Three Canadian Provinces are on Board with Minimum Nurse-to-Patient Ratios. Here’s How Implementation is Going.

Hospitals across three Canadian provinces are starting to adopt a strategy that has improved patient outcomes and reduced nurse turnover rates in other countries: minimum nurse-to-patient ratios.

Last month in Manitoba, health minister and deputy premier Uzoma Asagwara tabled Bill 28 — the first legislation of its kind that, if passed, would allow them to establish minimum nurse-to-patient ratios in hospital units across the province.

Ratios, or standards for how many patients each nurse can safely care for in different hospital units, were first introduced in Canada through negotiations by nursing unions in BC, then Nova Scotia, in 2023. 

Implementation of this policy is the furthest along in BC, where the agreement came with a $750 million commitment over three years from the provincial government, to be used for recruitment and retention by the province’s five health authorities. It’s far from perfect, but is already starting to show results. 

Today marks the start of BCNU’s first-ever conference on minimum nurse-to-patient ratios, bringing together nurses, researchers and health leaders from across BC, Canada and around the world to focus on the next phase of implementation. https://t.co/IMGbBhkJlM pic.twitter.com/EDGXJYyiek

— BC Nurses’ Union (@BCNursesUnion) March 11, 2026

“What we know is units that have moved to minimum nurse-to-patient ratios, they have very few vacancies because people want to take jobs there,” BC Nurses Union President Adriane Gear told PressProgress in an interview. 

“Health authorities are reporting they have nurses that were part time, but now they’re taking full-time [roles] because in the area that they work, the workload is better, because they know that they’re going to work at ratio.”

In a statement earlier this month, the union shared that 73% of all medical and surgical, rehabilitation, palliative, intensive care and pediatric units in hospitals across BC have “activated” minimum-nurse-to-patient ratios. 

This means that for nearly three quarters of all hospital units in these specific categories, the employer — health authorities — has funding in place to hire more nurses and must do everything they can, including calling in nurses to work overtime, to try to meet the established ratio. 

It does not necessarily mean that the ratio is always met, Gear said, and even when there is an appropriate number of nurses to patients as per the new standards, an influx of extra patients and/or poor planning by management sometimes leads to the ratio no longer being fulfilled. 

“For the most part, it is, I think, because we still have a serious resource issue; there aren’t enough nurses,” Gear said. 

“The employer, in some instances, has taken all those steps, and sometimes there’s still not a nurse to bring in, and so … that unit is currently not at ratio, but that doesn’t mean that they’re not going to be at ratio tomorrow, or that they weren’t at ratio consistently for the last two weeks.”

“This table lays out minimum nurse-to-patient ratios set for different hospital units in BC, during the first phase of implementation. It shows how, for example, Intensive Care Units (ICUs) are required to have one nurse per patient, while in Medical/Surgical units, the requirement is one nurse for every four patients.
Source: BC Nurses Union website.”

The call for minimum nurse-to-patient ratios as a way to safely staff hospitals, prevent burnout among nurses, and improve patient outcomes has picked up steam in Canada over the past three years, after being successfully implemented in other parts of the world, like Queensland, Australia, multiple US states, Ireland, and Scotland. 

But in some parts of the country, like Ontario, nursing unions still face an uphill battle with provincial governments in their bid to establish ratios. 

Are ratios too expensive? 

For Gear, the main impediment to minimum nurse-to-patient ratio implementation in other provinces is “sticker shock” that comes with the price.

“Obviously there’s an upfront cost. When I think about our economy and the deficit situation we have [in BC] it’s not great, but we’re actually not unique. All provinces are struggling,” she said. “However, if people are actually looking at this from a systems perspective, there’s also potential for huge savings.” 

There is evidence to suggest that ratios can result in long-term savings. 

A study published in The Lancet medical journal in 2021 found that after minimum nurse-to-patient ratios were introduced in Queensland, Australia, “in addition to producing better outcomes, the costs avoided due to fewer readmissions and shorter length of stay were more than twice the cost of the additional nurse staffing.” 

“That’s evidence of a strong business case for investing upfront in more nurses,” said Dr. Karen Lasater, a Registered Nurse and Associate Professor of Nursing at the University of Pennsylvania’s Center for Health Outcomes and Policy Research. 

“Literally, all of the bad things that could happen to patients in hospitals, they’re less likely to happen when nurses care for fewer patients at a time.”

In a paper Lasater published last year, the authors studied survey results from over 6,600 BC nurses working across 58 hospitals. Nearly 80% reported their workloads were unsafe for patients, about 60% said they were burnt out, and nearly 20% intended to leave their jobs. 

