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Nursing Issues

Personal protective equipment (PPE) and supplies

CNA recognizes that there is currently much debate over mode of transmission. CNA works within the framework of evidence-informed decision making and supports current evidence and guidance from PHAC and WHO in the assertion that the virus is not airborne, unless during aerosol generating medical procedures (AGMPs). We are hearing anecdotal accounts of shortages and anticipated shortages of supplies, including surgical and N95 masks. In addition, we are hearing about situations where, because of these shortages or anticipated shortages, supplies are not readily available for access (i.e., locked up, not kept within easy reach).

In response to the urgent shortages and ethical challenges arising around PPE, CNA has developed Key Messages on PPE [PDF, 196.8 KB] to support and advocate for nurses. Please refer to this document for CNA’s messaging, considerations on ethical dilemmas for nurses when appropriate PPE is unavailable, and information related to available guidance from national and international groups related to strategies to optimize the use of masks.

CNA is continuing to advocate for rapid deployment of protective equipment to ensure nurses have access to the supplies and equipment needed to provide safe quality and ethical care for their patients.  In order to optimize the use of the current supply of masks and respirators, the federal government has provided the following guidance:

Optimizing the use of masks and respirators during the COVID-19 outbreak

Given evidence related to transmission from persons who are asymptomatic, or pre-symptomatic, PHAC has also noted that for the public, when physical distancing may be difficult to maintain, members of the public can consider wearing a non-medical mask or face-covering.

Other equipment and supplies

Adequate medical equipment and supplies are an essential part of ensuring quality and safe care for patients. CNA is aware of the increasing reports and concerns of actual or potential shortages of other supplies, including ventilators, hand sanitizers.1,2 As described in PPE above, this has resulted in conservative management and rationing of supplies.3 Federal, provincial and territorial governments are rapidly attempting to purchase supplies, however industry and manufacturers may be limited in their capacity to meet the rapidly increasing needs of health-care facilities. Manufacturers and businesses are now being approached to supply products and services for the COVID-19 response.

Testing kits for COVID-19 are critical to the early identification and isolation of cases to limit spread within the community. Shortages of testing kits has been reported, contributing to more targeted testing of patients in provinces like Ontario and British Columbia, saving tests for those high risk or increased likelihood of spreading the virus. In response, the federal government has now expedited review/approval of COVID-19 testing kits for importation and sale in Canada to increase access for provinces/territories to a larger supply.4 On April 12, Health Canada approved a rapid molecular point of care test that can produce results in under an hour. This is expected to alleviate burden on public health laboratories, and also increase availability and efficiency of testing for many people, including those in rural and remote areas. See Health Canada’s list of authorized kits for use in Canada.

For nurses working at the point of care, lack of appropriate supplies can create moral distress due to level of care they are able to provide as well as concern for their safety and that of their family. Nurses recognize their duty to provide safe, competent, compassionate and ethical care.5 However, it is the employer’s duty “to protect and support them as well as to provide necessary and sufficient protective equipment and supplies that will “maximally minimize risk” to nurses and other health-care providers.”

Ethical dilemmas

Application of the CNA Code of Ethics during a pandemic

“In a global public health emergency, we may find ourselves questioning whether our existing ideas about what is good, right, and just continue to hold true, or whether we need to adjust our ethical beliefs because of the extreme situation we find ourselves in. This can be very unsettling.” Read Nurses’ Ethical Considerations During a Pandemic [PDF, 244.3 KB] to learn about practice issues specific to COVID-19. The paper examines not only new ethical dilemmas, but existing ones that have been brought into fuller view.

Relevant sections of the CNA Code of Ethics

The CNA Code of Ethics (2017) offers content on ethical considerations during a pandemic.

