Rural and Remote Hospital Sector Ratios
Last updated on January 17, 2025Approximately one in five people live rurally and 65% of the Indigenous population lives outside large urban centres in British Columbia. Multiple health indicators show persistent disparities in health outcomes for rural populations.
The Ministry of Health has taken the realities for nurses and patients in rural and remote hospitals into specific consideration and developed specific ratios, to ensure that the implementation of mNPR across rural areas is just as successful as the rest of the province. Click here for the full document.
The Ministry is current developing a wider Provincial Rural and Remote Health Strategy, which mNPR will be able to align with through Rural and Remote Hospital Sector Ratios.
Principles
The Ministry used the following guiding principles to develop, with partners at the BCNU and Health Authorities, including direct care nurses across the province. Many of these principles are consistent with the overall guiding principles for MNPR writ-large. They include:
- Collaboration & Engagement
- Quality Practice and Learning Environment (QPLE)
- Cultural Safety & Humility and Addressing Anti-Indigenous Specific Racism
- Adaptability and Flexibility
- Monitoring, Evaluation, and Continuous Improvement
- Data-Driven Decisions
- Training and Support
Overview and Definitions
4 different groups have been identified, which represent different hospital sector settings across rural and remote communities. Many of these groups are defined based on the volume of patients and type of care provided. Each group is assigned a baseline ratio of nurses. They are as follows:
| Group | Definition | Ratio(baseline*) |
|---|---|---|
| 1 | Diagnostic and Treatment Centres/Community Health Centres with Emergency Departments (EDs) with less than 7,500 annual visits and no inpatient beds (may have variable hours of service). |
2 nurses |
| 2 | Small rural/remote hospitals with 3 to 10 beds and less than 7,500 annual ED visits. |
3 nurses (assuming base of 4 inpatient beds) |
| 3 | Rural Hospital with 8 to 15 beds, some specialty services at a low volume, and between 7,500 and 14,000 annual ED visits. |
3 nurses (assuming base of 4 inpatient beds) |
| 4 | Rural Hospital with more than one inpatient unit, some specialty services and between 10,000 and 18,000 annual ED visits. | mNPR2.5 nurses/suite (2 per procedure)]. |
*NOTE: Higher ED volumes and/or bed counts may warrant additional baseline nursing staff. Visit gov.bc.ca/mnpr for the expanded definitions and application of the mNPR R&R Hospital Sector Ratio document.
Ministry direction to Health Authorities for applying Rural and Remote Hospital Sector Ratios
In addition to the definition for each of the four groups, above, the Ministry have provided direction to the Health Authorities and how to apply these ratios. Health Authorities are currently implementing the rural and remote ratios and will shortly identify which of their facilities fall into which group.
Group 1: Community Health Centre with an Emergency Department (ED) for Diagnosis & Treatment and no inpatient beds
The proposed ratio for Group 1, starts with a baseline of 2 nurses, and includes:
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Increase by a nurse if ED volume exceeds 7,500 and increase by a nurse in increments of 7,500 for annual visits exceeding 7,500.
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Shifts may be staggered according to patient demand mapping. Seasonal variations due to tourism population surges and the presence of industrial camps or itinerant industry workers and their families may need to be factored in above the mNPR.
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If the site or facility provides community health/primary care nursing services or provides long term care services on site, the staffing will remain status quo until the non-hospital ratio planning is underway.
Group 2: Small Rural & Remote Hospitals
The proposed ratio for Group 2, starts with a baseline of 3 nurses*, and includes:
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Increase by a nurse for every four acute care bed increment over the initial 4 beds included in the baseline. Rounding up to be applied.
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Increase by a nurse if the annual patient volume in the Emergency Department exceeds 7,500.
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Shifts may be staggered according to patient demand mapping.
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Until further work is completed in relation to mNPR in Long Term Care, sites with an integrated nursing rotation will retain existing nursing staffing levels and will comply with Ministry of Health Hours of Care per Resident Day policy. This will be revisited as the mNPR approach in LTC is clarified.
