting Work to a Single Long-Term Care or Retirement Home
Beginning April 22, 2020, nurses can work for only one long-term care (LTC) employer or retirement home employer.
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.
For more information:
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
- CNO: Supporting nurses in self-care and self-care fact sheet
- 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.