Note: This is a reproduction of the CFNU Position Statement on COVID-19, which was updated and published in PDF form on December 16, 2020.
Please also consult the following position statements:
2020-12-01: Pregnant Health Care Workers Should Not Be Forced to Work in COVID-19 ‘Hot Zones’
2020-07-15: Canada’s Nurses and Presumptive Legislation for COVID-19
2020-04-22: COVID-19 – the Right to Know, the Right to Participate and the Right to Refuse – Every Workers’ Right, Including Health Care Workers
2020-04-17: The Need for Transparency Regarding the PPE to Protect Health Care Workers
2020-04-08: Provision and laundering of uniforms for nurses providing care to COVID-19 patients
2020-04-02: Nurses with conditions that make them susceptible to COVID-19
When it comes to worker safety in hospitals, we should not be driven by the scientific dogma of yesterday or even the scientific dogma of today. We should be driven by the precautionary principle that reasonable steps to reduce risk should not await scientific certainty. Until this precautionary principle is fully recognized, mandated and enforced in Ontario’s hospitals, workers will continue to be at risk.
—Justice Campbell, Chair of the SARS Commission
New evidence and information on COVID-19 is emerging daily, and CFNU’s recommendations remain based on science and occupational health and safety legislation and principles, including the precautionary principle.
As well, the occupational health and safety principle of the hierarchy of controls applies. It starts with eliminating the hazard whenever possible. When that cannot be accomplished, a combination of engineering and administrative controls, combined with appropriate personal protective equipment, must be applied. The system is called a hierarchy because you must apply each level in the order that they fall in the list; a systematic comprehensive and integrated approach must be taken to reducing hazards; a hierarchy of controls cannot be applied in a piecemeal fashion.
In the midst of the second wave of COVID-19, it is incumbent upon federal/provincial/ territorial governments and employers to provide appropriate protection to health care workers and take a leadership role on infection prevention and control in health care settings.
The federal government has committed to procuring and allocating the necessary PPE to provinces, including fit-tested NIOSH-approved N95 respirators.
In light of the fact that the Public Health Agency of Canada (PHAC) has now formally acknowledged that one of the main routes of transmission for COVID-19 is from infected individuals, who spread the virus through respiratory droplets and aerosols generated when they cough, shout, talk or sing, and that these aerosolized particles may linger in the air and be inhaled [Public Health Agency of Canada. (2020, November 3) COVID-19: main modes of transmission], governments and employers must enhance their procurement measures to secure respiratory protection (fit-tested N95 respirators or better) so as to protect health care workers caring for presumed and confirmed cases of COVID-19.
Examples of engineering controls: plexiglas barriers; sufficient and effective ventilation systems with appropriate air changes per hour and air cleaners [U.S. EPA. Air cleaners, HVAC filters and Coronavirus (COVID-19]; designated COVID-19 units, negative pressure rooms; private rooms with private toilet and patient sink; designated hand washing sinks for HCW use.
Examples of administrative controls: employers’ pandemic plan; active screening protocols; respiratory protection program; enhanced environmental cleaning; application of precautions (droplet and aerosol (small droplets and particles which linger in the air), contact, airborne); safe patient transportation policies; training, testing and drilling; education, surveillance and auditing practices; visitor restriction and protection policies; policies on procuring, supplying and accessibility of adequate and appropriate PPE; provincial/territorial and federal guidance and directives to adequately protect workers from the risk of inhaling the virus via the aerosol/airborne route.
Examples of PPE: Fit-tested NIOSH-approved N95 respirators or better (e.g., reusable elastomeric respirators) for workers at risk of exposure to a suspect or confirmed COVID-19 patient/resident/client with an adequate and accessible supply (along with training on how to don and doff respirators); gloves, impermeable gowns, medical masks, full face shields or goggles, hair and foot coverings.
According to the Chief Public Health Officer of Canada, health care worker infections with COVID-19 comprised 19% of total cases in Canada as of mid-August. There have been at least 27 health care worker deaths from COVID-19 in Canada [PHAC. (2020, October). From risk to resilience: an equity approach to COVID-19: Chief Public Health Officer of Canada’s Report on the State of Public Health 2020]. Health care worker infections in Canada were twice the global average during the first wave of COVID-19 [ICN. (2020, October 28). ICN confirms that 1500 nurses have died from COVID-19 in 44 countries and estimates that HCW fatalities worldwide could be more than 20,000]. As the CFNU detailed in its recently published report, A Time of Fear: How Canada failed our health care workers and mismanaged COVID-19, other countries fared much better because they learned from the SARS epidemic in 2003. China’s COVID-19 infection rate for health care workers stood at 4.4% of the national total, while Taiwan and Hong Kong had infections of health care workers that remained in the single digits because they chose to protect health care workers with respiratory protection (N95 respirators) [Possamai, M. (2020). A Time of Fear].
