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How a social media post started a safe staffing revolution

An exhausted nurse’s comments about the number of patients she was caring for prompted action on staffing ratios in Canada

An exhausted nurse’s comments about the number of patients she was caring for prompted action on staffing ratios in Canada


A staffing board at Diana, Princess of Wales Hospital in Grimsby, North Lincolnshire.
Picture: Guzelian

Early this year, a social media post by a young Canadian nurse went viral – and started a movement on nurse-patient ratios.

Émilie Ricard, from the province of Quebec, posted a picture of herself in tears and exhausted, blaming a lack of staff at the hospital where she was working. Sometimes she was the only nurse looking after up to 70 patients. ‘I come home and I’m crying with fatigue’, she said.

In the wake of the outcry the post provoked, it emerged that Ms Ricard’s fellow nurses in the province had taken the extraordinary step of reporting themselves to their own regulator, claiming they could not meet their professional obligations.

A question of resources

They were stretched to such an extent that they felt they could not do their job properly, says Lucie Tremblay, president of the Quebec Order of Nurses. ‘It’s not a question of their competency. It’s a question of not having the resources to provide the care the way they are supposed to provide the care,’ she told CBC Radio in Canada.

‘We must take safe ratios out of the hands of managers and politicians’

Jérôme Rousseau, vice president of Quebec’s FIQ interprofessional health union

However it may have looked in Quebec, to British eyes the response of the authorities was swift and decisive. Within a few short weeks of Ms Ricard’s post on Facebook, which has received more than 43,000 responses and nearly 55,000 shares, the province’s health minister Gaetan Barrette had announced a pilot to put in place specific nurse-patient ratios in 17 hospitals and long-term care homes.

If it proves successful, nurse ratios will be rolled out to healthcare settings across Quebec, and if the nurses’ union has its way, they will be enshrined in law.


Emilie Ricard’s social media post
may have started a revolution.
Picture: Facebook

‘We must take safe ratios out of the hands of managers and politicians,’ Jérôme Rousseau, vice president of Quebec’s FIQ interprofessional health union, tells Nursing Standard. ‘We must give the nurses’ professional judgement the place it deserves.’

As in England and the other countries of the UK, governments worldwide have been grappling with the issue of how to ensure safe staffing levels. As yet, however, there is no consensus on the right way to go about it.

Different approaches

A small number, including Scotland and Wales, are following a legislative route. Others are making use of safe staffing tools, sometimes in a somewhat mandated way. Yet others are pursuing a more flexible approach.

According to James Buchan, professor in the School of Health Sciences at Queen Margaret University in Edinburgh, there is a continuum of safe staffing measures.

At one end is a system of mandated nurse ratios that are set nationally and backed by legislation. The other end leaves it entirely up to local decision-makers how many nurses or other health professionals they employ. Internationally, there are examples all the way along that continuum, he says.

Clarity can be attractive

‘I don’t think there is a single perfect approach,’ says Professor Buchan, an expert in healthcare human resources and a Nursing Standard columnist. ‘There’s a clarity about mandatory ratios: it’s clear-cut, you have to do it, and that clarity and certainty can be attractive. But it’s a blunt instrument, and doesn’t necessarily take into account how patient acuity can change from one day to the next, which means that at times it might be inefficient.’

‘Mandatory ratios are a blunt instrument and don’t necessarily take into account how patient acuity can change from one day to the next’

James Buchan, healthcare human resources expert

A system that allows for individual decisions to be made locally, and is able to react to changing circumstances, is obviously more flexible and also, in theory at least, allows professional judgement to be exercised. But it needs a huge amount of data, and the ability to analyse it, as well as the certainty that sufficient resources are available to meet needs.


James Buchan: ‘I don’t think
there is a single perfect approach.’

Professor Buchan points to California in the US and the Australian state of Victoria as the pioneers in mandated nurse ratios, but stresses that each took a different approach to get to where they are today.

California model

California, where nursing unions are only recognised in around one in five hospitals, began with legislation, passing a law in 2004 that stipulates a minimum nurse-patient ratio across different healthcare settings.

In Victoria, on the other hand, ratios began as part of a collective bargaining approach between staff and employers. ‘It was put into law years later [in 2015] on the basis of an electoral promise,’ explains Professor Buchan. ‘The union pushed for it because there was concern that governments of a different persuasion would push back – and it’s easier to push back if there isn’t legislation.’

Since then, the Australian state of Queensland has followed suit, again on the basis of an electoral promise, while in Victoria work is under way to amend the 2015 act to improve ratios.

