California’s push to implement new nurse-to-patient ratios at psychiatric hospitals has sparked widespread concern among hospital leaders and advocacy groups, who warn the rules could reduce an already limited psychiatric capacity, increase emergency department boarding and strain the behavioral health workforce.
Regulators have proposed emergency regulations requiring psychiatric hospitals to staff one licensed nurse for every six adult patients and one licensed nurse for every five adolescent patients. At least 50% of nurses counted toward staffing ratios must be registered and be awake and on duty in the hospital.
“We want to partner with the department to create regulations that focus on safety, quality and access that elevates all quality of care and safety without the unintended consequences of closing down psychiatric hospitals or closing down beds throughout the state of California,” Jesse Tamplen, executive administrator of behavioral health at Walnut Creek, Calif.-based John Muir Health, told Becker’s.
Some advocates of the rules expressed support for standardized staffing requirements but worry over its inflexibility.
“We are supportive of creating a statewide standard that they all know they need to follow, but it needs to take a common-ense approach,” Kirsten Barlow, vice president of public policy for the California Hospital Association, told Becker’s.
Hospitals that fail to meet the ratios would be required to reduce patient capacity. Violations would carry fines of $15,000 for the first violation, $30,000 for the second and each subsequent violation.
The state delayed the initial Jan. 31 implementation date following pushback from the public and hospitals and now expects to adopt staffing regulations by June 1, according to a letter from the California Department of Public Health. Permanent regulations are expected by July 31, 2027.
The proposed rules do not factor in the potential expense of hospital efforts tomeet the ratios, some leaders said.
“Simply hiring more nurses as a result of this is going to be very costly, but it also is going to drive up the competition for talent, and that’s where wage inflation occurs,” John Meier, CEO of Covina, Calif.-based Aurora Charter Oak Hospital, told Becker’s.
Psychiatric bed shortage concerns
California currently has about 7,000 psychiatric inpatient beds — roughly 2,000 beds short of demand. In 24 of the state’s 58 counties, residents do not have access to inpatient psychiatric beds. For adolescents, access is available in only 15 counties, Ms. Barlow said.
At John Muir Health, Mr. Tamplen said, a January implementation of the proposed ratios would have prompted the system to close 38 beds immediately, even if nursing schedules were adjusted in collaboration with unions.
“Then what’s hard is, every 24 hours, the state would fine us. The first day is $15,000 every 24 hours, then $30,000 [each subsequent day] if you don’t meet those staffing ratios,” Mr. Tamplen said. “So we’re getting penalized $30,000 a day if we don’t need those staffing ratios, then we would have to lower our available beds, because we don’t want to get fined $30,000 a day.”
Behavioral health inpatient care across payers is underfunded by 34.3%, according to an analysis from the American Hospital Association.
Health system leaders say the effects could extend beyond behavioral healthcare.
“Our psychiatric hospitals are essential to the health care system throughout California to support timely access to emergency room care and timely access to med surge care,” Mr. Tamplen said. “If our psychiatric hospitals either have to close or decrease in their beds due to meeting these nursing staffing ratios that’s going to impact Californians beyond behavioral health.”
In turn, community resources could bear the burden.
“If someone is in crisis, they have to go somewhere,” Mr. Meier said. “They go to emergency rooms, or it forces our law enforcement partners to be the primary responder for people who are having mental health crises.”
The California Association has urged regulators to provide hospitals with at least a one-year implementation timeline.
While nursing ratios are not new to California, the timeline is unprecedentedly fast. When the state implemented staffing ratios roughly two decades ago for acute hospitals, acute psychiatric hospitals and specialty hospitals, providers were given a year or more to comply.
“There was a clear acknowledgement that you can’t just flip a switch,” Ms. Barlow said.
Workforce and hiring challenges
Hospital leaders say workforce constraints are a major barrier.