Lasater said the researchers’ plan is to go back and study the impacts after BC has fully implemented ratios. So far, according to Gear, a few challenges remain. 

“I’ve just come from a breakout session speaking with nurses who are working on units [where] ratios have been implemented,” said Gear, speaking from the province’s first nurse-to-patient ratio conference earlier this month. “What they’re telling us is the rules aren’t always followed.”

In some cases, employers will send nurses from a unit that is operating at ratio to a different unit to help manage a rising caseload there, resulting in the original unit no longer being at ratio. 

In other cases, an unexpected influx of extra patients on a unit is not responded to with a corresponding increase in nurses, to meet ratio requirements. Other times, nurses report that managers don’t proactively plan to have extra nurses on hand for periods known that there will be a surge of patients incoming — like during respiratory illness season. 

“Do I think health authorities are hiring? Yeah,” Gear said. “Are they hiring as fast as they should and could? That, I don’t know.”

Once the first phase of implementation is complete in BC, the plan is to introduce nurse-to-patient ratios in emergency departments and maternity wards in the next stage. 

How other provinces are approaching ratios

The Nova Scotia Nurses Union successfully added minimum nurse-to-patient ratios in their last round of collective bargaining, right after their BC counterparts, but unlike BC the Nova Scotia agreement did not come with an influx of cash from the province.

“We already have like, five or six hundred vacancies, similar to every other province in the country,” said Janet Hazelton, Nova Scotia Nurses Union president in an interview with PressProgress. “If every position was filled, they would be at full complement.”

In addition to an overall shortage of workers, Hazelton said implementing ratios is slow going in Nova Scotia because of a key difference in their approach compared to BC. 

With around 200 hospital units — compared to BC, which has thousands — Hazelton said the union has been working on customizing nurse-to-patient ratios on a unit-by-unit basis. 

“We just now have all of the guaranteed ratios for all of our 200 units,” she said. “Then we are going to publicly put them in the units, where nurses and the public can see…[If] nurses feel that this ratio [is] not good enough… there’s a process in the collective agreement [through which] they can ask for an evaluation.” 

Unlike BC and Nova Scotia, Manitoba is kicking off its journey towards safe staffing ratios for nurses via legislation — the first in Canada to take this route. 

Manitoba’s Bill 28 — The Health System Governance and Accountability Amendment Act — tabled last month, would allow the NDP government to legislate nurse-to-patient ratios, in a national first. 

Legislating nurse-to-patient ratios.

If you want safer care, you need enough nurses on every shift. It’s that simple. And this spring, legislation is coming to set nurse-to-patient ratios in key areas of our health care system.

We’ve already hired 3,500 more health care… pic.twitter.com/XkBAYprRC0

— Wab Kinew (@WabKinew) December 15, 2025

Like in other provinces, a ratio would establish the number of patients each nurse would see in Manitoba, which would vary from unit to unit. An “implementation committee” would be established through this legislation, which would then work to develop ratios for each department and oversee their rollout. 

This bill was introduced at the same time as Bill 26, which, if passed, would end or put a limit to mandatory overtime for nurses.

Other provinces are less enthused by the prospect of establishing safe staffing levels in hospitals. 

Nurse-to-patient ratios were a key sticking point in the latest round of collective bargaining last year, between the Ontario Nurses Association (ONA) and the province’s Progressive Conservative government — represented by the Ontario Hospital Association during talks with the union. 

A stalemate resulted in talks moving to an arbitration panel, which ended up siding with the province and Hospital Association, noting a few differences between the ONA’s proposal and ratios established in other jurisdictions.

For one, ONA’s proposal wanted ratios to be met exclusively by Registered Nurses, while other jurisdictions included different nursing classifications. 

The second, “most striking” difference for the arbitration panel is that ONA wanted all non-urgent patient procedures to be cancelled when a nursing ratio requirement is not met — a stipulation that is not a part of any other jurisdiction’s ratio agreements or proposals. 

Despite this initial loss at the bargaining table, the union said its members are not likely to give up. 

“Although hospital bargaining is scheduled for next year and members will play the central role in identifying and advancing their priorities, it is highly likely that nurse-to-patient ratios will once again arise as a key issue in the next round of negotiations,” said ONA provincial president Erin Ariss, in a statement emailed to PressProgress.

The Ontario health ministry did not respond to a request for comment. 

“We are starting to see other provinces come on board, and maybe they haven’t committed yet but there’s interest, and that’s really exciting,” Gear said. 

“The nature of healthcare, it is the jurisdiction of provinces, so if [ratios] were being coordinated federally, maybe it would be a different conversation. But it’s not.”