On behalf of more than 400 hospitals and health systems, including 32 free-standing acute psychiatric hospitals and 72 general acute care hospitals with psychiatric units, the California Hospital Association (CHA) offers the following recommendations on acute psychiatric hospital staffing regulations in response to the
discussion questions that CDPH provided as an attachment to
All Facilities Letter 25-18.
These recommendations follow the California Department of Public Health (CDPH) announcement on April 29 that it would be developing new regulations, and all recommendations support one critical fact: staffing mandates for psychiatric hospitals must reflect the nationally recognized, multi-disciplinary team approach to providing high-quality care and safety for patients experiencing a mental health crisis.
These recommendations were developed with input from a task force of leaders and frontline staff working in more than two dozen hospitals, including non-profit and investor-owned acute psychiatric hospitals and inpatient psychiatric units in general acute care hospitals. Notably, several task force members are themselves registered nurses (RNs) who worked for decades as nurses in acute psychiatric hospital settings.
CHA also reviewed national accreditation standards, existing federal policies governing inpatient psychiatric care, published scientific research on staffing and nursing practices in inpatient psychiatric treatment settings, and the position papers and recommendations of national professional associations representing nurses and psychiatrists.
This extensive review of research, academic papers, policies, and practices — combined with frontline clinical expertise developed over decades treating thousands of children, adolescents, and adults in psychiatric inpatient hospital settings — confirms the following facts that CDPH must consider as it develops minimum staffing regulations for acute psychiatric hospitals.
(1) The overall staff teams’ experience and composition, patient acuity and complexity, and workplace culture are far more closely linked to patient safety and care quality than nurse quantity specifically.
The push by nursing unions in California to impose RN-only staffing ratios ignores the research and is out of step with national RNs’ views of how best to do this work.
What Research Shows
- No substantial research ties safety indicators to nurse staffing levels.[1] A nationwide study of 345 hospitals and 16.3 million patient days found that patient assault rates were frequent, and one-third were against RNs.[2] However, in a subsequent study designed to determine whether odds of an injurious assault are higher in months in which psychiatric unit staffing levels are higher or lower relative to unit average, rates of assault could not be tied to the units’ staffing levels.[3]
- A significant amount of published literature has detailed the importance of the therapeutic relationships between patients and primary treatment providers, characterized not by the quantity of nurses or other staff interacting with patients, but rather mutual respect and trust, jointly established treatment goals, and coordination with family and community supports.[4]
- A systematic review published this year in the International Journal of Mental Health Nursing examined more than 30 quantitative studies of the effects of nurse staffing levels and skill‐mix on patient conflict and containment, and found no clear implications for workforce planning or deployment.[5]
- The Safewards clinical trial study found that simple interventions that improve all psychiatric hospital staff’s relationships with patients can reduce the frequency of conflict and patient containment by as much as 15% and 26%, respectively.[6]
- Trauma-informed care implementation significantly reduced seclusion and restraint use across multiple settings, with results attributed to training of both clinical and milieu staff.[7]
- Interdisciplinary staffing models that included social workers reduced seclusion hours by 44%.[8]
What National Associations Representing Nurses Recommend
The American Psychiatric Nurses Association and the American Nurses Association recommend nurses champion inpatient psychiatric care that relies on sufficient staffing, supported by teams with specific expertise and capabilities.
[9] An American Psychiatric Nurses Association task force reviewed current staffing research to revise and update its 2011 “Staffing inpatient psychiatric units” position paper
[10] and provide recommendations to its board of directors on how psychiatric mental health nurses might champion the staffing needs of inpatient psychiatric units. In 2023, the task force published an updated position paper for psychiatric mental health nurses practicing throughout the country and found:
- The “evidence does not support the universal use of a single method or model of determining staffing needs, for example, nursing hours per, case mix index, mandatory ratios.”
- “Building a structure that links staffing and outcomes requires a holistic approach, incorporating patient, staff, and unit variables.”
- “Staffing is not an external calculation.”
- The “complexity of the patient population influences the care needed. In psychiatric mental health, elements that increase population complexity include medical comorbidities, stability of the psychiatric illnesses, age, functional ability, and health care literacy.”
(2) Patients who are experiencing mental health crises have very different clinical and environmental needs than those who need care in general acute care hospitals.
