Last week, an arbitration panel in Ontario sided with hospitals and rejected the Ontario nurses union’s call for minimum staffing requirements, dealing a blow to the movement.Cole Burston/The Canadian Press
In a recent round of collective bargaining, the top priority of the Ontario Nurses’ Association wasn’t a predictable ask such as higher wages or better benefits.
Instead, it was an increasingly discussed way of retaining burned-out health workers: mandating minimum nurse-to-patient ratios.
The Ontario union and international nursing researchers say that nurses and patients alike are safer when hospitals are required to keep workloads in check by, for example, stipulating that nurses on medical and surgical units can’t care for more than four patients at a time.
“In other sectors that are dangerous, like fire and police, staffing ratios exist, and they exist to keep those workers safe,” said Erin Ariss, president of the ONA, which represents about 60,000 hospital nurses in Canada’s most populous province.
“When was the last time you saw a fire truck rolling to an emergency that is dangerous with one firefighter in the truck?”
But hospital executives in Ontario counter that establishing nurse-to-patient ratios would be too “rigid,” especially if the consequence for failing to meet them is cancelling some non-urgent medical services, as the union proposed.
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Last week, an arbitration panel in Ontario sided with the hospitals and rejected the union’s call for minimum staffing requirements, saying the ONA failed to demonstrate they were necessary. The arbitrator also awarded nurses a 5.25-per-cent raise over two years.
The decision dealt a blow to a growing national campaign to make minimum staffing ratios the norm in Canada’s struggling public health care system, where shortcomings ranging from shuttered emergency departments to long waits for surgery can be traced back to a lack of nurses, doctors and other health professionals.
The British Columbia government broke new ground when it announced in March, 2024, that B.C. would become the first province to implement nurse-to-patient ratios around the clock. The Canadian Federation of Nurses Unions followed that news by hosting the first summit on nurse-patient ratios in Ottawa last November, with the support of Health Canada.
Mandating nurse-to-patient ratios isn’t a new idea, according to Linda Silas, president of the CFNU.
She said some Canadian nursing leaders have been advocating for them since the early 2000s, when a seminal study published in the Journal of the American Medical Association found that each additional patient per nurse was associated with worse patient outcomes and a higher likelihood of burnout and job dissatisfaction among nurses.
That research, conducted in Pennsylvania, was released not long after California legislated minimum nurse-to-patient ratios in its hospitals, with fines as punishment.
Ms. Silas said that, in Canada, provincial governments and hospital executives were for years “almost allergic” to specific ratios. This led nursing unions to push for “safe staffing” provisions, which are generally clauses in collective agreements that help nurses escalate concerns about their workload and safety.
“But what we learned over the last 10 years is, even if they agree on safe staffing, if you do not have that line in the sand, they do not respect it,” Ms. Silas said. “So, we had to move forward again with mandated nurse-patient ratios.”
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In B.C., the NDP government worked with nursing unions to come to a voluntary agreement on minimum nurse-to-patient ratios, backed by $750-million in extra funding over three years to hire more nurses. Planned ratios include one nurse for every four patients on medical and surgical units, one nurse for every two patients in high-acuity units and a one-to-one ratio in intensive care units.
Adriane Gear, president of the BC Nurses’ Union, said that although it is taking some time to implement ratios on the ground, every health authority in the province is making progress on the first phase on medical and surgical wards.
“We can’t just flip a switch,” Ms. Gear acknowledged. “But my members remain really excited. The feedback where ratios have been implemented has been really, really positive.”
The main stumbling block is that there still aren’t enough nurses in B.C., despite a training and hiring blitz that Ms. Gear said has contributed to her union adding about 5,000 new members in recent years.
Karen Lasater, an associate professor in the Center for Health Outcomes and Research Policy at the University of Pennsylvania, said minimum staffing ratios could help persuade registered nurses who’ve cut back on hours or left the profession to return to full-time work.
“Inadequate staffing is a leading reason why nurses leave the workplace,” she said.
Prof. Lasater led a recent study of staffing at B.C. hospitals designed to set a baseline to measure the impact of the minimum staffing plan as it unfolds.
Back in Ontario, the provincial government and the Ontario Hospital Association − the group across the table from the nursing union during collective bargaining − say there are better ways to ensure hospitals are properly staffed.
“In today’s complex and demanding environment, there isn’t a one-size-fits-all approach to staffing,” said Kirk LeMessurier, chief of communications and public affairs for the Ontario Hospital Association, in a statement. “Rigid nurse-to-patient ratios would remove the flexibility required to tailor staffing levels.”
Mr. LeMessurier went on to say that a particular challenge was the ONA’s proposal that some non-urgent health services be cancelled when ratios aren’t met, which arbitration chair Sheri Price agreed “could jeopardize patient care.”