Dear Governor Newsom:

California Nurses Association/National Nurses United (CNA), representing more than 100,000 registered nurses (RNs) who provide direct patient care in California including nurses who work in acute psychiatric hospitals (APHs), writes to you about the distressing understaffing crisis in our state’s psychiatric facilities. CNA applauds your ongoing work and dedication to expanding and prioritizing behavioral health care for patients across California. By fully implementing safe registered nurse-to-patient ratios throughout acute psychiatric care facilities in California, your administration has the ability to lead our state to an historic victory in this imperative effort to ensure all Californians can access high-quality behavioral health care services. To this end and to protect behavioral health patients, RNs, and other health care workers in our acute psychiatric care facilities, CNA urges you to order by executive action that the California Department of Public Health (CDPH) issue emergency regulations mandating unit-specific minimum numerical registered nurse-to-patient ratios in acute psychiatric facilities throughout the state.

As nurses, CNA members know that one of the most effective ways to protect patients is through safe and effective staffing. Staffing levels of registered nurses that facilitate safe, competent, therapeutic, and effective care are vital to the safety of patients in our hospitals. For decades, research has demonstrated that safe nurse-to-patient staffing ratios are associated with lower mortality, lower nurse burnout, and better nurse retention.[1] The only way to ensure that all hospitals—including APHs—have safe staffing levels that are consistently adhered to is through legally mandated minimum registered nurse-to-patient ratios. California’s legislature recognized this in 1999 when it passed A.B. 394 (Kuehl) and mandated that California’s health services agency promulgate regulations on numerical nurse staffing ratios for all hospitals in the state, including APHs.

While California’s general acute care hospitals (GACH) safe staffing regulations have successfully been in effect for over two decades, state regulators have yet to promulgate rules to mandate minimum safe nurse staffing ratios for our patients in acute psychiatric hospitals. Although our state should have issued APH safe nurse staffing ratios promptly after A.B. 394 went into effect, the recently revealed dire state of patient care in APHs emphatically demonstrates the urgent need to issue these regulations. For these and the reasons below, CNA urges you to promptly order the emergency promulgation of APH minimum numerical registered nurse-to-patient staffing ratios.

• Over Two Decades Have Passed Since State Law Mandated that Safe Nurse-to-Patient Ratios be Enacted for Acute Psychiatric Hospitals.

California’s experience demonstrates that mandatory minimum registered nurse-to-patient ratios in our GACHs have increased patient safety and quality of care. Implementing this necessary protection is sound, life-saving healthcare policy, which our state legislature determined over 25 years ago for both general acute care hospitals and acute psychiatric hospitals.

In October 1999, the California legislature passed A.B. 394 (Kuehl), which was signed by Governor Davis, to mandate that the California Department of Health Services, now CPDH, promulgate regulations to establish unit-specific mandatory minimum numerical nurse-to-patient staffing ratios for all acute care hospitals in the state, including APHs. With A.B. 394, a new Health and Safety Code, § 1276.4, went into effect, requiring that the state public health agency adopt rules to establish not only safe nurse-to-patient ratios for general acute care hospitals but also for acute psychiatric hospitals.

The enactment of A.B. 394 in 1999 was followed by a three-year rulemaking process and years of litigation over the establishment and adoption of safe nurse-to-patient ratios in general acute care hospitals. In January 2004, California’s safe staffing regulations for GACHs went into effect under Cal. Code Regs., Title 22, § 70217. With the promulgation of these regulations, our state became the first jurisdiction in the country to legally mandate unit-specific minimum numerical nurse-to-patient ratios throughout general acute care hospitals. However, as gubernatorial administrations changed after the adoption of staffing ratios for GACHs, the legislative mandate that CDPH also promulgate minimum nurse-to-patient staffing ratios for APHs has yet to be fulfilled.

Today, it has been over two decades since California’s regulations on GACH safe nurse staffing ratios went into effect and over 25 years since the state legislature passed law to ensure that all hospitals in the state have minimum safe nurse-to-patient ratios to protect our patients and health care workers, but no regulations ensuring that safe nurse-to-patient staffing ratios are established and enforced in acute psychiatric hospitals have been proposed or promulgated.