In Appendix B: Applying the Code in Selected Circumstances (pages 38-40), the Code states:

  • Historically and currently, nurses provide care to those in need, even when providing care puts their own health and life at risk (for example, when they work in war-torn areas, places of poverty, places with poor sanitation, etc.). 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. 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)

  • A duty to provide care refers to a nurse’s professional obligation to provide persons receiving care with safe, competent, compassionate and ethical care. However, there may be some circumstances in which it is acceptable for a nurse to withdraw from providing care or to refuse to provide care (CRNBC, 2017b; CRNNS, 2014). Unreasonable burden is a concept raised in relation to the duty to provide care and withdrawing from or refusing to provide care. An unreasonable burden may exist when a nurse’s ability to provide safe care and meet professional standards of practice is compromised by unreasonable expectations, lack of resources or ongoing threats to personal and family well-being (CRNBC, 2017b).

  • The following criteria could be useful for nurses to consider when contemplating providing care in a disaster or communicable disease outbreak:

    • the significance of the risk to the person in care if the nurse does not assist;
    • whether the nurse’s intervention is directly relevant to preventing harm;
    • whether the nurse’s care will probably prevent harm; and
    • whether the benefit of the nurse’s intervention outweighs harms the nurse might incur and does not present more than an acceptable risk to the nurse (ANA, 2006).
  • When demands on the health-care system are excessive, material resources may be in short supply and nurses and other health-care providers may be at risk. Nurses have a right to receive truthful and complete information so they can fulfil their duty to provide care. They have a clear understanding about the obligations and expectations around their role. They must also be supported in meeting their own health needs. Nurses’ employers have a reciprocal duty to protect and support them as well as to provide necessary and sufficient protective equipment and supplies that will “maximally minimize risk” to nurses and other health-care providers. At the same time, nurses use their professional judgment to select and use the appropriate prevention measures; select, in collaboration with the health-care team, the appropriate agency, manufacturer and government guidelines concerning use and fit of personal protective equipment; and advocate for a change when agency, manufacturer or government guidelines do not meet the infection control requirements regarding appropriate use and fit of personal protective equipment (CNO, 2009b).

  • Nurses carefully consider their professional role, their duty to provide care and other competing obligations to their own health, to family and to friends. In doing so, they understand the steps they might take both in advance of and during an emergency or pandemic situation so that they are prepared for making ethical decisions (CNA, 2008; Thompson, Faith, Gibson, & Upshur, 2006). Value and responsibility statements in the Code support nurses’ reflection and actions.

  • A. In anticipation of the need for nursing care in a disaster or disease outbreak, nurses:

    • work together with nurse colleagues, unions and joint occupational health and safety committees, and others in positions of leadership to develop emergency response practice guidelines using available resources and guidelines from governments, professional associations and regulatory bodies;
    • learn about and provide input into the guidelines the region, province or country has established regarding which persons are to receive priority in care (e.g., priority based on greatest need, priority based on the probability of a good outcome, etc.);
    • learn how support will be provided for those providing care and carrying the physical and moral burden of care;
    • request and receive regular updates about appropriate safety measures nurses might take to protect and prevent themselves from becoming the victim of a disaster or disease;
    • assist in developing a fair way to settle conflicts or disputes regarding work exemptions or exemptions from the prophylaxis or vaccination of health-care providers; and
    • help develop ways in which appeals or complaints can be handled within the occupational health and safety framework.
  • B. When in the midst of a disaster or disease outbreak, nurses:

    • refer to regulations and guidelines provided by government, regulatory bodies, employers and professional associations;
    • help make the fairest decisions possible about the allocation of resources;
    • help set priorities in as transparent a manner as possible;
    • provide safe, compassionate, competent and ethical care (in disasters, as much as circumstances permit);
    • help determine if, when and how nurses may have to decline or withdraw from care; and
    • advocate for the least restrictive measures possible when a person’s individual rights must be restricted.

Long-term care

The vulnerability of the long-term care (LTC) sector has been increasing for decades. LTC is comprised of an aging population, requiring more complex care, but simultaneously a critical shortage of care providers. In addition, as the complexity of care has increased over recent decades, staff mix has shifted. At a time when more nursing care is required, the bulk of the caregiving falls on unregulated care providers. “Before the 1980s, most patient care was provided by regulated nurses.” (Regulated nurses include licensed/registered practical nurses, registered nurses, nurse practitioners and registered psychiatric nurses.)

