Nurses in the Niagara Health System are facing overwhelming patient loads that are undermining care and risk triggering staff burnout, according to internal hospital documents obtained by the Star and Investigative Journalism Bureau.
Workload reports filed by front-line nurses repeatedly call for staffing levels like those that have been mandated in other jurisdictions to improve the quality of care.
Despite years of pleading from health care professionals and more recently politicians, Ontario has failed to pass legislation that would enforce nurse-to-patient ratios.
The reports filed in Niagara in the summer of 2024 detail nurses working on acute medical and surgical wards responsible for as many as 10 patients at a time. British Columbia, as well as several U.S. and Australian states, have imposed ratios of no more than 1:4 or 1:5.
Hospital managers responding to the Niagara workload complaints dismissed calls for higher nurse staffing levels, the records show.
A Niagara Health executive said the network 鈥渇ollows internal staffing guideline levels across medical and surgical wards.鈥 The spokesperson declined to say what those guidelines are.
The workload reports, which Star/IJB reporters obtained under freedom of information legislation, are designed to alert hospital management of patient safety issues. The Star/IJB is seeking similar records from other hospitals across the province.
During a chaotic shift, pressures mount
Nurses from hospitals throughout Ontario and interviewed for this story said nurse-to-patient ratios are a common problem.
After the shift on Aug. 26, during which two patients died, a nurse recorded some details from the hectic night:聽
Patients were left in hallways, there were delays to administering medications, and restrained patients tried to force their way out of bed and fell to the floor, the workload report said.
The nurse reported ratios of one nurse for every nine patients.
Nurse workload reports filed with the Niagara Health System last summer reveal overwhelming patient loads that undermine care and risk triggering staff burnout. The St. Catharines site is seen here.
Bob Tymczyszyn Torstar鈥淢ultiple (medications) delayed due to high patient ratios,鈥 the workload report reads. 鈥淯nable to provide the care 鈥 in a timely manner due to patient:nurse ratios.鈥
With such ratios, 鈥測ou’re lost in a tornado of things going on,鈥 said a Niagara Health System nurse who spoke the Star/IJB on the condition of anonymity for fear of reprisals. 鈥淚t’s not safe at all.鈥
How nurse-patient ratios can impact care
Studies show that hospitals with lower nurse-to-patient ratios provide better care, with higher patient satisfaction, lower mortality, and shorter stays.
鈥淓ight, nine, ten (patients to one nurse) is an extreme number,鈥 said Karen Lasater, a chair in nursing and health policy at the University of Pennsylvania School of Nursing, who reviewed the documents. 鈥淲hen a nurse cares for one additional patient, that patient has a 7-per-cent higher odds of dying. That nurse has a 23-per-cent higher odds of experiencing burnout.鈥
The Niagara Health statement said unexpected sick calls and other factors beyond the hospital system鈥檚 control can impact staffing levels. Though the reports offer only a snapshot of nurse workloads, they also reflect other pressures on the health care system, including overcapacity in hospitals, the statement added.
鈥淲e remain committed to providing the best possible care under all circumstances.鈥
In one Niagara report, a nurse said nurse-to-patient ratio should be 1:6. A manager鈥檚 note at the end of the form expresses that the 1:7 and 1:8 ratios are the expectation, not the exception.
鈥淲hile specific ratios vary depending on the complexity of care, the skills and experience of nursing staff, and the type of unit, our ratios align with or exceed the median for peer hospitals in Ontario,鈥 said Simon Akinsulie, Niagara Health鈥檚 executive vice president of practice, clinical support and chief nursing executive.
The hospital network did not respond to requests for details on median nurse-to-patient ratios at Niagara Health or elsewhere in Ontario.
B.C., Australian states have ratios
A lack of mandated ratios is why nurses are leaving the profession, said nurses from hospitals across Ontario.
鈥淭his is why Ontario is in a huge deficit of nurses and this is just going to get worse,” said Jenn Miller, a registered nurse who works in the GTA.
Niagara Health told the Star/IJB that it has a strong retention rate.
New guidelines in B.C. set a ratio of 1:4 for patient care in emergency rooms, acute medical wards and surgical wards. In California and Oregon, legislation requires ratios of 1:5 and in Australian states Victoria and Queensland, the legislated ratio is 1:4.
