One More Patient, One More Life

ALL TOGETHER Nursing union presidents from across Canada support minimum nurse-to-patient ratios. Left to right: Nova Scotia Nurses Union President Janet Hazelton, Canadian Federation of Nurses Unions President Linda Silas, BC Nurses’ Union President Adriane Gear, Manitoba Nurses Union President Darlene Jackson and New Brunswick Nurses’ Union President Paula Doucet. 

For most nurses in BC, walking into work means facing a patient assignment that already feels too heavy – and often being told they’ll need to take on even more.

“For every additional patient a nurse cares for, there’s a 3.6 percent increase in nurses experiencing physical violence at least monthly.”

Dr. Karen Lasater

For the public, “just one more patient” may not sound like much. But for nurses, that extra assignment can be the difference between catching an early warning sign or missing it, between finishing a shift safely or suffering an injury and sometimes, the difference between life and death.

“It’s one more life to be responsible for. One more opportunity to miss an early warning sign of a patient decompensating. One more family to answer questions from,” says Dr. Karen Lasater, associate professor of nursing at the University of Pennsylvania. “And the complexity keeps growing exponentially with each additional patient.” 

Lasater, together with Dr. Linda Aiken and colleagues, recently released a new study on nurse staffing in British Columbia. Published this summer, the peer-reviewed article Are minimum nurse-to-patient staffing ratios needed in hospitals? An observational study in British Columbia, Canada surveyed 6,685 direct-care nurses across 58 hospitals and paired their staffing data with hospital-level patient outcomes from the Canadian Institute for Health Information.

The results confirm what nurses have been saying for decades: better staffing means safer care, lower mortality and higher nurse retention. Hospitals where nurses cared for fewer patients at a time had fewer preventable deaths, lower readmissions and higher safety ratings.

Unsafe staffing, unsafe conditions

Throughout the study, nurses reported caring for more patients than they believed safe. On medical-surgical units, the average assignment was five patients, though nurses said they could safely manage about four – a number that aligns with BC’s new minimum nurse-to-patient ratio (mNPR) standard.

The study found that every additional patient in a nurse’s workload was associated with worse outcomes. Specifically:

• A 7 percentage point increase in the hospital standardized patient mortality ratio – a number that compares a hospital’s observed number of deaths to the expected number of deaths, based on factors including age, sex and comorbidities.
• A 0.3 percentage point increase in 30-day readmissions.
• A 3.6 percent higher likelihood of nurses experiencing physical violence.

The study found especially concerning links between short staffing and violence. Nearly half of nurses reported monthly work-related injuries, and 44 percent reported experiencing physical violence at least monthly. “When nurses work in understaffed hospitals, they’re more likely to experience physical violence,” Lasater explains. “That’s a striking and deeply troubling association.”

Burnout and intent to leave

The study also confirmed that the scale of the staffing crisis is driving nurses out of the profession. Nearly 60 percent reported symptoms of burnout, more than a third were dissatisfied with their jobs and almost one in five said they intended to leave their hospital within a year. The top reasons were unsafe staffing (67 percent), burnout (62 percent) and dissatisfaction with management (50 percent).

Nurses in hospitals with higher patient-to-nurse ratios were more likely to report unsafe workloads, missed care, poor safety culture and intentions to leave.

For BCNU President Adriane Gear, those numbers underscore the urgent need for change. “Behind each percentage point is a nurse who is questioning whether they can keep doing this work. We’re talking about people who came into nursing to make a difference, and who are now being pushed to the brink. If nurses cannot safely care for patients, then we all pay the price.”

A clear baseline

Lasater says one of the most important aspects of this study is that it asked nurses what they thought was safe – and their answers were remarkably consistent. Across all 58 hospitals, nurses’ views of safe staffing closely matched the standards negotiated in the memorandum of understanding between the government and BCNU that established minimum nurse-to-patient ratios.

“That alignment is powerful,” Lasater says. “It shows that what nurses say is safe is the same thing the policy requires.”

The authors conclude: “Nurses in BC hospitals are caring for more patients at a time than they believe is safe. If hospitals adhere to the new nurse staffing policy requirements, they are likely to see improvements in outcomes for patients and nurses.”

