Dear Colleagues: Welcome to our Friday, August 7 report – now in the sixth month of COVID-19 in Ontario. Visit the COVID-19 Portal for the many resources RNAO offers on COVID-19. Find earlier updates here, including thematic pieces in my blog. RNAO media hits and releases on the pandemic can be found here. Daily Situational Reports from Ontario's MOH EOC can be found here. As always, feel free to share this report and links with anyone interested.

Reminder to take action regarding Nursing Homes before it’s too late! Add your name to almost 8,000 who have written to Premier Ford demanding the Nursing Home Basic Care Guarantee!

School reopening: Ontario government can still do the right thing on class sizes and

There is little doubt that school reopening in September is one of the most crucial policy decisions in terms of the handling of the COVID-19 pandemic in Ontario and everywhere else. Ontario has about two million school age children and 160,000 teachers – those are huge numbers. That means wrong decisions will have fateful implications both for the health and wellbeing of children and their parents, teachers and staff, as well as for the pandemic curve.

Ontario has been successful in containing the virus, and this is key to the reopening of schools: the virus must continue to be contained and very low levels of community spread must remain the norm. If the pandemic curve reverses course and starts to point up, this will require aggressive action from government, curtailing back societal activities with lesser priority, such as indoor bars and restaurants, as well as other indoor events.

As reported by the Globe and Mail, school boards want to keep the elementary school classes small but acknowledge they don’t have the funding to do so. The Ontario government is not mandating or providing funding for reducing class size in elementary grades, which can have classes of more than 30 students. The number of children in each class has become the subject of discussion across the country as public-health experts and educators argue that more physical distance reduces the spread of COVID-19. Ontario has limited classes in high school to about 15 students, but not in the elementary grades, saying the risk of transmission is greater among older students. However, there begins to be evidence regarding children and the risk of transmission. Elementary students would remain with their class group all day, including lunch and recess, with children in grade 4 and up required wearing a mask. This is different than in Quebec, where the school plans contemplate children remaining within a bubble of six children.

Journalist Robyn Urback points to the contradictions that are raising doubts with the public:

“Many parents, particularly in Ontario, are understandably upset by the province’s return to nearly normal for elementary students. After all, for the past several months, medical experts and political leaders have been preaching about the grave importance of physical distancing and reduced in-person interactions, and about the dangers of congregating in poorly ventilated indoor spaces. And now, the province is telling parents to send their kids to school with none of the conditions they were told are essential to staying safe. Of course parents were going to balk at the plans.”  

The science regarding the role that schooling and children play in transmitting COVID-19 is still hazy, and that adds to the challenges and confusion. The effectiveness of students wearing masks in a classroom setting has been the subject of discussion. While children have worn them to school in Asian countries, that’s not the case in several European jurisdictions. RNAO is recommending that children three years and older use masks. In schools, they are most important while on hallways, bathrooms, entrances, buses, and other congested areas. Class sizes should be reduced – see discussion below – so that during class time, it is possible to keep physical distancing, and thus, when children are sitting, there can be breaks from masks. It can be hard for children to use masks all day without a break.  

Some infectious disease experts warn that transmission could be underestimated among children since they are less likely to be tested and might not have symptoms. A school guidance document from Ontario’s pediatric hospitals released last week says: “Smaller class sizes should be a priority strategy as it will aid in physical distancing and reduce potential spread from any index case.” However, the Ontario government, which claims to follow their advice, is not addressing that key recommendation in elementary schools.

Not going to school can have serious impacts for children, particularly during a prolonged period. In September, it will be six months since Ontario children have been away from school. There can be social, emotional, and academic implications for children, as well as mental health challenges. Much depends on the context at home, and these factors are highly correlated with socioeconomic and other status characteristics. Situations of crowded housing, financial difficulties, lack of access to healthy food, parents who must go out to work and cannot stay at home, lack of good access to internet and technology – these are some of the numerous factors that can make a stay-at-home situation unhealthy for a child. There are also extraordinary situations such as children that live in an abusive or neglectful home.  On the other side, there are households, particularly those well-accommodated where one or both parents can dedicate themselves fully to the children’s care, with the proper housing and means to pay for supports, extra-curricular activities, and more – these are contexts where children can have a much better experience or even thrive in young age while being at home.