According to a report from Quebec’s Institut national de santé publique du Québec, health care workers were ten times more likely to be infected than the general population during the first wave of COVID-19 [RCI. (2020, October 15). Over 13,500 health care workers in Quebec infected during first wave of pandemic].
In the midst of the second wave of the COVID-19 in Canada, tens of thousands of health care workers have now become infected with COVID-19. It is unacceptable that so many health care workers are getting sick. It is also apparent that current measures being taken to protect workers, including the personal protective equipment provided, are not sufficient or appropriate.
Since January 2020, the Canadian Federation of Nurses Unions and its member organizations have documented the potential risk of aerosol transmission of COVID-19, and urged that the precautionary principle be applied to protect health care workers from contracting the virus. As the evidence has mounted with respect to COVID-19 being spread in the air, many experts now consider close-range aerosol transmission the dominant mode of transmission [CFNU. Research Summary on COVID-19].
In November 2020, the Public Health Agency of Canada (PHAC) confirmed that close-range aerosol transmission of COVID-19 occurs. According to the PHAC, when a person infected with COVID-19 coughs, sneezes, sings, shouts or talks, small aerosolized droplets or particles called aerosols can linger in the air and potentially be inhaled into the nose, mouth, airways and lungs of those in the room. The PHAC recognizes the virus is spread most commonly amongst those in close contact within indoor environments, and one can become infected from someone with or without symptoms. The PHAC also notes the importance of adequate and appropriate ventilation in order to decrease the concentration of aerosols that may be suspended in the air in the room, and reduce the chances of SARS-CoV-2 spread if those aerosols contain the virus [The Public Health Agency of Canada (2020, November 3). COVID-19: Main Modes of Transmission].
Further, according to the U.S. Centers for Disease Control and Prevention, long-range aerosol transmission of COVID-19 has occurred under certain circumstances, although it is an uncommon transmission route (the U.S. CDC refers to ‘airborne’ transmission of COVID-19 as aerosol particles travelling farther than 6 feet and remaining in the air for more than 30 minutes up to multiple hours). Factors that may contribute to aerosol transmission of the virus include: a) enclosed spaces; b) inadequate ventilation or air handling that allows a build-up of suspended small respiratory droplets and particles; c) prolonged exposure to respiratory particles and d) an infected person breathing heavily [U.S. Centers for Disease Control and Prevention. (2020, October 5). How COVID-19 Spreads].
It is the position of the Canadian Federation of Nurses Unions (CFNU) that, in the event of an outbreak of any new respiratory virus, we acknowledge that the required and best respiratory protection for health care workers at risk is, minimally, fit-tested NIOSH-approved N95 respirators or higher levels of protection (e.g., powered air-purifying respirators (PAPR) or elastomeric respirators), given the emerging science, occupational health and safety legislation, and the precautionary principle.
Failure to institute the precautionary principle throughout the health care system, including in acute and long-term care facilities, home and community care, has resulted in nurses and other health care workers becoming vectors spreading the disease to each other and their patients, residents, clients or families. For infection and prevention control measures to be effectively implemented, the hierarchy of controls, as described above, must be implemented throughout the organization, in conjunction with joint health and safety committees that include direct care providers (including nurses) and their unions.
Based on an organizational infectious disease risk assessment, all nurses and frontline health care workers at risk in their area of work, or any area they may have to work in, with the potential for exposure, and/or who are caring for a suspected or confirmed COVID-19 patient, should be provided, fitted for and have unfettered access to a NIOSH-approved N95 or greater respirator (i.e., powered air-purifying respirator (PAPR), elastomeric respirator), and be trained, tested and drilled by the employer to safely don and doff it. All PPE (gloves, impermeable/isolation gowns, medical masks, N95 respirators, and face and eye protection (such as full face shields or goggles) should be supplied in all patient/resident care areas and in adequate amounts, and stored so they are readily accessible at the point of care for all health care workers.