• The Understaffing Crisis in California APHs Impedes the State’s Goals to Expand Access to Behavioral Health Care.

As a critical part of California’s efforts to expand access to behavioral health care, acute psychiatric facilities in our state are meant to provide important, lifesaving care for Californians with behavioral health needs on a 24-hour inpatient basis. However, without the necessary safeguards of mandatory minimum nurse-to-patient staffing ratios, acute psychiatric hospitals have been permitted to make decisions on staffing levels based on budgeting and revenue rather than safe and effective patient care. For example, without regulatory mandates to provide minimum numerical staffing ratios, APHs may engage in nurse staffing cuts to save money, thereby adversely affecting patient outcomes.

Today, in California, there are 119 facilities that are licensed as acute psychiatric hospitals—43 facilities that are standalone acute psychiatric hospitals and 76 acute care hospitals that provide acute psychiatric services as a “distinct part” that are licensed as acute care hospitals.[2] In total, these 119 facilities licensed as APHs are licensed to provide care for over 14,000 beds throughout the state. Of these facilities, 52 are for-profit APHs, 41 are non-profit APHs, and 26 have public (state, county, health district, or University of California) or exempt ownership.

However, a recent San Francisco Chronicle investigative series on the current state of APH’s in our state, “Failed to Death,” revealed shocking stories of assault, abuse, and neglect in the care of vulnerable behavioral health patients resulting from inadequate staffing in our acute psychiatric hospitals.[3] Journalists Joaquin Palamino and Cynthia Dizikes were puzzled by the lack of staffing standards for APHs despite our quarter-century old legislation that directed CDPH to adopt numerical minimum staffing standards for all California hospitals. Palamino and Dizikes wrote:

[F]or-profit psychiatric hospital operators have taken advantage of lax state staffing regulations to generate hundreds of millions of dollars in earnings. Although California law required CDPH to set minimum nurse-to-patient ratios in psychiatric hospitals, the agency has failed to do so, contributing to understaffing, violence and deadly neglect.[4]

The investigative series cite numerous deficiency notices that were given by CDPH to for-profit APH operators for staffing inadequacies resulting in patient harm but describe no evidence of improvement in hospital staffing standards. But the inability of CDPH to enforce failures in safe staffing in APHs does not come as a surprise given that the Department can only enforce regulations that are in effect. With virtually no staffing standards in effect in APHs, CDPH has limited tools to ensure safe staffing at APHs despite the statutory mandate in Health and Safety Code, § 1276.4 to adopt minimum numerical licensed nursing standards to protect patients in all hospital settings.

Additionally, Palomino and Dizikes describe the dangerous working conditions in APHs, which is driving nurses and other psychiatric workers to leave these facilities. They described the dangerous understaffing conditions and extreme risks for workplace violence at Aurora Behavioral Healthcare Santa Rosa that lead to a riot in the facility where police were called after “patients were kicking, scratching and spitting on employees as staff members struggled to pin them down and quell the riot” and “[a] girl ripped a block of sheetrock from the wall and hurled it at workers.”[5] The report goes on to describe how hospital administrators were nowhere to be found leaving only a handful of underprepared staff to desperately try to care for their adolescent patients.

The stories from Aurora Behavioral Health Care underscores that improvement in the staffing levels and working conditions will be an essential element of both ensuring that patients receive the high-quality care that they deserve and retaining RNs and other licensed health care workers to continue their work in the environment of inpatient behavioral health care. Given the current understaffing and lack of enforceable mandatory minimum numerical nurse-to-patient ratios at APHs, increasing the numbers of behavioral health patients admitted to California’s acute psychiatric hospitals does not equate with and ultimately impedes the state’s goal of improving access to behavioral health care.

• For-Profit APHs are Dangerously Understaffed Compared to Public and Unionized APHs.
  

Another important revelation from the San Franciso Chronicle investigative series is the dangerously low staffing standards at for-profit APHs when compared to their public and non-profit APH counterparts.