People living in LTC are particularly vulnerable and more likely to experience severe disease or death from COVID-19 due to age, frailty, comorbidities, immune system weakness and the lack of prevention (vaccine) and treatment.

Once COVID-19 is detected in staff or residents, self-isolation of contacts means staffing shortages are exacerbated. This increases patient ratios as patient illness and acuity also increase. In many facilities, there is no reserve of care staff, and no contingency if a significant proportion of staff are not working due to illness, isolation or other factors. Family pressures and threats of eviction from landlords add significant pressure on care aides to continue working. Also notable is that not all unregulated care providers have sick benefits, as many employers opt for part-time and casual staff to reduce benefit costs.

While sources of data vary, Canada has unacceptable rates of LTC COVID-19-related deaths compared with the general population. In late April, Canada’s chief public health officer noted that 79% of the country’s COVID-19-related deaths were linked to outbreaks in LTC. Indeed, a recent international report found Canada had the highest rate of LTC-linked deaths among the countries studied.

Read CNA’s Key Messages on COVID-19 and Long-Term Care [PDF, 87.3 KB] for more information on LTC.

Mental health

CNA’s key messages

  • Nurses are facing unprecedented challenges and can experience significant work-related stress due to increased workload, lack of resources and personal protective equipment (PPE), concern for personal and family safety, moral distress, and exposure to significant human suffering. Additionally, they face the same stressors as the rest of the population; these stressors include exposure to constant news coverage, uncertainty about the virus, and confusion over social distancing, self-isolation and quarantine requirements.
  • Mental health and well-being is equally as important as physical health, particularly as we confront the longevity of this pandemic.
  • Nurses and health-care providers are not exempt from threats to mental health caused by COVID-19. In fact, they may be at greater risk for worse health outcomes. In a Canadian Public Health Association poll of health-care providers, 67% of nurses said they felt anxious, unsafe and overwhelmed. A second poll found that feelings of anxiety have tripled among health-care workers since COVID-19.
  • It is normal to experience fear, uncertainty and apprehension in these challenging times. It is important to recognize these emotions as real and valid and identify effective coping strategies — beginning with self-compassion.
  • CNA recognizes the need for dedicated resources and investment to support nurses and health-care providers during this pandemic.
  • CNA is advocating for rapid access to no-cost accessible mental health support services specific for nurses and health-care providers both during the pandemic and long after. While virtual and mental health support services for the general public are welcomed, immediate investment in multi-faceted mental health interventions (along with secured investment for long-term mental health support) is needed to ensure the nursing workforce remains healthy beyond the immediate crises.

The long game

Prior to the pandemic, approximately 20% of people in Canada were expected to experience a mental health issue or illness every year. Mental health services have been struggling to meet the demand due to a number of barriers including geography, stigma and cost. A recent poll from the Mental Health Commission of Canada found that over half of participants reported delays in accessing mental health services.

The global spread of COVID-19 and accompanying public health interventions (i.e., physical distancing, isolation and quarantine) have resulted in a surge in mental health issues among the general public and health-care workers. There has been a robust response to meet the acute needs of the population and CNA is pleased that services are being provided quickly and efficiently. However, there is increasing evidence that the COVID-19 pandemic may persist for many months, so long-term supports are needed. In particular, nurses and health-care providers are under significant work-related strain that will persist long after the initial crisis as the health-care system tackles the backlog of delayed care (e.g., surgeries and procedures to maintain chronic conditions). Also, the cohort of nursing students entering the workforce this year — some of who have been fast-tracked in their final year due to the pandemic — will face an unprecedented challenge. New nursing graduates already face challenges transitioning into the workforce; the additional stress of the pandemic will mean an increased need for mental health supports, training and mentorship.

