Policy and Political Action

Policy & Political Action

School re-opening and planning for the 500 public health nurses in Ontario

Dr. David Williams
Ontario’s Chief Medical Officer of Health 21st Floor, 393 University Ave
Toronto, ON M5G 2M2

Aug. 19, 2020

Dear David,

Re: School re-opening and planning for the 500 public health nurses in Ontario

I am writing to follow-up on our meeting August 5, 2020. RNAO believes that planning for the reopening of schools in September in the safest way possible is central to managing the ongoing challenges that COVID-19 presents to Ontarians’ health, the health of our communities, and our economy. Balancing pandemic health risks related to the reopening of schools with risks related to developmental, mental health and social risks to our children and youth from not opening is the challenge we must get right.

With approximately two million school-age children and 160,000 teachers in Ontario, it is clear the health and well-being of these children, their parents, teachers and staff must be central to the decision-making process. We must make decisions that avoid major risk to health and life, and continuously consider the impact on the pandemic curve. We all understand that the reopening of schools in Ontario is only possible because of the successful containment of the virus, as well as very low levels of community spread, both of which must remain the norm. For RNAO, it’s clear that if the pandemic curve reverses course, aggressive action from government will be required to curtail societal activities with lower priority, such as indoor bars and restaurants, as well as other indoor events.

The safest approach to reopening Ontario schools is keeping elementary classes small. The announcement to unlock $500 million from school board reserves to improve ventilation and physical distancing was deeply disappointing. That’s because it is akin to mortgaging the future of our schools. Most concerning is that the announcement was silent on the urgent issue of smaller class sizes in elementary schools. Rather, it allows school boards to make necessary adaptations in consultation with their local public health unit. We are less than three weeks away from the start of classes and still the funding required to meet your public health mandate of two metres distance is not forthcoming. David, it is the view of RNAO that you have and should take the responsibility to publicly advance this goal.

Limiting class size for elementary school children – which is being done for secondary school students – is of utmost urgency. RNAO disagrees with the rationale that the risk of transmission is greater among older students. There is evidence regarding children and the risk of transmission and RNAO will continue to insist the government mandate elementary class sizes of no more than 15 students – unless larger places (i.e., gyms, outdoor classes, etc) can enable the two metres required for physical distancing. Reduced class sizes mean physical distancing will be enabled and students can take breaks from wearing masks while seated in their classrooms.

David, RNAO also recommends that children three years and older use masks in schools. This is most important while they are in hallways, bathrooms, entrances, buses and other congested areas. We believe these measures are crucial given some infectious disease experts warn that transmission could be underestimated among children as they are less likely to be tested and might not have symptoms.

We also want to express concern over the repeated suggestions by the government that parents should consider keeping their children at home if they so wish. There is little doubt this type of choice is not equitable across class and social groups, which means it will aggravate the inequities already caused by COVID-19. Simply said, many families that need to work would not have the choice to leave kids at home, thus reinforcing social divisions based on income, race, migrant status, home situation, neighbourhood and region.

In this regard, we are aware of situations in which wealthier parents are now considering options such as: organizing school pods (where a few households get together to hire a private teacher); home schooling; hiring a nanny to support home schooling; or placing children in private schools. This is a sure path to the decay of our public education system where the wealthy send children to private schools and public support is eroded.

David, RNAO cannot be fully supportive of the current plan for reopening schools. We are calling for urgent attention to the following to ensure the highest degree of success in this critical step for Ontario children and youth:

  • 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 mandating smaller class sizes for elementary schools. This position is unjustified, contradicts the recommendations of experts and public health officials, and may lead to many harmful effects. Class sizes should be reduced and proper funding must flow to the school boards immediately. Time is of the essence.
  • Masks must be mandatory for all students in schools. We know children as young as three years of age can be taught to wear a mask and do this consistently over a period of time.
  • Assuring physical distancing and appropriate class sizes would allow scheduled breaks from using masks (mandatory for all students) 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 congested spaces.
  • The opening of schools should be postponed, if necessary, until all the conditions are in place for a safe reopening, including smaller class sizes.