Evaluating data on the number of registered nurse hours per patient day (RN HPPD) in 2023 among APHs, provides a stark picture of the wide-ranging levels of RN staffing in APHs throughout the state. For example, the University of California San Francico (UCSF) operated APH, Langley Porter Psychiatric Institute, provided the highest number of RN HPPD at 12.68 while 27 APHs provided less than 3 RN HPPDs in 2023.[6] By comparison, UCSF Langley Porter provided nearly seven times as many RN staffing hours for patients than Aurora Behavioral Healthcare Santa Rosa, the APH analyzed in the San Francisco Chronicle series, which only provided 1.89 RN HPPD in 2023.[7] Notably, while UCSF Langley Porter is not lawfully mandated to comply with the GACH psychiatric unit nurse-to-patient ratios, registered nurses at UCSF Langley Porter are unionized workers, represented by CNA. Unionization has allowed RNs to speak without fear of retaliation regarding understaffing and thereby uphold higher staffing levels.

Additionally, the use of unlicensed staff in for-profit APHs and many non-profit APHs mirrors the staffing of GACH hospitals during the 1990s, prior to the adoption of GACH nurse-to-patient ratios, where some hospitals dangerously increased levels of unlicensed staff to substitute RNs.[8] For example, today, UCSF Langley Porter staffs with 60.3% registered nurses and only has 20.5% unlicensed staff. In contrast, Aurora Behavioral Healthcare Santa Rosa’s APH utilizes only 32.3% registered nurses but utilizes 66.2% unlicensed staff.[9] Examining APHs across the state, for-profit APHs tend to have dramatically lower RN HPPDs when compared to publicly owned or operated APHs and tend to staff more unlicensed personnel.[10]

Only through the implementation of mandatory minimum nurse-to-patient staffing ratios at APH can California reverse this dangerous trend of understaffing at for-profit APHs and use of woefully unprepared and unlicensed staff, which jeopardizes both the quality of care and safety of patients at APHs.

• Safe Nurse-to-Patient Staffing Ratios Have Saved Lives in California’s General Acute Care Hospitals.

After over two decades California’s implementation of its nurse-to-patient ratios law, both California nurses’ experience and the research literature indisputably demonstrate that legislative and regulatory mandates on minimum nurse-to-patient staffing improves patient care and saves lives. Research has shown overwhelmingly that safe staffing levels and ratios help improve patient outcomes in mortality, adverse events, complications, failure to rescue, quality of care, costs, and length of stay.[11] Safe staffing levels also help decrease nurse burnout and job dissatisfaction.[12] In short, lawfully mandated minimum nurse staffing levels at general acute care hospitals in California have been proven to save lives and enhance patient care.

A seminal study from 2010 on the impact of California’s ratios compared California hospitals’ post-implementation of the state’s minimum nurse-to-patient ratios law to hospitals in New Jersey and Pennsylvania.[13] The study found, unsurprisingly, that if New Jersey and Pennsylvania had matched California’s ratios in medical surgical units, New Jersey would have 13.9 percent fewer patient deaths and Pennsylvania 10.6 percent fewer deaths. Compared to states without ratios, the study found that California RNs reported having more time to spend with patients and that hospitals were more likely to have enough RNs on staff to provide quality patient care. The study also found that California nurses were significantly less likely than their New Jersey and Pennsylvania counterparts to report that workload causes them to miss changes in patient conditions.

A later study from 2016 that compared hospitals in Pennsylvania, New Jersey, Florida, and California confirmed the earlier findings that California’s improved nurse-to-patient staffing ratios improved patient care.[14] This study focused on hospitals that saw ten or more cardiac arrest events during the time under study and found that for every additional patient assigned to a nurse, the likelihood of a patient surviving cardiac arrest decreased by five percent per patient.

The success of California’s nurse-to-patient ratios law confirms what other more general studies on nurse staffing have long shown. For example, a 2013 meta-analysis of twenty-eight prior studies found a consistent relationship between higher RN staffing and lower hospital related mortality.[15] These are just a small sample of studies that reaffirm California’s statutory mandate that minimum numerical registered nurse-to-patient ratios be established by regulation for all hospitals, including APHs, in our state.

• Research Literature Demonstrates that Safe Nurse Staffing Levels Saves Lives in Acute Psychiatric Facilities and Units.

