Minimum Nurse-to-Patient Ratio FAQ

mNPRs are a critical policy solution aimed at addressing the severe nurse staffing shortage in BC’s health-care system. mNPRs represent the minimum number of nurses deemed necessary to care for a maximum number of patients on a given unit, and provides a simple, clear formula that transparently indicates staffing requirements for licensed practical nurses, registered psychiatric nurses and registered nurses throughout the province.

mNPRs will drastically improve patient care across the province and make BC the best place in the country to be a nurse. mNPRs will allow nurses to do what they were trained to do: devote time and attention to patients’ needs and provide the health care everyone deserves. Addressing the staffing shortage will see patients benefit from reduced medication errors and hospital-acquired infections as well as a measurable and significant reduction in patient mortality.

The evidence shows mNPRs save lives. They reduce patient mortality, as well as nurse occupational injuries, incidents and missed care. They help create the safe, healthy and supportive workplaces required to retain the nurses we have now, return nurses who have left and recruit the new nurses we need to address the staffing shortage.

For years, BC’s nurses have struggled to provide safe patient care while facing a reality that sees them running from patient-to-patient, working short-staffed and juggling multiple duties on every shift. These untenable working conditions are leading to high levels of nurse burnout and significant moral distress, forcing many nurses to leave the profession altogether. BC now has an unprecedented number of nurse vacancies – more than 5,000 according to Statistics Canada.

This severe staffing shortage has also resulted in a growing frequency of temporary emergency room closures and service disruptions in the health-care system. Health employers have responded by spending tens of millions of dollars on expensive for-profit staffing agencies to bring nurses to the bedside and fill the staffing gap. This costly and unsustainable health human resources strategy has resulted in a 24-fold increase in spending on agencies between 2016 and 2024. Research has linked the use of agency nurses to increased staff turnover, deterioration of the quality of care, inequities in working conditions and salaries, and destabilization of health-care teams.

For the first time in a generation, we have a solution in mNPRs that has the potential to help heal the chronic staffing crisis in our health-care system and help chart a path forward so that patients can finally receive the care they need and nurses can practice their profession under safe and sustainable working conditions.

BC will be the first jurisdiction in Canada to adopt mNPRs. California, and Australia already have them in place, and Oregon is currently in the implementation stage. Experience in these jurisdictions has shown that mNPRs create safer care and more satisfied nurses.

BCNU has advocated for mNPRs for over 25 years. Until now, however, provincial governments had resisted the move. In April 2023, the Nurses’ Bargaining Association signed an agreement with the Ministry of Health to introduce mNPRs in hospitals, long-term care and assisted living, and community and non-hospital care settings.

Our sister nursing unions in California and Australia engaged in years-long campaigns to achieve ratios for their members. In 1999, the nurses of the California Nurses Association successfully sponsored and lobbied the California Legislature to pass a bill that made mNPRs a requirement throughout the state, and they were implemented in 2004. mNPRs were first implemented in Victoria, Australia in 2000.

The evidence from California and Australia, where mNPRs are currently in place, clearly demonstrates positive outcomes for patients, nurses and health-care organizations. After the implementation of mNPRs, California hospitals saw nurse turnover and vacancy rates fall below five percent, well below the national average, and nursing vacancies in Sacramento, California, decreased by 69 percent within four years. The results of California’s mNPR mandate show that it has enabled three hours a day more nursing care to each patient. In Victoria, Australia, the number of employed nurses grew by 24 percent, with more than 7,000 inactive nurses returning to the workforce after mNPRs were implemented.

The provincial government has allocated $200 million in 2023/2024, $250 million in 2024/2025 and $300 million in 2025/2026 to implement mNPRs. To support implementation, the province announced in March 2024 an investment of $237 million in one-time funding initiatives to help retain, return and recruit new nurses into the health-care system. This includes $169.5 million for the expansion of provincial rural retention incentives and $68.1 million for training and licensing investments.

Staffing to support the implementation of mNPRs requires measures to train and recruit new nurses, retain the nurses already working in the system and return nurses who have left the profession back to the bedside. These efforts require a multi-pronged approach that includes financial incentives, increased access to training and career opportunities, improvements in working conditions and supports for nurses’ well-being.

Yes. To support mNPRs, the province announced in March 2024 an investment of $237 million in one-time funding initiatives to help retain, return and recruit new nurses into the health-care system. This includes $169.5 million for the expansion of provincial rural retention incentives, signing bonuses to participate in GoHealth BC, the province’s travel nursing program, recruitment signing bonuses for rural and remote communities, signing bonuses for difficult-to-fill urban and metro vacancies, and additional funding to support nurses in the areas of recruitment, retention and/or mental wellness.