Research by nursing professor Linda Aiken shows that in California, where ratios were legislated two decades ago, patients received three times more hours of nursing care per day compared to states without such legislation.
鈥淢inimum nurse staffing mandates would save lives and money,鈥 said Aiken, who teaches at University of Pennsylvania. 鈥(It is) the single most important factor in reducing adverse outcomes, unnecessary expenditures and reducing turnover.鈥
Ontario Health, which manages hospital funding on behalf of the Ministry of Health, did not respond to questions from the Star/IJB.
In May 2024, NDP health critic France G茅linas proposed Bill 192 to legislate ratios of 1:4 for acute medical care. The bill failed to move past the second reading in June, stymied by a 39-68 vote led by Conservative MPPs.
NDP health critic France G茅linas tried to get ratios of 1:4 legislated, but the attempt failed after Conervatvie MPPs voted it down.
Christopher Katsarov The Canadian Press file photoThe Ontario Hospital Association has pushed back against mandatory nurse-to-patient ratios, saying in a statement to the Star/IJB that they limit a hospital鈥檚 flexibility to 鈥渢ailor staffing levels鈥 and represents 鈥渁ntiquated 20th century thinking at a time when Ontario鈥檚 hospitals are innovating to respond to the demands and complexities of the 21st century.鈥
Nurses use the forms to comply with the College of Nurses of Ontario鈥檚 requirement to report medical errors, safety risks or systemic problems to employers.
Nurses file reports, but do they make a difference?
The reports are reviewed by union and hospital officials. But nurses who have filed reports said they often receive a written response from management without any meaningful changes made.
They also said the reports are not welcomed by hospital managers.
鈥淵ou are definitely not encouraged to fill them out,鈥 said the Niagara nurse interviewed by the Star/IJB.
The Star/IJB has filed formal freedom of information requests for nurse workload reports in hospitals across Ontario. Niagara Health initially denied an August 2023 request for the reports. Following a protracted appeal process, reporters obtained reports covering the period between July 22 and Sept. 21, 2024.
They detail chaotic moments during a string of shifts in September 2024.
On Sept. 15, nurses had as many as 10 patients each. Patients in hallways had no access to life-saving equipment including oxygen tanks and suction machines, and there was 鈥渘o call bell system,鈥 reads the report from that day.
On Sept. 17, 2024, three patients fell 鈥渨ithin less than three hours of the start of shift,鈥 a nurse said in the report.
Four nurses were ratioed at 1:8 and two were ratioed at 1:7. There was a lot to do. Twelve of the 46 patients were under infection precautions and required 鈥渉eightened surveillance鈥 and PPE equipment, which takes extra time to put on and take off.
The report from that day identified 鈥渉igh ratios鈥 as the reason they were 鈥渞ushing with vitals so we can try to give meds on time 鈥. Multiple confused patients (trying to crawl out of bed), some of them needing 1:1 (attention).鈥
No relief after a ‘silent code white’
After some of the September shifts, nurses reported the dangers caused by a lack of staff.
During the night shift on Sept. 11, nurses treated patients in hallways as the ward was overcapacity by four patients. They placed an 80-year-old patient with an amputated leg in a hallway with other patients 鈥渒nown to have a history of violence.鈥
During the same shift, a nurse reported a 鈥渟ilent code white鈥 鈥 which triggers a rapid response by security officers 鈥 as a patient tried to strangle people nearby.
鈥淚t was unsafe and has potential for serious errors,鈥 reads the report.
Linda Steele, a retired registered nurse in Ottawa who reviewed the documents, said they highlight the risks nurses face when workloads are high.
鈥淚t’s not like the cops who are wearing steel-toed shoes and vests and have a baton and have the right to subdue the patient,鈥 said 鈥淲e have none of that, so you’re vulnerable the whole time you’re working.鈥
The workload report forms ask for recommendations for management to consider. During the chaotic week in September, a nurse checked the box beside the words 鈥渞eview nurse/patient ratio.鈥
At the end of the report, the nurse requested that the unit restore the seventh nurse for night shifts.
鈥淪even is not the budgeted amount of registered staff on nights,鈥 wrote a manager in response. 鈥淧atient ratios appropriate.鈥
With files from Max-Binks Collier/Investigative Journalism Bureau