It is critical that employers recognize, promote and respect the importance of health care workers performing a point-of-care risk assessment (PCRA) before every client interaction, to determine the personal protective equipment (PPE) health care workers require for the patient, task and environment. Guidance must make it clear that an employer cannot deny access to the necessary and appropriate PPE – regardless of the care/task being provided or undertaken – including fit-tested N95 respirators, if a health care worker determines that they are required.
Given the evidence of non-symptomatic transmission, health care workers and visitors should wear a medical mask at all times when in patient care areas in hospitals, long-term care facilities and community settings.
Patients/residents/clients who are able to comply should wear medical masks as a form of source control anywhere within the health care facility and within their homes or their rooms when health care workers request they don a mask.
Given the evidence of close-range aerosol transmission, the potential for non-symptomatic transmission, and the collection of a specimen from an anatomic region where viral loads may be higher, health care workers performing nasopharyngeal or throat swabs must be provided the ability to access fit-tested N95 respirators (or higher levels of protection) based on their PCRA (minimally, contact and droplet precautions must be in place) and be trained, tested and drilled in all PPE use.
For those workers involved in triage and screening and testing for COVID-19, ideally a floor‑to‑ceiling plexiglas barrier with a speaker phone would eliminate worker exposure to the hazard, if there is no further direct contact with a patient required. If the barrier is not in place and direct contact cannot be avoided, other administrative and engineering controls (such as disposable equipment, signage procedures, training, separate examination rooms and waiting area with adequate ventilation with appropriate air changes per hour throughout the facility) should be in place before direct contact with the patient. Workers must have the ability to access fit-tested N95 respirators based on their PCRA (minimally, contact and droplet precautions must be in place) and be trained, tested and drilled in all PPE use.
To reduce the spread of COVID-19 in health care facilities, emphasis must be placed on preventing the virus from entering the facility. Therefore, effective and comprehensive screening and testing programs for both visitors and staff entering all facilities must be in place.
Hospitals and long-term care residences must cohort and isolate patients with presumed or confirmed cases of COVID-19. This has been an effective infection prevention and control model used internationally.
Given the potential for non-AGMP aerosol spread of the virus, all workers caring for suspected or confirmed cases in designated COVID-19 units must be required to wear, minimally, fit-tested NIOSH-approved N95 respirators, if available, to prevent aerosol transmission of the virus. Head and foot protection, eye protection (i.e. full face shields or goggles), gloves, impermeable (or at least fluid-resistant) gowns must also be worn in these areas.
It is essential that airborne precautions and the use of fit-tested NIOSH-approved N95 respirators or preferably better (i.e. elastomeric respirators, powered air-purifying respirators (PAPRs)) be mandated at all times in clinical areas considered aerosol-generating medical procedures ‘hot spots’ (e.g.: intensive care units (ICU), emergency rooms, operating rooms, post-anaesthetic care units and trauma centres) that are managing COVID-19 patients. Where possible, AGMPs should take place in negative pressure rooms (or AIIR – airborne infection isolation rooms), or single-patient/resident rooms if an AIIR room is unavailable, and PAPRs should be used as respiratory protection for AGMP procedures.
Upon producing evidence to the joint occupational health and safety committee of the employers’ procurement attempts for all types of respiratory protection (fit-tested N95 respirators and reusable/cleanable respirators) from all vendors and from government – and as a last resort in the event of dire supply shortages of disposable N95 respirators – employers must notify and discuss alternative strategies to immediately address and resolve the supply issue with affected health care unions.
At a minimum, in this eventuality all employees must be equipped with personal protective equipment for contact and droplets precautions for suspected, presumed or confirmed cases of COVID-19, including gloves, eye protection (full face shield or goggles), isolation/ impermeable gowns, head and foot coverings, and medical masks, for which they must also be trained, tested and drilled in safe use.
Point-of-Care Risk Assessment is required to be completed by all health care workers for all interactions with patients/residents/clients.
Even in the event of supply issues, the point-of-care risk assessment (PCRA), an activity that is based on the individual nurses’ professional judgment (i.e., knowledge, skills, reasoning and education) must determine the protective equipment a nurse is provided, and if it is inadequate – given the patient acuity, environment or other factors – nurses must be provided access to a higher level of PPE regardless of the care/task being undertaken. Guidance must make it clear that a health care worker cannot be denied appropriate protection as required by the PCRA.