There is one aspect of the government’s plan that has not been fully discussed in the media and other forums, which has mixed implications. The Ontario government may be addressing the concern of class size – not by providing budget for hiring more teachers and creating more classrooms, but by “inviting parents to keep their children at home if they so wish.” It may be the government hopes many parents will decide to leave kids at home and thus the actual number of students in school in September will be smaller, thus addressing the issue of class size without increasing budgets. However, if this situation materializes, it will happen across class and social group lines – we know which kids will (or at least have the choice to) stay at home and which will have no choice but to go to school.

That means the actions of government may be aggravating the inequities of COVID-19, which show themselves insidiously elsewhere as well – we’ve heard about the unequal impact of COVID and of the measures taken to address the pandemic. The toll of more than six months at home for children who do not have the proper conditions at home can have lasting negative effects. Many of these families would not have the choice to leave kids at home, even if they would so prefer. This is another major inequity that plays along social divisions based on income, race, Indigeneity, migrant status, home situation, neighbourhood, and region.

What has also not been emphasized is how COVID-19 and the government’s response may also be encouraging privatization of schools. Some well-endowed parents are now considering, given their concerns about the school plans, whether instead they should organize school pods (where a few households get together to hire a private teacher), home schooling, hire nannies, or place children in private schools. This represents a major inequity, as most parents do not have those choices and they depend on what they may perceive as a disappointing public-school system. This is a sure path to decay in public education where the wealthy send children to private schools and public support is eroded. These dynamics, prevalent south of the border, also play out in Canada and we should be very cautious about them. Shelley Laskin, a long-time Toronto school board trustee, says “Confidence in our public education system is at risk.”

It is not too late for the Ontario government to do the right thing. Premier Ford should be commended for connecting with the public since the pandemic started and paying attention to the feedback he receives. Arguably, together with healthcare, there isn’t anything as important to our social fabric as education. Premier, this is not the item or the time to skimp on money. Ontario is a very rich jurisdiction and must make decisions to channel that wealth where it needs to go: for the health and wellbeing of Ontarians, and particularly its children. Premier, nurses ask you to act now and provide the school boards the funding they require to reduce class sizes in elementary school!

Let me turn to a different aspect of this discussion. RNAO gives kudos to the government for the announcement of “$50 million to hire up to 500 additional school-focused nurses in public health units to provide rapid-response support to schools and boards in facilitating public health and preventative measures, including screening, testing, tracing and mitigation strategies”. RNAO advocated for hiring these public health nurses (PHNs), which will play a critical role in the school re-opening. On this action, RNAO applauds Dr. David Williams for taking on this issue and ensuring it gets funded for 2020 and 2021.

In RNAO’s view, these PHN will be:

1. Educating, teaching, training, facilitating, interpreting, and communicating COVID-19 related information to students, parents and teachers.

2. Contributing to surveillance of children and youth health -- especially given the months of lock-down and the re-opening under unique circumstances (i.e., physical distancing and wearing of masks). These colleagues will conduct the usual PHN school health work in addition to the likely increased anxiety given the situation. They will also have the capacity and competencies to link up with important community resources.

3. They will be a source of expertise, constant problem-solving and stability in what are, otherwise, uncertain times with lots of unpredictability. As we know, the experiences of opening schools in other countries have been mixed, from good to difficult, and we have no experience of our own addressing a pandemic in schools, as they were closed in March and have not reopened since them. In every respect, these are anxious times for students as well as for teachers and parents.

The PHN nurses hired should be RNs and ideally RNs with a BScN, as per public health standards. The school environment during a pandemic period is undoubtedly “highly complex, unpredictable and high risk for negative outcomes,” which requires the competencies of an RN, according to CNO Practice Guideline (p. 5). The requirement is that PHNs are registered nurses with a baccalaureate degree in nursing.

Where these PHNs will be located is important. The ministry announcement mentions the need for “rapid-response support to schools and boards in facilitating public health and preventative measures, including screening, testing, tracing and mitigation strategies.” These are public health responsibilities, so RNAO has urged Minister Elliott and Dr. Williams that these PHNs be located in public health units (PHU) across the province. They should be part of broader public health work under the purview of Chief Nurse Officers, and they must receive on-boarding that includes awareness of local community resources for COVID-19 and for mental health, addictions and social services - so they can assist schools – administrators, teachers, and parents. 