In addition to the body of research about the importance of safe RN staffing in proving high-quality, effective patient care in hospitals generally, there are numerous studies that support the importance of RN staffing in the acute psychiatric hospital setting. Findings in the research literature include:

• Readmission rates for psychiatric disorders within 30 days were reduced with high levels of nurse staffing.[16]
• Nurse communication involves interpersonal approaches and modalities that exemplify highly developed communication and personal skills designed specifically for the acute inpatient mental health units.[17]
  
• Increases in mental health staffing led to a reduction in suicide-related events for patients.[18]
  
• Lower nurse staffing results in nursing care left undone.[19]
  
• The nurse-to-patient staffing ratio in inpatient psychiatric settings was strongly and significantly related to the rate of work-related injuries experienced by hospital staff. Higher numbers of RNs to patients were associated with fewer work-related injuries.[20]

Attached to this letter as Attachment 1 is a complete list of research literature specifically supporting safe staffing levels for inpatient psychiatric patients.

• Safe Staffing Ratios in GACHs have Improved Nurses’ Health and Safety.

Numerical nurse-to-patient ratios in GACHs improved not just patient safety but also improved nursing work environments and nurses’ health and safety. Improved working conditions and safe staffing levels in hospitals have attracted and retained nurses to practice in the state.

California’s success with implementation of its mandated minimum nurse-to-patient staffing ratios law belies industry arguments that there are not enough RNs to comply with mandated nurse-to-patient ratios. Numerous studies demonstrate that California’s ratios have resulted in California nurses caring for fewer patients at a time, positively impacting both the working environment and patient care. The comparative study of California to New Jersey and Pennsylvania also found that California’s ratios have positively affected nurses’ overall work environment and their corresponding ability to deliver patient care. Overall, compared to their nurse counterparts in New Jersey and Pennsylvania, nurses in California care for an average of one fewer patients and reported more favorable outcomes with respect to every work environment measure analyzed, including reasonable workload, adequate support staff, and enough RNs to provide quality patient care.[21]

A different survey of California nurses after the implementation of California’s ratios law also found that California nurses reported significant improvements in working conditions and job satisfaction.[22] A more recent 2015 study, which examined occupational injury and illness rates before and after the California RN staffing ratio law was passed, also showed what RNs already know—safe staffing improves RN health and safety.[23] Other research supports these findings that RN staffing ratios mean safer RNs. These findings include:

• Nurses from units with low staffing and poor organizational climates were twice as likely as nurses on well-staffed and better organized units to report risk factors for needlestick injuries and near misses.[24]
  
• An increased patient load per nurse was associated with significantly higher likelihood for neck, shoulder, and back musculoskeletal disorders.[25]
  
• Risk for workplace violence injuries was twice as high for lower-staffed hospitals compared to higher-staffed hospitals.[26]
  

Safe working conditions allow nurses to focus on their patients rather than taking time off to heal themselves. In sum, safe patient workloads and safe working conditions for RNs go hand-in-hand to ensure nurses are able to provide safe and therapeutic patient care.

• Safe Nurse Staffing Levels Improves Nurse Retention and Results in Hospital Savings.

The experience of California in GACH also has demonstrated that the specter of outsized costs to industry to implement minimum nurse-to-patient ratios was unfounded. Improved nurse job satisfaction and patient outcomes that resulted from the implementing nurse staffing ratios reduced spending on temporary RNs and overtime costs and also resulted in savings from lower RN turnover.[27]

Minimum safe nurse-to-patient ratios both attract and retain registered nurses in direct care positions in our hospitals. After the implementation of California’s ratio law, nurses in California experienced burnout at significantly lower rates than those in New Jersey and Pennsylvania, and reported less job dissatisfaction.[28] Both burnout and job dissatisfaction are precursors to turnover. More recently, the Texas Center for Nursing Workforce Studies published research on hospital nurse staffing vacancy and turnover rates for registered nurses, which showed RN turnover rates in California to be dramatically lower than states without ratios, such as Florida and Texas.[29]

Studies on the cost of RN turnover can put an actual number on the savings potential of implementing safe nurse-to-patient staffing ratios. According to a PricewaterhouseCoopers’ report on nursing workforce recruitment and retention, the estimated cost of replacing one RN in 2007 was between $40,000–$85,000.[30] The report goes on to state that, “Every percentage point increase in nurse turnover costs an average hospital about $300,000 annually.”[31] Considering the costs of nurse turnover, it is evident that implementing safe registered nurse-to-patient staffing ratios saves individual hospitals from both the expense and clinical disruption of a rapid turnover of its nursing staff.