STANDING FOR RATIOS BCNU Central Vancouver members Ivan Chao, Yolanda Samra, Sophie Pelletier and Allison Stewart share information on the union’s fight for mNPR

Implementation begins

For BC nurses, this research comes at a critical time. Phase 1 of the new minimum nurse-to-patient ratios – negotiated alongside the 2022–2025 Nurses’ Bargaining Association collective agreement after decades of advocacy – is now being rolled out. This agreement makes BC the first province in Canada to adopt province-wide ratios.

“This study validates what BC nurses have been saying for years: minimum nurse-to-patient ratios save lives and keep nurses in the profession.”

BCNU President Adriane Gear

For Gear, the study validates what BC nurses have been saying for years – minimum nurse-to-patient ratios save lives and keep nurses in the profession. “We now have independent, peer-reviewed evidence that links unsafe staffing directly to worse outcomes for patients and nurses,” she says.  “That’s not something we can afford to ignore. It is imperative that this work continues so we can deliver safer, higher-quality care for British Columbians and the nurses who care for them.”

Gear adds that the study should be seen as a call to action for hospital administrators and government alike. “The evidence is here. The policy is in place. What matters now is accountability. Health employers must meet ratios consistently, not just on paper but on the floor where nurses and patients live the reality every day.”

BCNU CEO Jim Gould points out that BC is just getting started with ratios, and there’s a long way to go.

“These research findings are an important and encouraging confirmation of the union’s work,” he says. “This is clear, independent validation that minimum nurse-to-patient ratios will make care safer for patients and keep nurses in the profession. We look forward to continuing the work with the provincial government to ensure ratios are implemented fully and successfully for the benefit of every patient in BC.”

Gould points out that the study also has international relevance. “The world is watching what BC is doing. By adopting ratios, BC has joined a very small group of jurisdictions willing to make patient safety a priority. This is about setting a new standard, and I believe others will follow.”

BCNU director of ratios Kelley Charters highlights the value of establishing a starting point. “The research gives us a province-wide baseline to measure from. As ratios roll out, we’ll be able to track how conditions improve for nurses and patients,” she says. “Ratios are only meaningful if they’re met consistently – and this study helps us hold the system accountable.”

EYES ON US BC is the first province in Canada to announce minimum nurse-to-patient ratios, garnering attention from major news outlets like the Globe and Mail.

Looking ahead

Lasater and Aiken’s localized study shows empirically significant increases in adverse outcomes when health-care units are understaffed, yet it does not prove causation. But its associations mirror decades of international evidence from California and Australia, both of which have shown improvements in patient outcomes when staffing standards are introduced.

Lasater says the real test will come in the years ahead: “When we return after full implementation, the question will be whether nurses are caring for fewer patients, whether the variation across hospitals has narrowed and whether we see trends in safer care and better nurse well-being.”

For Gear, the stakes are deeply human. “When we talk about ratios, we’re not talking about abstract numbers. We’re talking about whether a nurse can sit with a family and answer their questions, whether they can notice a subtle change in a patient’s breathing, or whether they can finish a shift without injury. That’s what this fight has always been about.”

“Nurses from across the province have advocated for and successfully negotiated the best ratios in the world. Now it's up to the employers and government to consistently meet ratios, and us to vigilantly monitor and report any deviations, so that safer care becomes the norm, not the exception.”

BCNU Vice President Tristan Newby

Gould echoes that sentiment. “Safe staffing is not a luxury. It’s the foundation of a functioning health-care system. Without it, nurses leave, patients suffer and the system breaks down. With it, we give nurses the conditions to thrive and patients the care they deserve.”

BCNU Vice President Tristan Newby emphasizes that the study adds objective data to nurses’ decades-long advocacy for safe staffing. “Nurses from across the province have advocated for and successfully negotiated the best ratios in the world. Now it's up to the employers and government to consistently meet ratios, and us to vigilantly monitor and report any deviations, so that safer care becomes the norm, not the exception.”

At its core, this work is about people – the nurses who shoulder the responsibility of care, and the patients and families who rely on them. As Lasater reminds us: “It’s not just one more medication to give – it’s one more life to be responsible for. And all of the complexity that comes with that.”

UPDATE (Winter 2025)