The role of School Health Nurses is doubly important as we reopen from COVID. I paraphrase next RNAO member Austin White, RN, BScN, a public health nurse at the School Health Elementary Team, Niagara Region Public Health, who describes the role from own experience:

School Health Nurses use an evidence-informed approach, and youth engagement principals, to create health programming tailored to the needs of students. We have experience working with schools and understand the importance of really getting to know the school community and their individual needs. We need to adapt to our schools’ needs and will continue to do so in the upcoming months, using our comprehensive school health model. This is particularly important to address the anxieties caused by the pandemic and provide them with the necessary education to promote their health and well-being.

I have been redeployed to our Infectious Disease team for Contact Tracing and Case Management, and, moving forward, having School Nurses address these issues is important as we already have relationships within our own school communities. We will bring the voice of our expertise.

There are slow burn/shadow pandemic effects of COVID-19 on children and youth and PHNs/School Health Nurses are critically positioned to address them.

Summarizing, RNAO’s policy recommendations to the Ontario government are:

• A fundamental factor in the success of school reopening is the continued containment of the virus and absence (or very low levels) of community spread. This may require curtailing other societal activities that are lower priority, such as closing indoor bars and restaurants and reducing numbers for other indoor events.
• The province must rethink its position on not addressing class sizes for elementary schools. This position is unjustified, contradicts the recommendations of experts and public health officials, and leads to many harmful effects. Class sizes should be reduced, and proper funding must flow to the school boards – immediately – as time is of essence.
• The opening of schools should be postponed, if necessary, until all the conditions are in place for a safe reopening, including smaller class sizes.
• Assuring physical distancing and appropriate class sizes would allow to schedule breaks from using masks during the school day, targeting their use to situations where there is no physical distancing, such as when students are moving within the classroom, hallways, bathrooms and other congregate/congested spaces.
• We commend the government on the hiring of 500 public health nurses to support the school reopening. These should be RNs with a baccalaureate degree and should be positioned as staff within public health units across the province. The hiring and onboarding must take place in August – thus, funding flow is essential.   

Take action: Sign a petition started by a parent demanding to Reduce Class Sizes to Keep Schools and Communities Safe in Ontario. I’ve signed and urge you to do so right away!

Update on webinars

RNAO held weekly COVID-19 webinars every Monday evening between March 30 and early July, with decreased frequency after that. Attendance is always anywhere between 200 and 350! The COVID-19 Webinars: Together We Can Do It! are free and open to all.

The next webinar will be on Monday, August 10, 6:45-8:00 pm, focusing on nurses’ mental health and wellbeing. The global pandemic has exacerbated health and mental health concerns amongst nurses. Shortages of PPE, fear of infecting family members, isolation from family members, increased emotional and physical exhaustion, and inability to take time off – all exacerbated mental health concerns among nurses which predated the pandemic. Come hear about the healthy professional worker partnership that aims to identify interventions to better support nurses’ mental health and facilitate healthy return to work. Share your experiences and find out how to support this research. You can register here. An article presenting the issues is here. The guest speakers are: 

• Abby Ayoub (University of Ottawa)
• Melanie Lavoie-Tremblay (McGill University)
• Ivy Bourgeault (University of Ottawa)

If you have not had a chance to watch previous webinars, here are a couple of them:

• On July 1, we hosted Dr. Jennifer Kwan, a family physician and one of the organizers of #Masks4Canada. She spoke about what we need to do to have a successful re-opening of the economy, and the role that COVID-19 surveillance, good data and masking have in achieving that. You can watch it here.
• On June 22 we discussed the Impacts of COVID-19 on Indigenous Communities with three guest speakers: Ontario Regional Chief RoseAnne Archibald; Mae Katt, Nurse Practitioner with Temagami First Nation; and Marilee A. Nowgesic, CEO of the Canadian Indigenous Nurses Association. You can watch it here.