At John Muir Health, it takes six to nine months to recruit and onboard a qualified psychiatric registered nurse, Mr. Tamplen said. If the proposed rules are implemented as is, the system would need to hire 30 additional registered nurses.
“There’s no way that we can hire 30 registered nurses if we wanted to, even if we had the money to, within five months,” he said. “The proposal is completely devoid of acknowledgement of the workforce challenges that have persisted in behavioral health for the last 10 to 15 years, if not more, and which were exacerbated by the COVID-19 pandemic.”
Workforce availability also varies widely across the state. Metropolitan areas such as Los Angeles County have a greater concentration of nurses than rural counties, Mr. Meier said.
“I feel confident we will be able to get enough nurses hired and trained, but I don’t know if that’s the case for every provider throughout the state, particularly when you look at more rural areas, where it’s a smaller populace in general and a much more constrained nursing workforce,” he said.
According to the state Department of Health Care Access and Information, 25 counties are designated nurse shortage areas.
Hospitals also note that the hiring process itself can be lengthy. Background checks alone can take 10 to 12 weeks after a candidate is identified, Ms. Barlow said.
Training compounds the challenge: Behavioral health roles require specialized preparation, and some newcomers may hesitate to work in high-acuity psychiatric settings, she said.
Still, Mr. Meier said, Aurora Charter Oak Hospital will not shorten training requirements simply to meet staffing targets.
Another ramification front of Ms. Barlow’s mind concerns experienced behavioral health technicians, who often conduct patient rounds and provide continuous observation and could be lost to meet the quota.
“For all of these nurses who we hire, we’re going to be letting go with almost a corresponding amount of mental health technicians who have worked in those hospitals for years, and in many cases, have undergone that hospital’s training,” Ms. Barlow said.
Unlike nurses, the technicians do not have organizations advocating for them during the rulemaking process, she added.
Differences in psychiatric care delivery
The CHA has urged regulators to consider how psychiatric care differs from medical-surgical care.
In psychiatric hospitals, overnight care is typically focused on monitoring patient safety and supporting rest and recovery.
John Muir meets staffing requirements during day shifts but faces challenges meeting the ratios during overnight hours. The system has asked regulators to allow for flexible nighttime staffing, proposing a 1-to-12 nurse-to-patient ratio.
The California Police Chiefs Association, which represents 334 municipal police chiefs across the state, has also supported flexibility for overnight staffing.
The County Behavioral Health Directors Association — representing all 58 California counties — has similarly urged the state to adjust the overnight ratios.
The CHA conducted its own literature review and said it found no conclusive evidence that a specific psychiatric staffing ratio alone predicts safety or care quality.
Instead, the association is calling for a multidisciplinary model.
“It’s really about the mix of staff you have, their experience and training and their attitudes toward patients, and the compassion that many people who work in the behavioral health field bring to that job,” Ms. Barlow said.
Mr. Tamplen said the proposal is particularly concerning amid a growing youth mental health crisis.
“If they don’t change [the rules], not only are we going to decrease beds throughout the state of California… but it’s really going to challenge an already impacted pediatric and adolescent mental health system,” he said.
In 2021, suicide was the second leading cause of death for individuals ages 10 to 24. Additionally, nearly 1 in 5 children ages 3 to 17 had been diagnosed with a mental or behavioral health condition, according to the CDC.
Preparing hospitals for potential changes
At Aurora Charter Oak Hospital, leaders have already tested staffing models aligned with the proposed regulations to see how care delivery might change.
Mr. Meier described the shift as a “stark operational change.”
The rules would move psychiatric hospitals toward a primary nursing model similar to medical-surgical care. Historically, psychiatric facilities have relied on multidisciplinary teams.
“The value of didactic training or real world immersion is you get to experience challenges rather than hypothesize issues that may arise,” he said.
Hospital leaders were also deployed to answer any staff questions and address concerns as planning continues.
“We’re doing everything we can to turn over every stone and be able to mitigate those challenges to the best of our ability from now until June 1,” Mr. Meier said.
