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COVID-19: Practice resources
Nurses and nurse employers: A new provincial order authorizes health care professionals, including nurses, to provide patient care services outside their regular scope of practice. It also enables hospitals to engage regulated health professionals from out of province.
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 understands that, more than ever, the health care system and all health care professionals are experiencing challenging and unsettling times. We understand that for nurses these challenges bring a high degree of uncertainty and stress as we experience change in ways we have never felt before. You may be concerned about being able to maintain standards of practice, particularly when mobilized to work in other areas, and 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 in the health care system during a pandemic requires continual adaptation and adjustment in nursing practice. 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 pandemic, we appreciate that nurses are always doing their best in every situation and we will assess all information with consideration to the circumstances in which nurses are working.
CNO continues to appreciate and applaud your commitment and dedication within this emergent context. We understand you are considering patient needs, public safety, and doing your very best each and every day.
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. Point-of-care tests that involve controlled acts, such as nasopharyngeal swabs, can only be performed by a health care provider who has the authority to perform it under the Regulated Health Professionals Act, 1991 (RHPA).
A nasopharyngeal swab is the controlled act of putting an instrument, hand or finger beyond the nasal passages where they normally narrow. Under the RHPA, Nurse Practitioners (NPs) are authorized to perform and order nasopharyngeal swabs. Registered Nurses (RN) and Registered Practical Nurses (RPN), however, 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.
- 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 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 that offers personal care services, they must comply with any restrictions set out by the provincial or municipal governments. We encourage nurses to refer to the provincial and municipal legislation, regulations, and guidance for additional information.
It is important for all nurses to follow Ministry of Health guidance 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 the COVID-19 spread and regional health care capacity as a whole
- Whether your workplace meets safety measures identified by the province. 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
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.
1 Nurses administering cosmetic injectables should always reflect on their practice to keep patients safe and prevent harm.
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 than ever, including working overtime, covering extra shifts and working in new practice environments, perhaps outside a nurse’s comfort zone. 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, consider the circumstances and your practice setting. Continue to work within your knowledge, skill and judgement. 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 as well as consider the context of the situation.
- 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.
- Recognize that health care providers, including nurses are being asked to be more flexible and adaptable than ever due to the pressure on the health care system.
- 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.
- Find ways to address your learning needs specific to the new practice setting.
- Seek role clarity, and discuss your competency and expected responsibilities with your employer.
- Seek advice, collaborate and support your 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 exemptions for COVID-19 vaccine
CNO recognizes that NPs may be asked to provide patients medical exemptions for the COVID-19 vaccine.
NPs need to be aware that there are very few acceptable reasons to issue a medical exemption for the COVID-19 vaccine, for example:
- the patient has a confirmed severe allergy or an adverse (anaphylactic) reaction to a previous COVID-19 vaccine or to any of its components that cannot be mitigated
- the patient has a diagnosed episode of myocarditis/pericarditis after receipt of an mRNA vaccine1
NPs must clearly document any medical exemption including the reason the patient cannot be vaccinated and the effective time period for the medical reason (unlimited or time-limited).
You can find additional information in the Ministry of Health’s Medical Exemptions to COVID-19 guidance document.
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.
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:
- 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.