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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.
In July 2020, Ontario entered the recovery phase with the Reopening Ontario (A Flexible Response to COVID-19) Act, 2020. However, some public health measures and restrictions have recently been enacted because of an increase of COVID-19 cases. 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 they 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.
- Virus respiratory kit (Nasopharyngeal) specimen collection instructions
- Public Health Ontario COVID-19 Health Care resource
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.
It is also important that you consider the rapidly changing environment due to COVID-19. For example, several public health directives from the Chief Medical Officer of Health and government orders are still in effect under the Reopening Ontario (A Flexible Response to COVID-19) Act, 2020. These affect legislation, health service providers and collective agreements. 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.
- Nurses must take reasonable necessary measures to respond to, prevent and alleviate the outbreak of COVID-19. 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.
As an NP, the provincial Vital Statistics Act gives you the authority to complete a Medical Certificate of Death (Form 16) when:
- you had primary responsibility for the deceased’s care,
- the death was expected,
- a medical practitioner has documented medical diagnosis of a terminal disease
- there was a predictable pattern of decline, and
- there were no unexpected events or complications.
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.
Prescribing methadone and buprenorphine
- For NPs who treat opioid addiction, the Centre for Addiction and Mental Health has guidelines for prescribing and managing treatment with methadone and buprenorphine while social distancing and self-isolating. These guidelines “address office visits, remote visits, carry doses and frequency of urine drug testing.”
- We encourage NPs to work with pharmacists and others on the care team who may be affected by changes to a patient’s treatment regime.
Hydroxychloroquine and azithromycin prescriptions
- Only prescribe drugs, including hydroxychloroquine and azithromycin, in alignment with current evidence.
- Until there is supporting evidence, do not prescribe hydroxychloroquine and azithromycin to prevent or treat COVID-19. This is leading to drug shortages and may compromise care for other patients.
- Nurses have an obligation to ensure that their practice and any treatment they prescribe is evidence-informed.
- OPA, OMA and RNAO’s Joint statement on the use of hydroxychloroquine and azithromycin for COVID-19 Prophylaxis
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, with the following information in a letter on the prescriber’s clinical or hospital letterhead:
- Reporting prescriber’s full information (name, address, phone/fax numbers, etc.)
- Areas/cities where the forgeries have been identified (if known)
- Names of the drugs mentioned on the forgeries (if known)
- Details about how the prescriber would like the pharmacist to handle the situation, such as not dispensing, or calling the clinic directly
- Any other relevant information
They will also attach any forged prescription pages they have.
- 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)
- We know the current environment is stressful, and we thank you for your efforts to support safe patient care. If you have concerns, engage with the broader health care team to discuss strategies encouraging the appropriate use of PPE.
- 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.
On March 19, 2020, the Chief Medical Officer of Health issued a statement about health care workers who had recently traveled. For other up-to-date information and resources on travel recommendations, refer to:
- Government of Canada's travel advice which includes recommendations for individuals returning from travel.
- Sector specific guidance documents
- We encourage you to work with your employer to support policies that align with the latest recommendations and evidence.
We encourage you to work with your employer to support policies that align with the latest recommendations and evidence.