#Togetherwecandoit

MOH EOC Situational Report

As announced above, we will be posting each day the Daily Situational Reports from Ontario's MOH EOC at RNAO’s website. That way, you will be able access the Ministry’s guidance without having to wait for my COVID-19 report. Again, the link is here and you can check it every day.

Since this report will come out once weekly, that will provide a more timely access to Ministry guidance.

For a more detailed Ontario epidemiological summary from Public Health Ontario, you can always go here.

Here is a segment from the latest Situation Report #195 for 7 August: 

Actions taken:

• Several documents have been updated and shared to the Ministry’s website including:
  • COVID-19 Case Definition with new information on cases confirmed through serology testing
  • COVID-19 Reference Document for Symptoms with an updated section on MIS-C in children
  • COVID-19 Provincial Testing Guidance with new information on serology testing, and updated guidance on asymptomatic individuals and targeted asymptomatic testing campaigns
  • A new appendix document (Appendix 8: Serology Testing and MIS-C) has also been shared to support the public health management of serology testing and MIS-C.

 Staying in touch         

Please continue to keep in touch and share questions, comments and challenges. Send these to me at dgrinspun@rnao.ca and copy my executive assistant, Peta-Gay (PG) Batten <pgbatten@rnao.ca>. Due to the volume of comments and questions, we are responding as fast as we can. RNAO’s Board of Directors and our entire staff want you to know: WE ARE HERE FOR YOU!

Thank you deeply to each and all of you for being there for our communities – everywhere and in all roles! Together, in solidarity, we are stronger and more resilient. These continue to be tough times for many colleagues – especially those working in the front lines in Australia, India, Brazil, Peru, Chile, Colombia, Mexico, the US, Russia, South Africa, Iran, and UK – who are still hit hard by evil COVID-19!

Remember, during stressful and exhausting times, the only silver lining is -- coming together and working as one people – for the good of all!

Together, we must redouble our efforts to tackle COVID-19 with the best tools at hand: full, accurate and transparent information, calmness, determination and swift actions. 

Doris Grinspun, RN,MSN, PhD, LLD(hon), Dr(hc), FAAN, O.ONT
Chief Executive Officer, RNAO

PAST BLOG ITEMS:

31 July - Preparing for the second wave of COVID-19: Discussion – go here.

31 July - Important announcement regarding the VIANurse program – go here.

31 July - Government must immediately mandate hiring to avert second tragedy in LTC – go here.

24 July - Preparing for the second wave of COVID-19: What is the plan? – go here.

17 July - RNAO launches new social media campaign #Maskathon – go here.

17 July - RNAO calls on government to reunite families in LTC homes in Ontario – go here.

10 July - Nurses’ mental health, leave of absence and return to work experiences – go here.

10 July - RNAO continues to pursue family reunification in LTC – go here.

10 July - Support Zimbabwean nurses arrested and fired for protesting deteriorating pay and working conditions during pandemic – go here.

3 July -   RNAO launches task force to tackle anti-Black racism within the nursing profession – go here.

3 July -   Rather than praise, let’s protect our nurses – go here.

3 July -   Nurses celebrated diversity during Pride month – go here.

26 June - Nursing Home Basic Care Guarantee – go here.

26 June - Masks for all – the policy imperative in Canada – go here.

18 June - Annual General Meeting – an exhilarating week! – go here.

12 June - Petition on masks for Canada – go here.

12 June - LTC: RNAO releases list of 35 reports and recommendations dating back 20 years – go here.

6 June   - Statement – RNAO stands together with our Black sisters and brothers – go here.

3 June   - Adapting harm reduction during a pandemic – go here.

29 May - Foot care nurses – go here.

29 May - Update on pandemic pay; pandemic pay in consumption and treatment sites – go here.

28 May - RNAO Calls for Immediate Action in Response to the Canadian Armed Forces’ LTC report – go here.

26 May - Update on VIANurse – go here.

26 May - Ending homelessness: Will you join us to build a COVID-19 recovery for all? – go here.

24 May - Technology as a solution: Opportunities and pitfalls of COVID contact-tracing apps – go here.

21 May - Debunking PPE myths with Dr. Jeff Powis: Which masks should health care workers wear during COVID-19? – go here.