An improved nurse working environment, likewise, translates into savings from improved patient outcomes[32] and shorter patient lengths of stay.[33] A 2009 study estimated that adding 133,000 RNs to the U.S. hospital workforce—the number of RNs needed to increase nursing staff to the 75th percentile—would produce medical savings of $6.1 billion, not including the value of increased productivity when nurses help patients recover more quickly.[34] Combining medical savings with increased productivity, the addition of 133,000 RNs would result in an economic value of $57,700 for each additional RN.[35] Mandatory minimum nurse-to-patient staffing levels are feasible, resulting in better nurse workloads and hospital savings from lower turnover and improved patient outcomes.

Tellingly, the implementation of California’s ratios law for GACHs attracted, and continues to attract, nurses to practice in our state. There is a significant difference between the number of RNs with active licenses before the implementation of GACH minimum staffing ratios and today. California has added nearly 300,000 RNs with active licenses since 1999. In 1999, California had 244,105 registered nurses with active licenses[36] and as of April 1, 2025, there are 542,896 registered nurses with active licenses.[37] The number of licensed GACH beds in California has been remarkably stable since the GACH staffing ratios regulations when into effect on January 1, 2005. From 2004 to 2013, there was virtually no numerical change in the number of licensed GACH beds with 81,179 licensed beds in 2004 and 81,729 in 2013, meaning that there are even higher numbers of RNs to patient beds in California GACHs today.[38]

Implementing minimum nurse-to-patient ratios in GACHs not only improved nursing workforce retention but also resulted in savings for hospitals by reducing turnover rates and costs associated with negative patient outcomes. Likewise, implementation of safe nurse-to-patient staffing ratios in APH would have a similar impact of improving patient care and working conditions, retaining a dedicated and skilled behavioral health workforce, and ultimately saving money for hospitals from reduced worker turnover and improved patient care.

• Executive Action is Needed to Ensure that Safe Nurse-to-Patient Staffing Ratios are Promulgated by CDPH Promptly as Emergency Regulations.

The evidence overwhelmingly demonstrates that in the face of an epidemic of preventable medical errors and constant reports of workplace violence at APHs, RN staffing ratios in California acute psychiatric facilities must be implemented without delay to prevent further patient harm and preserve thousands of lives. Attached to this letter as Attachment 2, CNA has included proposed regulatory language for an emergency rulemaking on APH minimum safe staffing standards.

Fortunately, the work of developing regulatory language for nurse-to-patient ratios compliant with the statutory mandate in Health and Safety Code § 1276.4 and necessary for staffing ratio enforcement has already been done by CDPH under our GACH safe nurse staffing standards in Cal. Code Regs., Title 22, § 70217. The GACH rulemaking on minimum nurse-to-patient ratios was the largest rulemaking in department history and spanned more than 10,000 pages.[39] CNA’s proposed regulatory language below for APH staffing standards has been adopted from the GACH rulemaking, adapted to reflect the inpatient psychiatric units and unit types found in APHs.

Patients in the APH setting are entitled to staffing protections that, at the very least, mirror those in GACHs. To the greatest extent possible, the proposed regulatory language mirrors the unit-specific numerical ratios and other implementation standards found in Cal. Code Regs., Title 22, § 70217. CNA’s recommendations for pediatric/adolescent care numerical ratios mirror the GACH pediatric minimum nurse-to-patient ratio language since the population has unique developmental needs and differences than the adult/geriatric psychiatric unit population. Additionally, some APHs have supplemental services for skilled nursing facility (SNF) and/or intermediate levels of care, which are not units included in the GACH staffing ratio regulation. For these supplemental services, we have recommended APH staffing standards that recognize the unique needs of this behavioral health population and the fact that they are provided on a 24- hour basis by the APH.