In the US, only California has legally mandated ratios across all settings

In the US, however, only California has legally mandated ratios across all settings, although different states have approaches of varying stringency. Massachusetts requires specific nurse-patient ratios in intensive care, for example, while several states require some form of public reporting of nurse staffing levels, and others require hospitals to have committees responsible for staffing policy.

The US also has a long history of developing tools and systemic approaches to determining nurse staffing levels, partly because of the need to be able to identify staffing costs for reimbursement and to meet hospital accreditation requirements, says Professor Buchan.

So how do ratios work in practice? According to Professor Buchan, there has been virtually no independent evaluation in Australia, although there is some evidence that it is popular with nurses. In California, the ratios led to more nurses being employed, which increased costs for hospitals when the law was implemented.

Not a simple issue

Deciding on the staffing levels was a major challenge, with both Victoria and California working on calibration in different settings for a long time.

American Nurses Association senior associate director of state government affairs Janet Haebler says it’s not a simple issue. She says a 2015 study shows that occupational injury and illness rates fell by more than 30% following implementation of the ratio law in California.

Another study from 2006 shows that while there was an increase in nurse numbers after the law was put in place, there was no significant change in the quality of care, and no change in the average length of stay.

‘We have concerns about prescribed nurse-to-patient ratios in law or regulation. Nurses and patients are more than numbers’

Janet Haebler, senior associate director, American Nurses Association

‘The greatest challenge associated with the law was fulfilling the required ratios at all times, and hospitals used various approaches to be compliant,’ says Ms Haebler. Nurses expressed frustration at the lack of autonomy over issues such as break times and a loss of flexibility in coping with changes of acuity and workflow, she says.

‘While the American Nurses Association respects any attempt to address staffing, we have concerns about prescribed nurse-to-patient ratios in law or regulation,’ she says. ‘Nurses and patients are more than numbers. And perhaps this is the reason Californian leaders did not witness a change to the quality of care after the ratio law.’

Ms Haebler says the association approaches the establishment of staffing plans through the eyes of the nurse, empowering front-line staff to represent their unit on hospital-wide staffing committees and establish staffing plans and policies that reflect the characteristics and workflow of their unit.

Both floor and ceiling

Establishing ratios in law or regulation brings the risk that these set staffing levels ‘become the floor as well as the ceiling’, and that facilities reduce numbers of unqualified staff to finance an increase in registered nurses, she says.


Michael Villenueve: There is no
consensus ratios are the solution.

These are issues that also concern Michael Villeneuve, chief executive of the Canadian Nurses Association. He says that while safe staffing remains a perennial topic around the country, there’s no consensus that ratios are the solution, regardless of what is happening in Quebec.

‘It’s very clear that the more eyes there are on patients and clients – educated and well-trained eyes – the better the outcome. It’s not a mystery,’ he tells Nursing Standard.

The right person at the right time

‘But the problem with mandated minimums is that it can sometimes pull everyone down to the lowest common denominator.’

‘The risk is that it comes down to “any warm body” to fill rota requirements – but what if that person isn’t the right “warm body” for that particular role or time?’

At Quebec’s FIC, which represents some 75,000 nurses, licensed practical nurses (who carry out direct patient care at the bedside, under the direction of registered nurses), respiratory therapists and clinical perfusionists, the view is very different. Its vice president, Mr Rousseau, is confident that the ratios will be maintained following the pilot periods, in view of commitments by the health minister.

‘The problem with mandated minimums is that it can sometimes pull everyone down to the lowest common denominator’

Michael Villeneuve, chief executive, Canadian Nurses Association

But the union is also seeking wider political guarantees. ‘Provincial election will be held in Quebec on 1 October. The FIQ is working to get all political parties to firmly commit to pursuing this initiative and to guarantee safe care ratios for healthcare professionals and patients in Quebec in a bill,’ he says.

‘The FIQ’s ultimate goal is to achieve guaranteed safe ratios for all Quebec healthcare institutions, regardless of their mission,’ he says, adding that the union has the backing of the public, with 83% agreeing there should be a maximum number of patients per nurse.

‘We are at the first step in our fight to ensure that nurses and patients everywhere in Quebec can eventually enjoy safe staffing. While other organisations elsewhere in the world have far more experience in obtaining and defending safe nurse-patient ratios, FIQ would be more than happy to discuss our experience so far with colleagues from the UK.’


Jennifer Trueland is a freelance health journalist

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