*assuming a baseline of 4 inpatient beds
Group 3: Rural Hospital with Low Volume Specialty Services
The proposed ratio for Group 3, starts with a baseline of 3 nurses*, and includes:
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Increase by a nurse for every four acute care bed increment over the initial 4 beds included in the baseline. Rounding up to be applied.
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If a Group 3 site provides low risk maternity services for less than 50 deliveries per year, <insert Health Authority> will support some of the nursing staff to receive skills training to provide care to low risk maternity families.
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If the ED volume exceeds 7,500 annual visits, increase by a nurse for every 7,500-visit increment e.g. increase by a nurse for 7,500 to 14,000 annual visits. Shifts may be staggered according to patient demand mapping.
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If there is an OR, apply ratios as outlined in the mNPR policy for the operating room. We will maintain status quo staffing for day surgery/ambulatory care until the provincial mNPR is confirmed.
*assuming a baseline of 4 inpatient beds
Group 4: Rural Hospital with greater than One Inpatient Unit
Health Authorities are to apply the approved mNPR ratio for med-surg inpatient units (1:4) and operating rooms [2.5 nurses/suite (2 per procedure)]. Rounding up should be applied when doing so.
Additionally, the following provides an overview of direction on application for maternity units and emergency departments.
|
MATERNITY Maternity services with up to 2 maternity beds with a volume of 50 to 250 births per year. |
EMERGENCY DEPARTMENTS EDs do not generally have separate areas for type of patient presenting to the ED. |
|---|---|
| Baseline of 1 nurse available to cover antepartum, labour & delivery, postpartum care 24/7 for volumes between 50 to 100 births/year. | Baseline of 3 nurses assuming an average of 14,000 to 15,000 annual visits. |
| Baseline of 2 nurses available to cover antepartum, labour & delivery, postpartum care 24/7 for volumes between 100 to 250 births/year. | Increase by a nurse for every 7,500 increment increase over 15,000 annual visits. |
| May require additional workload during a maternity surge. We will support some of the nursing staff to be cross-trained when additional staffing is required to provide care for maternity families. | If ED volume is less than 14,000 start with a baseline of 2 nurses. |
*NOTE: Health Authorities are to maintain status quo staffing for day surgery/ambulatory care and psychiatric care until the provincial mNPR is confirmed.
The role of the Charge Nurse in Rural and Remote Hospital settings
The Charge Nurse role in rural and remote facilities has the potential to be a powerful role for providing at the elbow clinical support and supporting quality improvement, continuous improvement, quality practice and learning environments, cultural safety and humility and team building.
The Charge Nurse in these settings may also provide the additional support needed to coordinate patient transport to definitive care.
The province is still planning and developing the role of the Charge Nurse for the entire mNPR initiative, which includes how this role will be utilized throughout rural and remote ratios.
Once the Charge Nurse role is finalized, the Province via Health Authorities will provide an update on how this role will be implemented in rural and remote sites, including updates to the Rural and Remote Hospital Sector Ratios.
Implementation
Implementation of the Rural and Remote Hospital Sector Ratios by Health Authorities is outlined by the Ministry to proceed as follows:
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Implement mNPR as outlined in rural and remote facilities early in the overall mNPR implementation process.
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Implement mNPR across the entire rural or remote facility with the exception of psychiatry, Long Term Care, and community, non-hospital which are currently under future development. This includes factoring in, where necessary, in rural and remote settings particularly.
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On an annual basis (or sooner if required), the ED mNPR Implementation will lead a site analysis with the support of the JRIC and operational leadership of volumes and services at each site over the past fiscal year to assess the appropriateness of the rural and remote site groupings and recommend adjustments accordingly.
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As outlined in the Ministry of Health Policy Instrument, Minimum Nurse-to-Patient Ratio – Hospital Based Care Settings, when additional patients above the bed base are admitted to the facility, every reasonable effort will be made to call in additional nursing staff, including for overtime, to bring the facility back up to the required ratio.