Underlying the PCRA is the principle that individual health care workers are best positioned to determine the appropriate personal protective equipment (PPE) required based on the situation and their interactions with an individual patient. They do so by evaluating the likelihood of exposure to themselves or others based on a specific task, environment, conditions, interaction or patient. Among the factors that should be considered in the PCRA are: the potential for contamination of skin or clothing; exposure to blood, body fluids or respiratory secretions; the potential for inhaling contaminated air or aerosolized particles; the patient’s ability or willingness to comply with infection control practices (e.g., wearing a medical mask); whether care requires very close contact or prolonged close contact; what engineering (i.e. appropriate ventilation/air changes per hour and air cleaners) and administration controls are in place; and whether the patient could require an aerosol-generating medical procedure at any point and/or is in an AGMP hot spot (e.g.: intensive care unit, emergency room, operating room, post-anesthetic care unit or trauma centre) that is managing COVID-19 patients. Personal protective equipment should be selected based on the potential for exposure in order to minimize the risk of exposure to HCWs, a specific patient or other patients in the environment.
The PCRA does not abdicate the employer, however, from their legal obligation to provide appropriate PPE and protect all workers adequately under the Occupational Health and Safety Act, as indicated below.
A recent legal opinion, posted by a leading Canadian law firm Osler, Hoskins & Harcourt LLP, recommends employers “benchmark to current best practices” and follow “appropriate precautionary measures”: “Where there is conflicting evidence as to whether a certain precautionary measure is required or not, hospitals should adopt the elevated precautionary measure(s). Hospitals should be cognizant that it will be the hospital that will be legally liable for any failures to protect patients and staff from harm, even if hospitals have relied on federal, provincial or municipal government directives in establishing its own plans, policies and procedures” [https://www.osler.com/en/resources/governance/2020/coronavirus-covid-19-lessons-learned-from-sars-a-guide-for-hospitals-and-employers].
Similarly, Katherine Lippel, Distinguished Canada Research Chair in Occupational Health and Safety Law, argues that: “The precautionary principle that provides that prevention measures be put in place when scientific uncertainty prevails is intrinsic to OHS law” [Possamai, M. (2020). A Time of Fear].
The legal ruling in Ontario from Justice Morgan in Ontario Nurses’ Association v. Eatonville/Henley Place, 2020, and the Stout award have reinforced the importance of the point-of-care risk assessment and respecting nurses’ professional and clinical judgement when determining what PPE is necessary: “Nurses must be provided with PPE, including N95 respirators if, in the nurses reasonably professional and clinical judgment, they determine such PPE is necessary” [Possamai, M. (2020). A Time of Fear].
Employers’ responsibilities are clearly laid out in provincial OH&S law: employers must work with joint OH&S committees on their pandemic plans, protocols and measures; provide training, testing and drilling for all employees on health and safety measures; establish a respiratory protection plan and provide fit-testing for N95 respirators or better to all employees who may need them as based on their areas of work or potential work responsibilities; and employers are also responsible for making PPE readily accessible and available to health care teams so they can do their jobs safely.
It is our position that a pan-Canadian approach to emergency preparedness must incorporate the precautionary principle so that all nurses and health care workers across Canada have the same access to health and safety in their workplaces, including the same standard for personal protective equipment (PPE) and pandemic planning.
Effective infection control and health and safety strategies must incorporate a hierarchy of controls approach, as described above, developed and implemented throughout the organization, in conjunction with joint health & safety committees that include nurses and their unions.
If AT ANY TIME you feel that your employer is not following the OH&S laws and principles as outlined above, please contact your union immediately.
Nurses are expected to be prepared, 24 hours a day, to face any number of health emergencies. The ability to respond quickly and efficiently to emergencies is fundamental to the nursing profession. However, rapid response requires the support of many parts of the health care system. It requires emergency preparedness planning, proper administrative and engineering controls, the support of the administrators of the health system, as well as employers and governments to ensure the necessary protocols, measures, procedures, training and protective equipment that take into consideration risk and the precautionary principle.
For workers, we recognize the critical importance of the point-of-care risk assessment and that individual health care workers, using their knowledge, skills, judgement and education, are best positioned to determine the appropriate PPE required based on their interaction with an individual patient in a particular environment.
Questions or concerns? If you have any questions or concerns, please speak with your union or a member of your Joint Occupational Health & Safety Committee.