Sustainable, accessible, long-term mental health support is needed to protect the mental health and well-being of the nursing workforce. Interventions should be initiated across all levels of the health-care system, including governments, regional health authorities, employers and units. Innovative strategies should be explored to deliver support where it’s needed — while recognizing that everyone copes differently. Investment in research to support evidence-informed interventions will be key to the delivery of effective services. CNA will continue to advocate on behalf of nurses to ensure their mental health and well-being are no longer overlooked.

Health human resources challenges

Prior to the emergence of COVID-19, jurisdictions across Canada had undergone significant health-care transformations, leading to disruption in the nursing workforce, work environment and workload. Reports of unplanned closures of nursing units and emergency departments across the country, in part due to unsafe staffing levels, garnered public attention.6,7,8 COVID-19 is expected to significantly burden our health-care system, with estimates that 30-70% of the population could become infected. Of particular emphasis is how hard the long-term care (LTC) sector in Canada has been hit. By the middle of April, Canada had over 1,000 COVID-19 related deaths, a significant proportion of which were related to outbreaks in LTC homes. While Canada appears to be experiencing some success in “flattening the curve” — and therefore preventing the massive rates of illness, death and health system overburden we are seeing in other countries — LTC outbreaks continue to be a significant concern, as noted above.

Maintaining the nursing workforce, the largest health-care profession in Canada, is critical to a robust pandemic response. With this goal in mind, the following represent challenges that is stressing the shortages thus far:

  • Increasing population health needs — Canada’s cases are rapidly increasing, and health-care systems are implementing preparedness efforts to strengthen surge capacity. The significant aging population in Canada may increase the burden of illness from COVID-19. The expansion of health-care settings to triage and assess COVID-19 cases (i.e., assessment centres, telehealth) will challenge the health-care system to ensure all units are adequately staffed. 
  • Risk of exposure and illness acquired in practice — Nurses and health-care providers at the point-of-care are at higher risk of exposure to COVID-19. China has reported over 3,000 health-care providers were infected with COVID-19, and Italy reports that 9% of their cases are health-care providers.9 Canada is already experiencing worrisome trends  with cases of nurses being infected or exposed to COVID-19 in Ontario and British Columbia10,11 In the immediate future, losing health-care providers due to exposure and/or illness for weeks can put a significant strain on the workforce and highlights the importance of protecting our health-care providers. Long-term, the lasting impact of COVID-19 on the health of individuals is unknown, and the potential for chronic or prolonged health concerns is possible, and may have impacts on the health of the nursing workforce.
  • Work restrictions related to travel — All travelers returning from outside of Canada must self-isolate for a period of 14 days, however certain jurisdictions have exempted workers in essential services from this guidance, including nurses.12,13 Recognizing the increasing health-care needs of the population during a pandemic, the risk to patients and staff of nurses transmitting COVID-19 must be weighed against the critical service that would be limited.
  • Family responsibilities — Nurses are impacted by closure of schools and daycares. Coordinating with partners, families and friends to ensure their children are cared for can be extremely challenging. As an essential service care provider, where working from home is not an option, nurses may experience increased pressure and stress to obtain childcare and meet their professional responsibility. Ensuring that nurses can meet their family obligations is needed to ensure they can remain part of the workforce.

Emergency licensure/registration

In response to the increasing demands caused by the global pandemic of COVID-19, some provincial/territorial nursing regulatory bodies have initiated an expedited registration process for recently retired nurses or nurses practising in other jurisdictions. In consultation with respective jurisdictional governments, a temporary reinstatement or temporary emergency licensure allows retired nurses and nurses from other jurisdictions, respectively, to rapidly obtain a licence to practice in the event of an emergency. Links to all of Canada’s nursing regulatory bodies are below. Each regulator may have different eligibility requirements and processes that may change as the situation unfolds. Please contact the regulator for more information.

