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 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 “follows internal staffing guideline levels across medical and surgical wards.” The spokesperson declined to say what those guidelines are.
The workload reports, which IJB reporters obtained under freedom of information legislation, are designed to alert hospital management of patient safety issues. The 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:
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.
“Multiple (medications) delayed due to high patient ratios,” the workload report reads. “Unable to provide the care … in a timely manner due to patient:nurse ratios.”
With such ratios, “you’re lost in a tornado of things going on,” said a Niagara Health System nurse who spoke the IJB on the condition of anonymity for fear of reprisals. “It’s not safe at all.”
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.
“Eight, nine, ten (patients to one nurse) is an extreme number,” said Karen Lasater, a chair in nursing and health policy at the University of Pennsylvania School of Nursing, who reviewed the documents. “When 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.”
The Niagara Health statement said unexpected sick calls and other factors beyond the hospital system’s 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.
“We remain committed to providing the best possible care under all circumstances.”
In one Niagara report, a nurse said nurse-to-patient ratio should be 1:6. A manager’s note at the end of the form expresses that the 1:7 and 1:8 ratios are the expectation, not the exception.
“While 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,” said Simon Akinsulie, Niagara Health’s 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.
“This 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 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.
“Minimum nurse staffing mandates would save lives and money,” said Aiken, who teaches at University of Pennsylvania. “(It is) the single most important factor in reducing adverse outcomes, unnecessary expenditures and reducing turnover.”
Ontario Health, which manages hospital funding on behalf of the Ministry of Health, did not respond to questions from the IJB.
In May 2024, NDP health critic France Gélinas 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.
The Ontario Hospital Association has pushed back against mandatory nurse-to-patient ratios, saying in a statement to the IJB that they limit a hospital’s flexibility to “tailor staffing levels” and represents “antiquated 20th century thinking at a time when Ontario’s hospitals are innovating to respond to the demands and complexities of the 21st century.”
Nurses use the forms to comply with the College of Nurses of Ontario’s 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.
“You are definitely not encouraged to fill them out,” said the Niagara nurse interviewed by the IJB.
The 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 “no call bell system,” reads the report from that day.
On Sept. 17, 2024, three patients fell “within less than three hours of the start of shift,” 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 “heightened surveillance” and PPE equipment, which takes extra time to put on and take off.
The report from that day identified “high ratios” as the reason they were “rushing with vitals so we can try to give meds on time …. Multiple confused patients (trying to crawl out of bed), some of them needing 1:1 (attention).”
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 “known to have a history of violence.”
During the same shift, a nurse reported a “silent code white” — which triggers a rapid response by security officers — as a patient tried to strangle people nearby.
“It was unsafe and has potential for serious errors,” 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.
“It’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,” said “We have none of that, so you’re vulnerable the whole time you’re working.”
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 “review nurse/patient ratio.”
At the end of the report, the nurse requested that the unit restore the seventh nurse for night shifts.
“Seven is not the budgeted amount of registered staff on nights,” wrote a manager in response. “Patient ratios appropriate.”
This story was also published to the Toronto Star.
With files from Max-Binks Collier
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