What You Need to Know

You are accountable for making decisions that are in the best interests of your clients and for protecting them from harm. You are also accountable for protecting clients from infection risks. You can do this by:

• applying hand hygiene principles
• choosing appropriate measures to prevent and control infection transmission such as wearing personal protective equipment (PPE)
• understanding your workplace’s organizational policies about infection prevention and control
• participating in any training or education sessions on infection prevention and control
• consulting NANB’s Infection Prevention and Control Fact Sheet
• working with your employer to develop new policies as needed
• using sources of evidence to inform your practice (consult “Important Resources” section)

We encourage you to work collaboratively with your employer to recognize real or potential threats, review relevant organizational policies, and if needed, develop policies and guidelines specific to your practice setting.

RNs and NPs are expected to understand and apply precautionary measures to minimize the risk of infecting themselves, colleagues, clients and others. To learn more about these topics, refer to the Government of New Brunswick Office of the Chief Medical Officer of Health (Public Health).

TIPS FOR NURSES TO HELP LIMIT THE SPREAD OF COVID-19 AT HOME

The College of Nurses of Ontario granted permission to NANB to adapt content from the Novel Coronavirus (COVID-19) section of their website.

When your professional obligation to a client conflicts with your personal obligations, you have an accountability to demonstrate leadership and determine the best possible solution while still making decisions in the client’s best interest. Refusing assignments or choosing to discontinue care is an ethical dilemma without one clear answer.

Ultimately, you do have the right to refuse assignments that you believe will subject you or your clients to an unacceptable level of risk. However, you also have a professional responsibility and accountability to engage proactively with your employer, become informed and access the required education and training to ensure you have all available facts before considering refusal.

Here is a resource that could be helpful in this situation: Fact Sheet: Abandonment

The College of Nurses of Ontario granted permission to NANB to adapt content from the Novel Coronavirus (COVID-19) section of their website.

Clients who receive professional foot care services are often those who make up our most vulnerable population (e.g., elderly, diabetics) and therefore they are more susceptible to developing severe complications if they were to contract COVID-19. RNs practice foot care in a variety of settings such as hospitals, long term care facilities, community clinics and in client’s homes. To minimise risk to this client population nurses providing foot care, as in all nursing care settings, need to follow the guidance from the Office of the Chief Medical Officer of Health.

If you are providing foot care services as a self-employed nurse you must comply with the Mandatory Order rules and conditions aimed at reducing the spread of the COVID-19 virus. Everyone, including individuals, employers and businesses, must follow the order to ensure public health. For information how business owners can comply with the Mandatory Order see the following resources:

• Fact Sheet: Operational Plan development
• COVID-19 Operational Plan Guide: Keeping New Brunswickers Safer Together
• Embracing The New Normal As We Return to Work: Guidelines for New Brunswick workplaces re-opening in a COVID-19 Environment

Public Health and WorkSafeNB have created guidance documents and templates to help support businesses preparing to re-open. Businesses that meet the requirements, must have a copy of their COVID-19 Operational Plan Guide on site as a Public Health Inspector, WorkSafeNB or representative from the Department of Public Safety may show up unannounced and request to see it.

This information is available at NB’s recovery plan webpage.

RNs and NPs are accountable for their actions and inactions at all times. They make decisions based on an analysis of all the data at hand, the needs of the client, employer policy, their duty to provide care and their obligation to protect themselves and their families.

An unreasonable burden may exist in rare situations, such as public health emergencies, where the RN or NP is unable to provide safe care and meet professional standards of practice because of unreasonable expectations, lack of resources or ongoing threats to personal safety.

Refusing to provide care or withdrawing from care may be appropriate in very specific circumstances. Before withdrawing from care, you must fully consider the risk and impact to clients. Additionally, you must first attempt several other strategies to improve the safety of the situation, such as working with your employer to obtain the appropriate PPE and isolation spaces. 

Consider the following when contemplating withdrawing from care: 

• What is the risk to the client if I withdraw from care?
• Is the care I am providing directly preventing harm to the client?
• Does the benefit of the care I am providing outweigh my risk of harm?  
• What can I do to minimize my risk?
• What can I do to minimize the risk to the client if I withdraw from care? 

If I decide to withdraw from care, could I be accused of abandonment?

Abandonment occurs when an RN or an NP has engaged with a client or has accepted an assignment and then discontinues care without:

• negotiating a mutually acceptable withdrawal of service with the client; or
• arranging for suitable, or replacement services; or
• allowing the employer a reasonable opportunity for alternative or replacement services to be provided.

