Nursery-grown tree seedlings are a vital component of successful restoration and reforestation programs, useful when calls for increased planting for industrial forest management are made, and a tool for climate change mitigation. One of the most extensively planted and studied trees in Western North America is Douglas-fir. Building on that body of work, this review was conducted to identify if the root-to-shoot ratio (root:shoot, R:S), a commonly referred-to metric in reforestation planning, yields meaningful guidance for producing seedlings that are better able to establish across a variety of field conditions. The results indicated that there is wide variability in R:S of nursery-grown seedlings. The relationship between R:S and subsequent root growth and seedling survival varies depending on Douglas-fir variety, seedling stocktypes, and site conditions. The biological and physiological basis for using R:S remains, and likely could be used to enhance seedling quality; however, there is an ongoing need for planning and collaboration between researchers and practitioners to identify how to best deploy this evaluation tool.