Ontario’s hospital math: two RPNs for the price of one RN. What could go wrong?

Ontario is spending more on health care than ever before. But across the province, hospitals are cutting frontline positions as they struggle to balance their books. Since January 2025, 1,551 health-care positions have been cut across Ontario, according to the Ontario Nurses’ Association (ONA), with nurses making up the vast majority.

In the last two months, ONA reports that more than 215 registered nurse (RN) positions were cut across Ontario hospitals.

The cuts come as hospitals across the province struggle to balance their books amid rising costs and growing pressure on the health-care system.

“After more than a decade there have been so many RN cuts," said Bernadette Robinson, the provincial treasurer for Ontario Nurses’ Association. "Patient care and safety have declined.”

While unions warn the changes could leave already stretched teams with fewer nurses at the bedside, worsening wait times, burnout and patient-care concerns, hospitals say the changes are necessary to manage rising costs and better match staffing to patients’ needs. The province, meanwhile, points to what it says are record investments in health care, including more than 100,000 nurses and nearly 20,000 physicians added since 2018.

For Robinson, the cuts are directly connected to what she describes as the provincial government “intentionally underfunding” the health-care system. She warns that the changes will lead to longer wait times, “especially for acute care in emergency departments.”

Financial pressures push hospitals to rethink their staffing models

Earlier this year, Ontario’s Ministry of Health directed hospitals struggling with deficits to draft three-year plans to balance their budgets.

The result has been what unions describe as an erosion of the frontline health-care workforce across the province, with cuts affecting registered nurses, personal support workers (PSWs) and other essential health-care professionals.

At hospitals across the province, including Queensway Carleton Hospital (QCH), changes to staffing models have been announced in response to ongoing financial pressures.

The changes at QCH include a reduction of about 160 positions and the addition of 119 positions, representing a net reduction of about 41 positions, or roughly one per cent of QCH’s workforce. This includes the reduction of 87 RN positions in some areas, while adding 25 RN positions in others.

“These decisions affect people and teams and were not made lightly,” said a QCH spokesperson in an emailed statement. “Like many hospitals, QCH has faced rising costs…for drugs, food, supplies, salaries, electricity and other operating needs.”

These actions have helped QCH reduce its budget gap and “delay workforce impacts”.

“Unfortunately, they have not fully resolved the challenge,” QCH added.

The hospital’s spokesperson said there would be no reduction in patient-care hours, with some areas instead seeing changes to the mix of roles as part of an interprofessional model of care.

In Hamilton, St. Joseph’s Healthcare is also exploring this restructuring model after reducing 57 RN positions represented by the ONA. The hospital is also reinvesting in 80 positions, including 16 ONA positions, with the remainder consisting of registered practical nurse (RPN) and other support positions.

Dr. Mike Heenan, president and CEO of St. Joseph’s Health System, says these changes are a cost-neutral initiative, meaning the hospital is trying to restructure services without changing its current budget.

“The position changes are based on the models of care assessment that uses an evidence-based system to ensure our healthcare workers match the acuity and complexity of our patients,” said Heenan.

Heenan says the changes will allow some areas of the hospital to see an increase in RPNs and PSWs “who will use their skills to provide high-quality, compassionate care alongside RNs.”

However, while the restructuring represents a net increase of 23 positions, Richard Rigby, president of CUPE 786, which represents more than 2,000 staff at St. Joseph’s Healthcare Hamilton, said the move still represents a net loss of RNs. He fears this will worsen nurse-patient ratios.

“That’s a danger for mistakes and burnout which will affect patient care,” he explained.

Rigby's main concern, he says, is mismanagement, including “scheduling violation, scheduling manipulation” in which “people are making overtime or double time.”

“I may be wrong, but I think the government is trying–in the weirdest way possible–to fix the mismanagement,” he suggested.

Registered nurses account for a large fraction of the hospital’s wage budget. But Rigby insists that discussions surrounding executive wages need to be revisited, particularly after two rounds of cuts that he says left management positions untouched.

“I’ve yet to see management cuts,” Rigby said. “Yet every time I’m talking to somebody, they’ve created another management position.”

Experts say the impact depends on how hospitals replace the positions

While unions have raised concerns that shifting the workforce mix and reducing RN positions could lead to longer patient wait times, health-care experts say the impact will depend on how hospitals implement their new staffing models.

Dr. Abi Sriharan, a University of Toronto professor whose research focuses on health-care workforces and organizational leadership, argues that employing more RPNs in place of RNs could help hospitals expand their capacity and reduce wait times at a lower cost.

“In one way, yes, we need more trained RNs to provide care...but if they’re going to cost the health system more money, and at the same time (hospitals) can hire two RPNs for the same salary and they can care for more patients, it's better,” Sriharan said, highlighting the "huge salary gap between RPNs and RNs" that she believes is driving hospitals' decisions.

Sriharan highlighted that RPNs “can prescribe certain controlled substances” and perform many of the tasks RNs are responsible for. However, she acknowledged that RNs and RPNs do not receive the same level of training, a difference that underlies some union concerns about replacing RNs with RPNs.

“The additional two years (of studies) gives them more in-depth training for complex patient management,” she said. “That’s where the concerns come from, but it’s the organizations that have to make the decision to close that competency gap.”

Still, in her view, hospitals have been left with little choice as Ontario faces a “double paradox,” with hospitals struggling to address staffing shortages while operating under increasingly constrained funding.

Jennifer Zelmer, CEO of Healthcare Excellence Canada, says the impact of recent staffing decisions ultimately depends on whether the new models provide enough capacity while maintaining safe care.

“I definitely think there’s choices that have to be made,” Zelmer said. “So, that’s why it’s really important to be really mindful about what the implications are in terms of workforce capacity, in terms of staff safety, and safety of patients as well.”

That means looking beyond the number of RNs or RPNs employed and assessing whether the new staffing model is meeting patients’ needs, she said.

“Typically, when you have different types of healthcare providers, they’re working together. So, it’s not an RN separately from a physio separately from an RPN. They’re working in a team. So, how are you effectively putting together a staffing model that meets the needs of patients and that ensures safe care?” Zelmer said.

While Zelmer noted that the full impact of these staffing decisions remains to be seen, she said overtime and sick-time data, combined with the experiences of patients and frontline staff, can help assess how the changes are affecting the quality of care.

“Are patients saying that they’re able to speak up, that they’re getting the care that they need, for instance?” she said. “And then also important to be understanding the perspectives of frontline staff. Do they feel safe in the work that they’re doing?”

According to the most recent data from the Canadian Institute for Health Information (CIHI), the number of RNs working in direct care in Ontario hospitals increased 19 per cent between 2016 and 2025, from 59,544 to 70,625. In the same period, the number of RPNs increased by 51 per cent, from 16,148 to 24,360.

Despite this growth in direct-care nursing, hospitals continue to report staffing pressures, with increased reliance on overtime and purchased hours across hospital staff, including patient-care, management and support personnel.

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