While you have the right to refuse to work in situations where you cannot manage or reasonably mitigate the risk, it is equally important to note that you are accountable to take every reasonable action to prevent withdrawal from care and abandoning clients.

For more information on abandonment, you can refer to Fact Sheet: Abandonment. RNs and NPs should review relevant organizational policies and guidelines related to staffing and workload. If needed, you should advocate for and develop policies and guidelines driven by patient interest and safety. You can also refer to this document: Practicing with Limited Resources: A Guide for RNs and NPs.

The Nova Scotia College of Nursing granted permission to adapt content from Practice Scenario: Withdrawing from Care – Unreasonable Burden.

CNA’s key messages on PPE 

Temporary re-assignment is a legitimate employer practice to ensure they can meet the needs of the clients they serve every day. You and your employer have an accountability to ensure clients are receiving safe and competent care. While in this unusual circumstance of a public health emergency RNs, NPs and employers are accountable to work together to make the best decisions based on the information at hand, fully recognizing that the evolving situation may result in a different decision at a different time.

RNs and NPs Accountabilities

As RNs and NPs, you must ensure you have the knowledge, skill and judgement before performing any activity or procedure. There are elements of nursing knowledge and entry-level competencies that apply to all client groups and practice. You must practice within your level of competence; therefore, it is important to assess and communicate any practice limitations. While you may not be able to carry a full client assignment in the unfamiliar setting, there are many things you can do competently within your individual scope of practice to support the practice area. In some cases, you may need to recognize that your assignment may be to assist regular staff as they care for clients rather than caring for clients independently.

If you are assigned to an area that you are not familiar with, consider:

• Asking for a brief orientation to the new practice setting.
• Performing activities you are competent to do. For example, providing basic care to free up RNs and NPs with expertise to provide more complex or practice area specific 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.
• Seeking advice and collaborating with the health care team to uphold safe client care and working together with other health care experts to improve your clients’ care.

Employer Accountabilities

Your employer has an obligation to:

• Provide staffing and resources and to ensure that RNs and NPs are supported to work within their role and scope of practice. 
• Arrange for support for RNs and NPs re-assigned to unfamiliar practice settings.
• Assist RNs and NPs in understanding their expectations when providing care in an unfamiliar practice setting.
• Consider the competencies and qualifications of RNs and NPs or other care providers when making client assignments.

Part of content comes from Nova Scotia College of Nursing Practice Scenario: Re-deployed Nurses and College of Nurses of Ontario COVID-19 Information for nurses.  

RNs and NPs are accountable to legislation, the Code of Ethics, standards and employer policies. Here are a few key elements to keep in mind during the coronavirus outbreak:

Standards of Practice for RNs

RNs and NPs are accountable for:

• practicing safely, competently, compassionately, and ethically and are accountable to the client, public, employer and profession
• practising using evidence-informed knowledge, skill and judgement
• contributing to and promoting measures that optimize positive client health outcomes at the individual, organizational and system level
• establishing professional relationships and demonstrating leadership to deliver quality nursing and health care services

Standards for the Therapeutic Nurse-Client Relationship

RNs and NPs are accountable for:

• using a wide range of effective communication strategies and interpersonal skills to appropriately establish, maintain and terminate the nurse-client relationship
• ensuring that all professional behaviours and actions meet client’s therapeutic needs

Code of Ethics for RNs

Historically and currently, nurses provide care to those in need, even when providing care puts their own health and life at risk. Nurses also encounter personal risk when providing care for those with a known or unknown communicable or infectious disease. However, disasters and communicable disease outbreaks call for extraordinary effort from all health-care personnel, including nurses. (p. 38)

The Code states: “During a natural or human-made disaster, including a communicable disease outbreak, nurses provide care using appropriate safety precautions in accordance with legislation, regulations and guidelines provided by government, regulatory bodies, employers, unions and professional associations (A9)”. (p. 38)

Nurses carefully consider their professional role, their duty to provide care and other competing obligations to their own health, to family and to friends. (p. 39)

For more information on Ethical Considerations for Nurses in a Natural or Human-Made Disaster, Communicable Disease Outbreak or Pandemic, please consult pages 38-40 of the Code of Ethics.

Fact Sheet: Infection Prevention and Control (IPC) 

RNs and NPs have the responsibility to ensure they practise safely and competently at all times, including the use of safe and effective IPC measures. To do so, RNs and NPs are expected to be aware of applicable legislation, NANB standards, best practices and organizational policies related to IPC and to advocate for quality practice environments.