Many of the nurses needed to staff our health-care system are in our midst but have left the current system because they are unwilling or unable to tolerate the dire working conditions and demands of their work environment. Fixing the staffing shortage is key to addressing those problems.

In the short term, financial incentives can help address the shortage. BCNU successfully advocated for signing bonuses from the government for nurses who had left the profession. Those who commit to returning for two years to fill high needs vacancies are eligible to receive up to $30,000 to work in the North and $20,000 to work in other rural and remote areas.

Addressing concerns about nurses’ working conditions is key to retaining them – that includes addressing the staffing shortage, as well as other concerns such as health and safety issues in the workplace. Retaining nurses in rural communities can be particularly challenging, which led to BCNU negotiating the Provincial Rural Retention Incentive. The program makes nurses working regular positions in 74 rural communities eligible to receive financial incentives of up to $2,000 per quarter (prorated to productive hours) to a maximum of $8,000 per year.

Agency nurses are utilized as a last resort to fill staffing vacancies when no other nurse is available. Recognizing the health-care system’s growing reliance on private agency nursing and the skyrocketing costs associated with it, the BC government created GoHealth BC as a publicly delivered alternative.

GoHealth BC is the province’s travel nursing program, whose staff are made up of members of the BCNU. It’s numbers have grown to more than 200 nurses since it began in 2023. The program was established to help reduce health employers’ reliance on expensive nurse staffing agencies. To further reduce reliance on staffing agencies, some nurses will be eligible to receive up to $15,000 in signing bonuses if they choose to take a regular position with GoHealth BC. This incentive will focus on net-new entrants to BC’s health-care system, and help prevent churn and competition between employers. Nurses who are currently employed by third-party staffing agencies are encouraged to apply.

Measures in the BC government’s Health Human Resources Strategy are already leading to increased recruitment after a lapse in practice in the province in 2023. BC’s recruitment efforts continue to expand with BCNU negotiating $68 million in new government investments in training and licensing to expand the internationally educated nurse bridging program and introduce new post-secondary education tuition credits and bursaries in nursing programs.

The implementation of mNPRs is guided by a provincial executive steering committee made up of BCNU, the Nurses’ Bargaining Association, health authorities and the provincial government. The committee was established in the fall of 2023. It operates by consensus, and provides provincial recommendations to the Ministry of Health on the multiple investments outlined within the agreement.

Five working groups are responsible for the following topics: planning, implementation, monitoring, reporting and evaluation, recruitment and retention, and communications. These groups provide the executive steering committee with mNPR policy recommendations for endorsement to present to the health ministry.

In April 2023, the Nurses’ Bargaining Association and the Ministry of Health signed an agreement to support nursing in the province by adopting mNPRs in hospitals, long-term care and assisted living, and community and non-hospital care settings.

In March 2024, mNPRs began implementation planning in health authorities, and nurses working on the following units will begin to see changes in staffing allocations reflective of mNPRs by fall 2024:

• Adult medical and surgical units operating 24/7, 365 days a year (excluding surgical daycare): one nurse to four patients (1:4).
• Palliative care units: one nurse to three patients (1:3).
• Rehabilitation units: one nurse to five patients on day/evening shifts; one nurse to seven patients on night shifts (1:5 days/evenings, 1:7 nights)
• Focused (Special) Care units (Adult/Child): one nurse to three patients (1:3).
• High Acuity/Step Down units (Adult/Child): one nurse to two patients (1:2)
• Intensive Care (Adult/Child) units: one nurse to one patient (1:1)

Together with BCNU, the Ministry of Health has established the expectations for mNPRs in six health-care settings in acute care facilities. Examples include most adult medical and surgical units, where the ratio will be one nurse to every four patients, and high-acuity units where it will be one nurse to two patients.

In March 2024, the health ministry and BCNU began working with health employers to implement a policy directive issued in support of this first phase to establish these mNPRs. The next steps involve:

• Determining mNPRs in remaining hospitals settings.
• Establishing a nurse-to-client case management ratio or workload tool to support a standardized staffing approach for a community and non-hospital care services.

Performance metrics will be used to measure the expected outcomes of effectiveness, efficiency, safety, and quality environments. The three performance metric categories for the mNPR initiative include: patients, nurses, and the health-care system.

The policy will be formally reviewed every three years. Continuous quality improvement will be based on quarterly evaluation reporting, and will support the continuous quality improvement process.

The Ministry is requiring compliance reporting from health authorities. Compliance with mNPRs will be regularly monitored using pre-established reporting mechanisms and submitted to the health ministry for analysis and integration into the quality improvement process. Metrics will be tracked and shared with the BCNU through the provincial executive steering committee.