California’s staffing and nurse-to-patient ratios for medical-surgical hospitals are largely focused on nursing personnel because patients hospitalized for physical health conditions receive critical treatment performed most appropriately and typically by nurses (e.g., wound care, dressing changes, IV insertion, diagnostic tests, assistance with mobility, etc.). Acute psychiatric hospitals, however, focus primarily on restoring the emotional well-being of patients whose mental health symptoms put them at imminent risk of harming themselves or others. This treatment is typically — and appropriately — performed by an interdisciplinary team of health professionals.
Acute psychiatric hospitals provide 24/7 safety monitoring, individual and group therapy, coaching on coping skills, therapy with clinical and social work staff, and help with medications, among other types of care. This model necessitates a tailored, multidisciplinary care team approach that includes RNs and a variety of other personnel who are vital to keeping patients safe while they receive care, including licensed vocational nurses (LVNs), licensed psychiatric technicians (LPTs), mental health workers (MHWs), counselors, social workers, and others.
(3) California lacks sufficient access to this life-saving model of psychiatric inpatient care.
Well-established benchmarks suggest that at least 50 staffed psychiatric beds are needed per 100,000 people.
[11] While countries in Europe average 75 beds per 100,000 people,
[12] California only has a mere 25 — fewer than even Mississippi or Montana.
Psychiatric beds and units have been shuttered in recent decades, due in part to cost pressures and inadequate reimbursement, along with rising labor shortages and costs. In CDPH’s design of psychiatric hospital staffing ratios, clinical factors must, of course, be paramount. To support that principle, CHA recommends a multi-disciplinary care team approach with a proven, national track record that aligns with clinical best practices. But as the state creates a standard for personnel in psychiatric hospitals, it cannot ignore the current challenges in meeting demand, driven by a longstanding shortfall in clinical professionals needed to support access to inpatient psychiatric care.
In collaboration with CHA and other stakeholders, CDPH has an opportunity to establish minimum statewide staffing ratios that ensure patient safety and effective care, while maintaining the viability and sustainability of acute psychiatric hospitals in California.
CHA appreciates the opportunity to provide information that helps ensure the regulations under development are informed by the decades of combined expertise and knowledge of psychiatric hospital leaders throughout the state.
We look forward to working with you.
Sincerely,
Original Signed by Kirsten Barlow
Kirsten Barlow, MSW
Vice President, Policy
Attachments:
[1] Johnson, C., Delaney K.R., Cirpili, A., Marriott, S., O’Connor, J., (2023). American Psychiatric Nurses Association Position: Staffing Inpatient Psychiatric Units, Journal of American Psychiatric Nurses Association, DOI: 10.1177/10783903231198247
[2] Staggs, V. S. (2015). Trends, victims, and injuries in injurious patient assaults on adult, geriatric, and child/adolescent psychiatric units in US hospitals, 2007-2013, Research in Nursing & Health, 38(2), 115-120.
[3] Staggs, V. S. (2016). Deviations in monthly staffing and injurious assaults against staff and patients on psychiatric units, Research in Nursing & Health, 39(5), 347-352
[5] Woodnutt S, Hall S, Libberton P, Ball J, Dall'Ora C, Griffiths P. (2025). The Association Between Nurse Staffing and Conflict and Containment in Acute Mental Health Care: A Systematic Review. International Journal of Mental Health Nursing, doi: 10.1111/inm.70039.
[6] Bowers, L., James, K., Quirk, A., Simpson, A., Stewart, D., & Hodsoll, J. (2015). Reducing conflict and containment rates on acute psychiatric wards: The Safewards cluster randomised controlled trial. International Journal of Nursing Studies, 52(9), 1412–1422. doi: 10.1016/j.ijnurstu.2015.12.006.
[7] Huckshorn KA, CAP, I., & Director, N. (2005). Six core strategies to reduce the use of seclusion and restraint planning tool. National Association of State Mental Health Program Directors; Azeem MW, Aujla A, Rammerth M, Binsfeld G, Jones RB. (2011). Effectiveness of six core strategies based on
trauma informed care in reducing seclusions and restraints at a child and adolescent psychiatric hospital. J Child Adolesc Psychiatr Nurs. doi: 10.1111/j.1744-6171.2010.00262x.
[8] LeBel J. (2014). First randomised controlled-trial research on seclusion and restraint reduction achieves intent. Evid Based Ment Health. doi: 10.1136/eb-2014-101717.
[9] Johnson, C. et al., 2023
[10] Farley-Toombs C. Psychiatric Mental Health Registered Nurses (RN-PMHs): The Key to Patient Safety and Recovery-Oriented Care in Acute Psychiatric Settings (2011). Journal of the American Psychiatric Nurses Association. 17(5):356-358. doi:10.1177/1078390311421951