Importantly, the need for highly developed communication and personal skills designed specifically for the acute inpatient psychiatric patient merits a registered nurse-to-patient ratio of RNs that is not diluted by other licensed staff. Licensed vocational nurses and licensed psychiatric technicians can play an important role in acute psychiatric care but the utilization of other licensed health care staff must supplement and not replace the minimum RN-to-patient ratios. Additionally, unlicensed staff are also an important component of care in the inpatient care setting, but the GACH rulemaking did not provide specific guidelines for unlicensed staff and Health and Safety Code § 1276.4 did not direct the Department to establish such guidelines.

Finally, in our proposed regulatory language on APH minimum registered nurse-to-patient ratios, we have used the accepted format for regulatory change by underlining new language and strikethrough of regulatory language to be deleted or repealed.

• Conclusion

For all the above reasons, CNA urges you to issue an Executive Order directing the California Department of Public Health to promulgate, through emergency regulations, mandatory minimum safe nurse-to-patient staffing ratios for California’s acute psychiatric hospitals.

If you or your office have any questions, please contact me, CNA Government Relations Director Puneet Maharaj, at pmaharaj@calnurses.org or CNA Government Relations Assistant Director Carmen Comsti at ccomsti@calnurses.org.

Sincerely,

Original Signed by Puneet Maharaj

Puneet Maharaj
Government Relations Director
California Nurses Association/National Nurses United

cc: Richard Figueroa, Deputy Cabinet Secretary, Office of the Governor Gavin Newsom Kimberly Johnson, Secretary, California Health and Human Services Agency Paula Villescaz, Deputy Legislative Affairs Secretary, Office of the Governor Gavin Newsom Corrin Buchanan, Undersecretary, California Health and Human Services Agency Brendan McCarthy, Deputy Secretary of Program & Fiscal Affairs, California Health and Human Services Agency

Dr. Erica Pan, Director & State Public Health Officer, California Department of Public Health Susan Fanelli, Chief Deputy Director Health Quality & Emergency Response, California Department of Public Health

Attachments:

• Research Literature on Staffing in Acute Psychiatric Facilities & Units
  
• CNA Proposed Emergency Regulations​ - Acute Psychiatric Hospital Safe Staffing Ratios and Standards (PDF)​
  