Memo: Inappropriate Prescriptions for the Prevention and/or Treatment of COVID-19 Illness

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.
• 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, consult with the Department of Health 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.

Relevant Links:

• Health Canada Control Drug and Substances Act exemptions
• Health Canada Control Drug and Substances Act exemption FAQs 

The COVID-19 Pandemic is an evolving situation and the body that governs the safety for all New Brunswickers is Public Health and the Chief Medical Officer. We stand by and support any and all the recommendations that come out of that office and work in collaboration with the Department of Health ensure we continue to provide you with the most up to date information. Please follow the Public Health recommendations, available online:

Office of the Chief Medical Officer of Health (Public Health)

COVID-19: Fact Sheet on Operational Plan Development

Self-employed nurses can assist in other sectors

If your business is prohibited from providing services under this order, you may wish to consider assisting other sectors to respond to the pandemic.   More nurses are needed in New Brunswick’s health authorities, nursing homes, extra-mural hospital and telehealth. 

If you have  questions about where and how you may be able to help, please email HRP3CD19@gnb.ca.

Duty of care is the moral, ethical, legal and professional obligation that requires LPNs, RNs and NPs to adhere to a reasonable standard of care while providing, assigning, delegating, supervising, promoting, evaluating or advocating for care. Nursing professionals have a duty to provide care using appropriate safety precautions during a public health crisis, such as the COVID-19 pandemic. This FAQ was designed to help support nursing professionals in meeting their accountabilities regarding the duty of care during the COVID-19 pandemic. If you have further questions, please do not hesitate to contact your regulatory body:  ANBLPN or NANB.

FAQ: COVID-19 & DUTY OF CARE

As virtual or telenursing care is being required and adopted, NANB supports nurses providing care to clients through technology. 

Telenursing may change how you conduct your nursing practice, it does not fundamentally change the nature of nursing practice, or the nursing process that is foundational to the delivery of nursing care. The requirement to meet your standards of practice remains.

If you are providing nursing services using technology, you must: 

• Use the nursing process to assess, plan, implement, evaluate, and document nursing care.  
• Use effective communication to establish the nurse-client relationships.
• Develop the client’s care plan based on your virtual assessment and evaluation of their history / current health care needs. Ask the client enough questions to ensure that you have relevant and sufficient data to guide your decisions and interventions.
• Collaborate with members of the nursing and care team as needed. This may be required more frequently, when:
  • providing care to new clients to help relieve pressures in the health system
  • usual data is not available (such as recent assessments, lab or diagnostic results because the client chart is not available, or clients cannot access the health system)
  • needs of the client are beyond your individual scope of practice, area of expertise or competence.
• Make care decisions based on the data available to you at the time and in the context in which it is provided.
• Recognize when telenursing is not meeting the needs of the clients and a face-to- face assessment is required.
• Provide services that are consistent with your scope of nursing practice, your individual competencies and your employer’s expectations and policies.

You should be aware of employer policies related to:

• Privacy and confidentiality 
• Documentation 
• Security and approved type of technology or other required equipment
• IT support
• Informed consent

If you are practising in New Brunswick and providing virtual nursing services using technology to clients outside of New Brunswick, you: 

• Must hold a practising licence with NANB
• Are accountable to know what policies or legislation may apply to you in the jurisdiction where your clients reside. Different polices policies and legislation may affect telenursing in other jurisdictions. You may also be required to be licensed in that jurisdiction. 

All nurses are accountable for their own actions and for the things they know or reasonably should have known. They are expected to make care decisions based on the data available to them at the time, and in the context in which it is provided.

For more information on the provision of virtual care, please consult the NANB Guidelines for Telenursing Practice. 

The Nova Scotia College of Nursing granted permission to adapt content from Practice Scenario: Telenursing or Providing Virtual Care in a Pandemic. / Practice Scenario: NPs Providing Virtual Care for Unfamiliar Clients in a Pandemic.

ISMP Canada recommends using written orders, including electronic orders, as preferred practice. However, the current pandemic has increased the need for and frequency of telephone and verbal orders. They suggest safe practices that RNs and NPs can find in the following document: ISMP Canada Safety Bulletin.

• Legal Considerations When Nursing in a Pandemic
• Ask a Lawyer: Refusal to wear a mask and mask exemption requests
• Four things to Know about Professional Nursing Services During a Pandemic
• COVID-19: Footcare nursing during the pandemic
• Twelve Things to Consider Before Joining a Virtual Care Practice
• Six Considerations for Independent Practice during a Pandemic
• Telepractice
• Case Study: Virtual Care