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COVID-19: Practice resources
This page provides information about many COVID-19-related nursing 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 care may be compromised, including identifying strategies to prepare for, reduce and resolve situations that may leave patients without the nursing services they need.
- Take any reasonably necessary measure, with respect to work deployment and staffing, to respond to, prevent and alleviate the outbreak of COVID-19. This is according to Regulation 74/20 of the Emergency Management and Civil Protection Act. This order of the Ontario government relates to deployment and staffing. The order overrides certain aspects of CNO practice standards and guidelines, such as those relating to work assignments and work hours in CNO’s practice guideline, Refusing Assignments and Discontinuing Nursing Services.
- Nurses remain accountable to practice in accordance with CNO standards and guidelines during the pandemic. However, if there is conflict between the requirements under the Ontario government emergency order and a CNO practice standard or guideline, then the government’s emergency order takes precedence while in effect.
As of April 20, 2020
The goal of these emergency 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.
Requirements and timelines:
- By 5 p.m. on April 17, 2020, any nurse who works in a LTC home must have notified their employers (health service providers or retirement homes) that they are subject to this order.
- By 9 a.m. on April 20, 2020, any nurse working in a retirement home must have notified their employers (health service providers, other LTC homes or retirement homes) that they are subject to this order.
- Beginning April 22, 2020, nurses can work for only one LTC employer or retirement home employer, while the emergency orders are in effect.
For more information:
- Emergency Order Limiting Work to a Single Long-Term Care Home
- Emergency Order Limiting Work to a Single Retirement Home
- Guidance for Long-Term Care
- Ministry of Health and Long-Term Care COVID Action Plan: Long-Term Care Homes
The Office of the Chief Coroner (OCC) has a new temporary process for managing all deaths in long-term care (LTC) settings during the COVID-19 pandemic. As an RN or RPN, you may be required to work individually or as part of a team to manage a resident’s death, and to complete and submit a Managing Resident Death Report (MRDR) to the OCC. Since as an RN/RPN you do not have the authority to certify death, you must consult with the attending physician or NP for guidance on completing the report. The OCC will certify all deaths in LTC using the information provided on the MRDR and issue the Medical Death Certificate.
This new process is within RNs and RPN’s scope of practice when you consult the attending physician or NP and document the following information in the patient’s permanent record (CNO Documentation standard):
- clearly indicate the name of the physician or NP you consulted with for information and guidance on completing the MRDR
- indicate that you completed the MRDR acting as the designated recorder for the physician or NP
- sign the documentation with your credentials.
It is also important to consider the other elements that influence your scope of practice, including your knowledge, skill, and judgement and practice setting supports (for example, employer policies).
For more information
If you have questions about the new process, contact the OCC directly:
1-833-915-0868 (Toll Free)
647-792-0440 (Local – Toronto)
- Managing Resident Deaths Report Form – LTC Homes
- Managing Resident Deaths in Long-Term Care (LTC): Change in OCC hours of operation
- QA managing resident deaths in LTC sector
- Documentation practice standard
- Ask Practice: Who can certify death?
- Ask Practice: Can an RN or RPN pronounce death when death has occurred?
Information on PPE
- 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. Continue to 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.
- We know the current environment is stressful for many of you, and we thank you for your efforts to support safe patient care. If you have concerns, speak to the broader health care team to discuss strategies on how to encourage 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.
Deciding whether or not to refuse an assignment and discontinue nursing services creates an ethical dilemma for nurses. It creates conflict between your professional obligations to patients and your concerns about personal and patient safety.
Nurses’ primary accountability is to patients. In deciding whether to provide care in a particular situation, you should exercise your professional judgment and follow an ethical decision-making process. As a nurse, you are accountable for your actions and decisions.
When deciding whether or not 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 and 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 or a 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 while Regulation 74/20 of the Emergency Management and Civil Protection Act regarding work deployment and staffing is in effect, such as those about work hours and shifts.
It is also important that you consider the rapidly changing environment due to COVID-19. For example, several public health directives of the Chief Medical Officer of Health and government orders under the Emergency Management and Civil Protection Act have been made that impact 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.
If concerns are brought to CNO about your decision to refuse an assignment:
Be assured that we always assess the standard of care in context. We understand that it can evolve with the dynamic nature of the pandemic, including that resources, such as PPE, may become scarce or absent. We will assess all information, including any documentation by you regarding advocating for resources and your ethical decision-making process, with consideration to the circumstances in which you are or were working during the COVID-19 pandemic.
Reassignment/redeployment to other roles or duties
- As a nurse, you must ensure you have the knowledge, skills and judgement, and the appropriate authority before performing any activity or procedure.
- If you are deployed to an area that you are not familiar with, consider:
- Performing activities you are competent to do. For example, providing basic care to free up nurses with expertise to provide more complex care.
- Your learning needs specific to the new practice setting. Are there ways to address them?
- Discussing 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.
Mental health support for nurses
During these challenging times, when nurses are being asked to do more than ever before, remember to keep your own health and well-being a priority. 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
- Ontario COVID-19 Mental Health Network: free teletherapy for COVID-19 frontline health care workers
- Your employer’s Employee Assistance Program (if applicable).
Information for Nurse Practitioners
Sending prescriptions to pharmacists by email
- Unsecured email, texting and other digital platforms are generally not acceptable ways to send prescriptions.
- Whenever feasible, NPs should use appropriate channels, such as phone, fax or secure e-prescribing systems.
- We understand this is an unusual time and if these methods of communication are not an option, 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 messaging from the Ontario College of Pharmacist and the College of Physicians and Surgeons of Ontario.
- Work with your patients to meet their needs and to get informed consent before using unsecured email to send a prescription. If the patient consents to sending this 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 new guidelines for prescribing and managing treatment with methadone and buprenorphine while adhering to social distancing and self-isolation measures. 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 impacted by changes to a patient’s treatment regime.
Hydroxychloroquine and azithromycin prescriptions
- All drugs, including hydroxychloroquine and azithromycin, should only be prescribed in alignment with current evidence.
- Until there is supporting evidence, do not prescribe hydroxychloroquine and azithromycin to prevent or treat COVID-19 as 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.
Health Canada exemptions for prescribing controlled substances
- As part of its response to the containment of 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.
Prescription forgery notifications
- The Ministry of Health has made changes to the reporting of 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:
- The reporting prescriber’s full information (name, address, phone/fax numbers, etc.)
- The areas/cities where the forgeries have been identified (if known)
- The 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 important information that needs to be included in the notice
- Attach any forged prescription pages they may have
Providing phone and video consultations to patients
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, personal email, etc.)
- 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 regarding health care workers who recently traveled. For other up-to-date information and resources on travel recommendations, please refer to:
- Government of Canada's travel advice which includes recommendations for individuals returning from travel.
- Ontario’s Ministry of Health 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.