RNAO welcomes the provision of $50 million to hire 500 additional, school-focused public health nurses (PHN). We agree they must be located in public health units to provide rapid- response support to schools and boards in facilitating public health and preventive measures, including screening, testing, tracing and mitigation strategies.”13 RNAO is very pleased to see this component of the reopening plan. The association has advocated for this, and we believe the addition of PHNs in schools will be critical to pandemic management with students, teachers and families. These additional registered nurses will also play a key role in ensuring overall mental health in schools, in light of the pandemic, as well as ongoing student health and well-being matters. RNAO applauds you, David, for your leadership on this issue and ensuring it gets funded for 2020 and 2021. Furthermore, we believe these should be permanent positions as children and youth would benefit immensely.

RNAO’s position, as detailed on August 7, 2020, urges the following policy directions to ensure the most effective impact of the PHN role:

  • PHNs who are hired in this role should be registered nurses (RN) and ideally RNs with a Bachelor of Science in Nursing (BScN) degree, as per public health standards and the College of Nurses of Ontario (CNO) requirements. The school environment during a pandemic is undoubtedly “highly complex, unpredictable and at high risk for negative outcomes,” which requires the competencies of an RN, according to the CNO Practice Guideline.18
  • These PHNs must be located in local public health units (PHU) across the province. In doing so, PHNs can effectively manage the impacts of COVID-19 by leveraging existing relationships between local PHUs and school boards, as well as be easily available to teachers, parents and administrators when needed. They should be part of broader public health work under the purview of chief nurse officers, and they must receive on-boarding that, in addition to COVID-19 related information and protocols, includes increased awareness of local community resources for COVID-19 and for mental health, addictions and social services. This will allow them to assist schools, administrators, teachers and parents.
  • The role of PHNs in schools must include:
    • Educating, teaching, training, facilitating, interpreting and communicating COVID- 19 related information to students, parents and teachers. This includes surveillance of and response to COVID-19 symptoms. In-school testing should be considered.
    • Contributing to surveillance of children and youth health – especially given the months of lock-down and the reopening 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 increase in anxiety given the situation. They will also have the capacity and competencies to link individuals with important community resources.
    • The application of the PHN’s existing expertise, critical thinking and problem- solving skills to promote health and well-being in schools, thus ensuring community stability in what are otherwise uncertain times with lots of unpredictability.
  • Hiring and on-boarding of PHNs has begun and we are ready to help. The idea is to have all 500 positions filled in August.

David, RNAO appreciates the clear direction you provided to the health units, including chief nursing officers, on Aug. 11, 2020 related to the immediate hiring of RNs in schools to be broad health and safety stewards for students, teachers and families in this complex and unprecedented situation. We fully agree with the content of your memo, however are concerned that some units have been told to offer these positions until the “end of the year” or “for one year.” My understanding from you is that the budget had been approved for 2020 and 2021. Offering these positions for two years will help to facilitate the hiring of qualified candidates. There is little doubt that these 500 PHNs will be desperately needed at the local health unit level. Their role relates to all aspects of the pandemic that involve students, teachers and families, as well as other related health issues prevalent in schools. We urge you to intervene to clarify that these PHNs be hired for a two–year period.

As Ontario’s public health lead, we urge you David to ensure the most appropriate policy decisions are made for overall safety of students and teachers in Ontario schools, as well as their families, as we move to school reopening. It is absolutely imperative that changes are made to class size, that masks are mandated for all students in schools, and, if needed, a delay in reopening is considered until necessary actions are taken to mitigate risks.

RNAO welcomes further discussion to expedite these changes. As I shared with you on August 5, we are ready to assist the ministry of health and work with our chief nurse officer colleagues in Ontario’s public health units in the hiring, training and retaining of the 500 PHNs and the required on-boarding and supports for them.

With kind regards,

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

Chief Executive Officer, RNAO

CC: Hon. Doug Ford, Premier of Ontario Hon. Christine Elliot, Minister of Health
Hon. Stephen Lecce, Minister of Education Helen Angus, Deputy Minister of Health Nancy Naylor, Deputy Minister of Education
Dr. Barbara Yaffe, Associate Chief Medical Officer of Health
Dr. Fiona Kouyoumdjian, Associate Chief Medical Officer of Health
Dr. Michelle Acorn, Provincial Chief Nursing Officer, Ministry of Health

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