BRITISH COLUMBIA

Registered nurses, nurse practitioners, licensed practical nurses and registered psychiatric nurses:
British Columbia College of Nursing Professionals

ALBERTA

Registered nurses and nurse practitioners:
College and Association of Registered Nurses of Alberta

Licensed practical nurses:
College of Licensed Practical Nurses of Alberta

Registered psychiatric nurses:
College of Registered Psychiatric Nurses of Alberta

SASKATCHEWAN

Registered nurses and nurse practitioners:
Saskatchewan Registered Nurses Association

Licensed practical nurses:
Saskatchewan Association of Licensed Practical Nurses

Registered psychiatric nurses:
Registered Psychiatric Nurses Association of Saskatchewan

MANITOBA

Registered nurses and nurse practitioners:
College of Registered Nurses of Manitoba

Licensed practical nurses:
College of Licensed Practical Nurses of Manitoba

Registered psychiatric nurses:
College of Registered Psychiatric Nurses of Manitoba

ONTARIO

Registered nurses, nurse practitioners and registered practical nurses:
College of Nurses of Ontario

QUEBEC

Registered nurses and nurse practitioners:
Ordre des infirmières et infirmiers du Québec

Licensed practical nurses:
Ordre des infirmières et infirmiers auxiliaires du Québec

NEW BRUNSWICK

Registered nurses and nurse practitioners:
Nurses Association of New Brunswick

Licensed practical nurses:
Association of New Brunswick Licensed Practical Nurses

NOVA SCOTIA

Registered nurses, nurse practitioners and licensed practical nurses:
Nova Scotia College of Nursing

PRINCE EDWARD ISLAND

Registered nurses and nurse practitioners:
College of Registered Nurses of Prince Edward Island

Licensed practical nurses:
College of Licensed Practical Nurses of Prince Edward Island

NEWFOUNDLAND AND LABRADOR

Registered nurses and nurse practitioners:
College of Registered Nurses of Newfoundland and Labrador

Licensed practical nurses:
College of Licensed Practical Nurses of Newfoundland and Labrador

NORTHWEST TERRITORIES

Registered nurses and nurse practitioners:
Registered Nurses Association of the Northwest Territories and Nunavut

Licensed practical nurses:
Government of Northwest Territories, Registrar, Professional Licensing, Health and Social Services

NUNAVUT

Registered nurses and nurse practitioners:
Registered Nurses Association of the Northwest Territories and Nunavut

Licensed practical nurses:
Government of Nunavut, Department of Health

YUKON

Registered nurses and nurse practitioners:
Yukon Registered Nurses Association

Licensed practical nurses and registered psychiatric nurses:
Government of Yukon, Yukon Department of Community Services


6 Pontiac Hospital closes obstetrics unit for 10th time. (2019, December, 13). CBC News. Retrieved from https://www.cbc.ca/news/canada/ottawa/pontiac-hospital-shawville-obstetrics-closure-1.5394551

7 N.S. emergency departments see 60% jump in closure hours. (2019, December, 19). CBC News. Retrieved from https://www.cbc.ca/news/canada/nova-scotia/nova-scotia-emergency-department-closures-hours-april-2018-march-2019-1.5402970

8 Government of Nova Scotia. (2019). Annual accountability report on emergency departments. Retrieved from https://novascotia.ca/dhw/publications/Emergency_Departments_Report_2019.pdf

10 Patton, J. (2020, March, 23). Coronavirus: 13 health-care workers test positive for COVID-19 in Toronto. Retrieved from https://globalnews.ca/news/6717564/coronavirus-toronto-health-care-workers/

11 Thomson, C. (2020, March, 22). Dozens of nurses exposed to COVID-19 at St. Mary’s Hospital: ONA. Retrieved from https://kitchener.ctvnews.ca/dozens-of-nurses-exposed-to-covid-19-at-st-mary-s-hospital-ona-1.4862996

12 British Columbia Centre for Disease Control. (2020, March, 16). COVID-19 and determination of return to work of essential service workers who have traveled out of Canada. Retrieved from http://www.bccdc.ca/Health-Professionals-Site/Documents/COVID-19-Essential-service-workers-travel-determination.pdf

13 Ministry of Health, Government of Ontario. (2020, March, 20). COVID-19 Guidance: Occupational health and safety and infection prevention & control.  Retrieved from http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/2019_occupational_health_safety_guidance.pdf