In June 2024, Ontario’s Progressive Conservative government voted down Bill 192, a private member’s initiative supported by the New Democrats and Liberals that would have established a cap on the number of patients under the care of each nurse per shift.  

But nurses haven’t backed down. Armed with evidence showing how this policy improves the quality of care and the work environment, health-care professionals across the province rallied, organized and fought for a patient-to-nurse ratio at an institutional level. This long, exhausting fight has entered arbitration with the Ontario Hospital Association. 

A second chance for the province to act

The fight also continues in the provincial legislature. Bill 19 – essentially a reintroduction of Bill 192 after the election earlier this year – offers the Doug Ford government a renewed chance to show it values nurses and is committed to improving the health of Ontarians. It deserves a serious review in committee, along with opportunities for both professionals and the public to be heard. 

The bill would set a maximum number of patients a nurse can care for during one shift, depending on the clinical setting and the complexity of care required. 

For example, patients in intensive care units require more attention, so nurses must spend more time performing procedures, administering medications and assisting with activities that are often one-to-one. 

On the other hand, patients in rehabilitation facilities may be fully ambulatory and require far less monitoring. They are often able to manage their daily activities independently, meaning nurses are needed mainly for oversight and support. In such settings, one nurse can typically care for four or five patients effectively.   

A good ratio should take into account the specific demands of each clinical setting, including specialized procedures, such as ventilation or wound care, and variations in the workload between day and night shifts. 

Time and labour are finite resources. When the number of patients increases beyond what is manageable, nurses must allocate less time and effort to each patient. This leads to poorer patient outcomes, a higher risk of errors and reduced patient satisfaction. 

This simple arithmetic is backed by evidence. In 1999, California implemented a patient-to-nurse ratio, leading to a significant reduction in patient mortality. Queensland, Australia, adopted a similar policy in 2016 and saw improved patient outcomes, shorter hospital stays and lower readmission rates. 

Ratios improve care — and keep nurses on the job 

A good patient-to-nurse ratio would also create a more sustainable environment for retaining nurses. 

A 2024 study by the Registered Practical Nurses Association of Ontario found that many of its members were negatively affected by the nursing shortage and increased workloads. Due to limited time and resources, its members reported being unable to provide the level of care they felt was necessary. 

This increased pressure has created significant psychological strain, with nearly half of practical nurses considering leaving the profession. Among those planning to leave, 63 per cent said they intend to exit health care altogether. 

The Registered Nurses’ Association of Ontario reported similar findings regarding job dissatisfaction and workload challenges for its members. 

With the ongoing nurse shortage already straining the health-care system and causing emergency department closures across the province, urgent action is needed. 

When practical nurses planning to leave were asked what would make them reconsider, 72 per cent cited a better patient-to-nurse ratio as a key factor. Evidence shows this policy can reduce the risk of occupational injury, increase job satisfaction, decrease burnout risks and improve retention. 

Ontario is moving in the wrong direction 

However, during last year’s debate on Bill 192, the Ford government expressed no concerns about the quality of patient care or the burdens placed on nurses. Instead, it argued that an increase in the patient-to-nurse ratio would lead to an increase in the number of nurses needed in the province and a resulting increase in provincial spending. 

The trend is in the opposite direction. 

For every 100,000 Ontarians in 2021, there were 668 registered nurses. By 2022, this number dropped to 661 and despite the government’s so-called significant investments in the area, the number fell even further in 2023 to 651. 

These numbers are the lowest in Canada where the national average is 825 per 100,000 people. However, the nurse-per-capita metric in Ontario has decreased by seven per cent in the past decade. This is a staggering failure and it is shameful to treat nurses and patients this way.  

Nurses are fed up with the status quo. The system continues to show little regard for its staff, despite growing concerns about patient health. Those in power remain indifferent, even when presented with clear evidence. The persistent stubbornness and dismissiveness are disheartening. Beneath the frustration and sadness lies a deeper truth: nurses are exhausted. 

The health-care system is approaching a breaking point. Ontarians are frustrated with long hospital wait times and emergency room closures, yet we gave Ford and his party another mandate in the February provincial election. 

The government should repay this trust, listen to nurses, engage in meaningful constructive discussion and support the implementation of an effective patient-to-nurse ratio cap.