20 May - RNAO response to announcement of an independent commission into Ontario's long-term care system – go here.

19 May - With the pandemic curve flattening, VIANurse program will focus its effort on outbreaks – go here.

14 May - Nursing Week update – go here.

14 May - Pandemic puts health system to the test: Nurses have answers for shortfalls – go here.

14 May - Disappointment for not being included in pandemic pay – go here.

13 May - RNAO saddened by the loss RN Brian Beattie to COVID-19 – go here.

13 May - End racism and prejudice – go here.

12 May – Enhancing Community Care for Ontarians (ECCO 3.0) – go here

11 May - Nurses share their successes and challenges during National Nursing Week – go here.

10 May - A story of hope, ingenuity, support and genuine care for an LTC resident – go here.

7 May    - Counting the missing deaths: Tracking the toll of the coronavirus outbreak – go here.

5 May    - Life on the front lines of the pandemic: Profile of RNAO member NP Daria Gefrerer – go here.

5 May    - Addressing differential access to virtual care due to technology inequities – go here.

3 May    - Being person-and-family-centred during COVID-19 – go here.

1 May    - Migrant agricultural workers and the COVID-19 crisis – go here.

30 April - COVID-19 pandemic in provincial institutions and correctional centres – go here.

28 April - Supporting First Nation Communities during COVID-19 – go here.

27 April - Responses to COVID-19 for persons experiencing homelessness in Toronto: An update – go here.

25 April - Lessons learned through a COVID-19 nursing home outbreak – go here.

25 April - Letter from a retired RN to Premier Ford: The problems with LTC were evident long before COVID – go here.

23 April - Working with seniors in long-term care requires specialized knowledge – go here.

22 April - Shaking the stigma: We need a proactive COVID-19 response for mental health and addiction – go here.

21 April - We Require Expanded and Accessible COVID-19 Data in Ontario – go here.

20 April - Can Loss of Smell and Taste Help Screen for COVID-19? – go here.

18 April - COVID, Trump and the World Health Organization – go here.

16 April - A Home Based Model To Confront COVID-19 – The Case Of The Balearic Islands – go here.

15 April - COVID-19 and the Challenges in Homecare – go here.

14 April - Reprocessing Of N95 – An Update – go here.

14 April - A New COVID-19 Facility For Persons Experiencing Homelessness In Toronto – go here. 

13 April - Practical Tips for Safe Use of Masks – go here.

10 April - Ontario’s Tragedy in Long Term Care Homes and Retirement Homes – go here.

10 April - RNAO Action – Supporting Long-Term Care – go here.

10 April - Update For Nursing Students – NCLEX Exam – go here.

9 April - Celebrating Passover, Good Friday, Holy Saturday, Easter Sunday and the start of Ramadan during a pandemic – go here.

9 April - Guidance on use of N95 mask – go here.

7 April - Sentinel surveillance and on-site testing in the homeless service sector – go here.

7 April - Reprocessing of n95 – safe? – go here.

5 April - We must change the way we do testing and case definition – go here.

5 April - Ringing the alarm bells on critical care beds – go here.

4 April - COVID-19, stay at home and domestic violence – go here.

We have posted earlier ones in my blog here. Please go and take a look.

Information Resources

Public Health Ontario maintains an excellent resource site on materials on COVID-19. This is an essential resource for Ontario health providers. 

Ontario’s health provider website is updated regularly with useful resources here.

Ontario’s public website on the COVID-19 is there to inform the general public – encourage your family and friends to access this public website. The WHO has provided an excellent link for you to share with members of the public here.

Please promote the use of Ontario’s COVID-19 self-assessment tool: It also has a guide where to seek care, if necessary. Its use will provide the province with real-time data on the number and geography of users who are told to seek care, self-isolate or to monitor for symptoms. Data will inform Ontario's ongoing response to keep individuals and families safe.

Health Canada's website provides the best information capturing all of Canada. It contains an outbreak update, Canada's response to the virus, travel advice, symptoms and treatment, and resources for health professionals.

The World Health Organization plays a central role in addressing the COVID-19 pandemic. See here and here.

You can find up-to-date global numbers in Coronavirus COVID-19 Global Cases by Johns Hopkins CSSE.

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