[1] See Lasater K., Muir K. J., Sloane D., McHugh M., Aiken, L. (2024). “Alternative Models of Nurse Staffing May Be Dangerous in High-Stakes Hospital Care.” Med Care, 62(7): 434-40.
[2] See Cal Health Find Database, California Department of Public Health, (Accessed Mar. 18, 2025).
[3] Joaquin Palomino and Cynthia Dizikes, “Violence and neglect plague a Bay Area psychiatric hospital. California has lefts its patients in danger,” San Francisco Chronicle (Mar. 19, 2025).
Joaquin Palomino and Cynthia Dizikes, “California is embracing psychiatric hospitals again. Behind locked doors, a profit-driven system is destroying lives,” San Francisco Chronicle (Mar. 5, 2025).
Joaquin Palomino and Cynthia Dizikes, “The mystery shocked San Francisco. This is the story of the 15-year-old girl found dead in a driveway,” San Francisco Chronicle (Feb. 26, 2025).
[4] Palomino and Dizikes (Mar. 19, 2025), supra, note 3.
[5] Id.
[6] Department of Health Care Access and Information (HCAI), “Financial & Utilization Reports,” (Accessed April 8, 2025).
[7] Id.
[8] See A.B. 394 (Kuehl), Senate Floor Analysis (Sept. 3, 1999).
[9] See HCAI, note 7.
[10] Id.
[11] See also National Nurses United. “The Science of Ratios.” National Nurses United (Accessed Apr. 10, 2025). (compiling research literature on the successful implementation of mandatory minimum general acute care hospital nurse-to-patient staffing ratios in California).
[12] Bae S., Mark B., Fried B. (2010). “Impact of nursing unit turnover on patient outcomes in hospitals” J of Nurs Scholarship, 42(1): 40-49.
[13] Aiken L. (2010). “The California nurse staffing mandate: implications for other states.” LDI Issue Brief, 15(4): 904-921.
[14] McHugh M. et al. (2016). “Better Nurse Staffing and Nurse Work Environments Associated With Increased Survival of In-Hospital Cardiac Arrest Patients.” Med Care, 54(1): 74-80.
[15] Shekelle P. (2013). “Nurse-patient ratios as a patient safety strategy: a systematic review.” Ann Intern Med, 158(5): 404-09.
[16] Han K., Kim S. J., Jang S., Hahm M., Kim S. J., Lee S. Y., Park E. (Oct. 2015). “The outcomes of psychiatric inpatients by proportion of experienced psychiatrists and nurse staffing in hospital.” Psych Research, 229(3): 880- 86.
[17] Cleary M., Hunt G., Horsfall J., Deacon M. (2012). “Nurse-Patient Interaction in Acute Adult Inpatient Mental Health Units: a Review and Synthesis of Qualitative Studies.” Issues in Mental Health Nurs, 33(2): 66-79.
[18] Feyman Y, Figueroa S., Yuan Y., et al. (Apr. 2022). “Effect of mental health staffing inputs on suicide-related events.” Health Serv Research, 58(2): 375-82.
[19] Gehri B., Ausserhofer D. et al. (Apr. 2024). “Nursing care left undone in psychiatric hospitals and its association with nurse staffing: A cross-sectional multi-centre study in Switzerland.” Psych and Mental Health Nurs, 31(2): 215-27.
[20] Hanrahan N., Kumar A., Aiken L. (Jun 2010). “Adverse Events Associated With Organizational Factors of General Hospital Inpatient Psychiatric Care Environments.ö
Psych Services, 61(6).
[21] Id.
[22] Spetz J. (2008). “Nurse satisfaction and the implementation of minimum nurse staffing regulations.” Policy Polit Nurs Pract, 9(1): 15-21.
[23] Leigh J., Markis C., Losif A., Romano P. (2015). “California's nurse-to-patient ratio law and occupational injury.” Int Arch Occup Environ Health, 88(4): 477-84.
[24] Clarke S., Sloane D., Aiken L. (2002). “Effects of hospital staffing and organizational on needlestick injuries to nurses.” Amer J Pub Health, 92(7): 1115-19. AJPH.92.7.1115.
[25] Lipscomb J., Trinkoff A., Brady B., Geiger-Brown J. (2004). “Health care system changes and reported musculoskeletal disorders among registered nurses.” Amer J Pub Health, 1431-36
[26] Lee S., Gerberich S., Waller L., Anderson A., McGovern P. “Work-related assault injuries among nurses.” Epidemiology, 10(6): 685:91.
[27] Bland-Jones C. (2008). “Revisiting Nurse Turnover Costs, Adjusting for Inflation.” J of Nursing Admin, 38(1): 11-18.
[28] Aiken (2010), supra, note 13.
[29] Texas Center for Nursing Workforce Studies (2016). “Hospital Nurse Staffing Study, Vacancy and Turnover (PDF).” Texas Department of State Health Services, Publication #: 25-14909.
[30] PricewaterhouseCoopers' Health Research Institute (2007). “What Works: healing the healthcare staffing shortage (PDF).” PricewaterhouseCoopers.
[31] Id.
[32] Encinose W. & Hellinger F. (2008). “The Impact of Medical Errors on Ninety-Day Costs and Outcomes: An Examination of Surgical Patients.” Health Serv Research, 43(6): 2067-85.
[33] Needleman J., Buerhaus S., Mattke M., Stewart M., Zelevinsky, K. (2002). “Nurse-staffing levels and the quality of care in hospitals.” NEJM, 346(22): 1715-22.
[34] Dall T. (2009). “The Economic Value of Professional Nursing.” Medical Care, 47(1): 97-101.
[35] Id.
[36] California Board of Registered Nursing (1999). “The BRN Report – Winter 1999 (PDF).” California Department of Consumer Affairs.
[37] California Board of Registered Nursing (2025). “The BRN Report – Winter 2025 (PDF).” California Department of Consumer Affairs.
California Board of Registered Nursing (Apr. 1, 2025). “Monthly Statistics.” Department of Consumer Affairs. (Accessed Apr. 11, 2025).
[38] California Health Care Foundation (2015). “California Hospitals: An Evolving Environment. (PDF)” California Health Care Almanac, at 3.
[39] See California Department of Health Services (2003). Rulemaking File for Nurse to Patient Ratios By Unit Type in General Acute Care Hospitals (R-37-01). Office of Administrative Law File No. 03-0828-02S.