Pandemic Toolkit: Resources for Nurses and the Public

Nurses are accountable to legislation, standards, regulatory requirements, and employer policies. Nurses must also practice in accordance with the Canadian Nurses Code of Ethics for Registered Nurses. Here are a few key elements to keep in mind during a pandemic or communicable disease outbreak:

Standards of Practice for Registered Nurses

Nurses are accountable for:

• practicing safely, competently, compassionately, and ethically and are accountable to the client, public, employer, and profession.
• practicing 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.

• NPs are additionally accountable for the Standards of Practice for Nurse Practitioners

Standards for the Nurse-Client Relationship

Nurses 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 clients’ therapeutic needs

Code of Ethics for Registered Nurses

Nurses are accountable for following the Code of Ethics for Registered Nurses, which states that:

• “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).

• “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” (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).

Nurses have the responsibility to ensure they practice safely and competently at all times, including the use of safe and effective IPC measures. To do so, nurses 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.

Nurses are accountable for making decisions that are in the best interest of their clients and protect them from harm. Nurses are also accountable for protecting clients from infection risks. Nurses 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 employer organizational policies about IPC
• participating in any training or education sessions on IPC
• Applying best practices in IPC
• collaborating with the employer to develop new policies as needed
• using sources of evidence to inform nursing practice

NANB encourages nurses to work collaboratively with the employer to recognize real or potential threats, review relevant organizational policies, and if needed, develop policies and guidelines specific to their practice setting.

Nurses are expected to understand and apply precautionary measures to minimize the risk of infecting themselves, colleagues, clients, and others.

To learn more about COVID-19 specific guidance, refer to the Government of New Brunswick Office of the Chief Medical Officer of Health (Public Health).

Quarantine and isolation are public health measures used to protect the public by preventing exposure to people who definitively or potentially have a contagious disease. Isolation refers to the act of separating a person from the public with a contagious disease. Quarantine refers to the act of separating a person from the public who has had an exposure to a contagious disease (Government of Canada, 2022).

It is important to follow local public health advice and employer policy on when and how to quarantine or isolate.

For COVID-19 related advice:

Advice for when you or someone in your home is sick with COVID-19

Duty of care is the moral, ethical, legal, and professional obligation that requires nurses 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 a pandemic or communicable disease outbreak.

When a nurse’s professional obligation to a client conflicts with their personal obligations, the nurse has 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, nurses do have the right to refuse assignments if they believe will subject them or the clients to an unacceptable level of risk. But nurses also have a professional accountability to advocate for practice settings that minimize risk to both nursing professionals and the clients. Advocating for quality practice settings is one of the many ways nurses are leaders in client care.

Additional information can be found in NANB’s Practice Guideline: Duty to Provide Care

Nurses 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 nurse is unable to provide safe care and meet professional standards of practice. This may arise due to unreasonable expectations, lack of resources, or ongoing threats to personal safety.

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

Nurses must 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?

The Occupational Health and Safety Act (The Act) is provincial legislation that outlines required steps employees and employers must follow when an employee refuses to continue work. It is the responsibility of the nurse to understand their rights and responsibilities legislated by The Act. Nurses must also understand relevant organizational policies and procedures related to The Act.

Abandonment occurs when a nurse 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 nurses have the right to refuse to work in situations where risk cannot reasonably be managed or mitigated, it is equally important to note that nurses are accountable to take every reasonable action to prevent withdrawal from care and abandoning clients. For more information on abandonment, refer to Fact Sheet: Abandonment.

Nurses should review relevant organizational policies and guidelines related to staffing and workload, and advocate as required for policies and guidelines driven by patient interest and safety. For additional guidance refer to the: Working with Limited Resources Toolkit

The Nova Scotia College of Nursing granted permission to adapt content from Withdrawing from Care – Unreasonable Burden in a Pandemic

NANB supports nurses providing care to clients through technology.

Although telenursing may change how nurses provide care, 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 the standards of practice remain.

For more information on the provision of virtual care, please consult the NANB Telenursing Practice Toolkit and NANB’s Guideline for Telenursing Practice.

NPs are accountable to the Standards of Practice for Nurse Practitioners. Standard 3  specifies that that the NP utilizes advanced knowledge and judgement in applying pharmacological and non-pharmacological interventions.

There are some key considerations when sending prescriptions in the event of virtual care provision:

• 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.
• NPs should 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.
• NPs should work with their patients to meet their needs and to get informed consent before using unsecured platform 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.

NPs should also consider reviewing the following Institute for Safe Medication Practices Canada: Optimizing Medication Safety in Virtual Primary Care

Nurses providing nursing services in a self-employed practice, should be aware of legislation in place to respond to emergency situations (Canadian Nurses Protective Society, 2020). It is also essential to keep up to date on local public health measures and protocols which may impact self-employed practice.

The following Six Considerations for Independent Practice during a Pandemic  are important to review when working as a self-employed nurse during a pandemic or communicable disease outbreak.

WorkSafeNB offers additional guidance on communicable disease prevention as a business owner.

Temporary re-assignment is a legitimate employer practice to ensure they can meet the needs of the clients they serve every day. Nurses and their employer have an accountability to ensure clients are receiving safe and competent care. Nurses 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.

RN and NP Accountabilities

Nurses must ensure they 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.  Nurses must practice within their level of competence; therefore, it is important to assess and communicate any practice limitations.  While it may not be possible to carry a full client assignment in an unfamiliar setting, there are many things a nurse can do competently respecting their individual scope of practice to support the practice area. In some cases, may be assigned to assist regular staff as they care for clients rather than caring for clients independently.

When assigned to an unfamiliar setting, nurses should consider:

• Asking for a brief orientation to the unfamiliar practice setting.
• Performing activities they 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.
• identifying and addressing learning needs specific to the new practice setting.
• Seeking advice and collaborating with the health care team to uphold safe client care and working together with other health care experts to improve client care.

• Discussing individual competency and expected responsibilities with the employer

Employer Accountabilities

The employer has an obligation to:

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

For more information, please refer to NANB’s Fact Sheet: Reassignment to an Unfamiliar Practice Setting

The Institute for Safe Medication Practices Canada recommends using written orders, including electronic orders, as preferred practice. However, pandemics and communicable disease outbreaks can increase the need for and frequency of telephone and verbal orders. They suggest safe practices that nurses can find in the following document: Strategies for safer telephone and other verbal orders in defined circumstances

Legal Considerations When Nursing in a Pandemic

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

InfoLAW: Telepractice

Case Study: Virtual Care