Via electronic mail to CHCQRegulations@cdph.ca.gov.
June 16, 2025
Mandi Posner, Deputy Director
Center for Health Care Quality
California Department of Public Health
1615 Capitol Avenue, Sacramento, CA 95899-7377
RE: Comments on Questions for June 2025 Stakeholder Meeting – Acute Psychiatric Hospital Regulations AFL-25-18
Dear Deputy Director Posner:
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 in response to questions posed at the June 11, 2025, Stakeholder Meeting on Acute Psychiatric Hospital Regulations held by the California Department of Public Health (CDPH). These comments supplement CNA’s comments to CDPH on May 20, 2025, in response to CDPH’s questions from the first stakeholder meeting on APH regulations that occurred on May 13, 2025, and CNA’s letter to Governor Gavin Newsom on April 15, 2025, urging the issuance of CDPH emergency regulations establishing mandatory minimum registered nurse-to-patient staffing ratios for APHs.
CNA reiterates our request urging CDPH to issue emergency regulations that establish mandatory minimum registered nurse-to-patient staffing ratios for APHs. For decades, nurses’ experiences with California’s mandatory minimum numerical RN-to-patient staffing ratios in general acute care hospitals (GACHs) and the research literature have demonstrated that safe RN-to-patient staffing ratios are associated with lower mortality, lower nurse burnout, and better nurse retention.
[1] The statutory mandate under Health and Safety Code section 1276.4 has been clear for over two decades since A.B. 394 (Kuehl) was signed into law in 1999 that the Department must establish mandatory minimum registered nurse-to-patient staffing ratios. RN staffing ratios in California’s acute psychiatric facilities must be implemented without delay to prevent further patient harm and preserve thousands of lives.
For the reasons below and for the reasons described in CNA’s April 15, 2025, letter to Governor Newsom and May 20, 2025, comments to CDPH, CNA urges CDPH to promptly issue emergency regulations that establish APH minimum numerical registered nurse-to-patient staffing ratios.
1. Some stakeholders provided comments recommending a 1:6 nurse-to-patient ratio for adult patients and a 1:4 nurse-to-patient ratio for pediatric/adolescent patients, what specific patient needs justify a different ratio based solely on age?
As CNA has urged in previous comments, CDPH should implement a 1:6 registered nurse-to-patient ratio for acute adult patients and 1:4 for pediatric or adolescent patients with a lower maximum patient assignment for RNs and additional behavioral health staffing based on patient acuity and in alignment with unit-specific RN-to-patient ratios in GACHS. This ratio represents the maximum number of patients that APHs may assign to RNs and would ensure uniformity with the numerical staffing ratio requirements for GACHs.
Pediatric and adolescent patients in APHs should receive competent, therapeutic care in a safe environment, as well as the same standard of care as acute psychiatric patients in GACHs. Under Title 22, the minimum nurse-to-patient ratio for pediatric units in GACHs is 1:4 and is specific to RNs.
[2] The APH ratio should match the GACH pediatrics ratio for children and teens.
Importantly, pediatric and adolescent units require safe levels of RN staffing so that nurses can closely monitor and continuously assess patients for both their developmental and special psychiatric needs. RNs must have regular patient interactions to provide patients with trauma-informed care and therapeutic interventions to prevent retraumatization and suicide given the elevated risks of self-harm in both children and adolescents.
[3]
CDPH’s registered nurse staffing ratios must improve the staffing for adolescents and children, not codify the current woefully inadequate staffing levels at APHs. The status quo in APHs is failing pediatric and adolescent patients. The San Francisco Chronicle’s investigation of an acute psychiatric hospital in the Bay Area found that patients in a designated adolescent unit died by suicide and were sexual assaulted because the hospital did not employ enough staff to provide safe patient care.[4]
Finally, it is important to underscore the role of the registered nurse and the nursing assessment, which only an RN can conduct. Under Health and Safety Code section 1276.4, subdivision (a), minimum nurse-to-patient ratios in GACHs, APHs, and specialty hospitals must be numerical and, as detailed in CNA’s May 20, 2025, comments to CDPH, specific to RNs. The law makes the specific role of RNs clear by requiring the implementation of ratios to be in accordance with hospital licensing requirements and registered nursing scope of practice regulations. These requirements and regulations establish that only the registered nurse is responsible for both the initial assessment and ongoing assessments required to evaluate how the patient is responding to the nursing care plan and adjust the care plan as needed.[5] Further, the law prohibits hospitals from assigning unlicensed assistive personnel to perform nursing functions under Business and Professions Code section 2725.3, subdivision (a). In sum, the statutory language for hospital nurse staffing ratios, by incorporating both the strict regulation of the use of unlicensed staff and the RN scope of practice, establish the specific role of the RN in minimum nurse-to-patient ratios.
2. Do APHs recruit nursing staff (RNs, LVNs, and PTs) with specific skills for working with pediatric/adolescent patients that differ from those working with adult patients? What additional training should nursing staff receive when working with pediatric/adolescent patients in the APH setting?
As discussed above, acute psychiatric hospitals must ensure pediatric and adolescent patients receive care from RNs because they have the education and clinical skills necessary to provide competent care. As part of their education, every RN completes coursework in human growth and development; anatomy and physiology; psychology and deviations in mental health; and pharmacology.[6] All RNs also complete clinical rotations, with a minimum of 30 direct patient care hours, in both pediatrics and behavioral health as part of their prelicensure nursing education.[7] Importantly, RNs caring for pediatric or adolescent patients must demonstrate ongoing competencies to care for these young patients.[8]
Because of their nursing education, RNs have the clinical skills and competencies to assess pediatric and adolescent patients and implement the appropriate nursing care plan. To conduct patient assessments for children and adolescents, RNs use developmentally appropriate techniques and behavioral evaluations.
[9] Nursing assessments also often involve gathering information from parents and legal guardians, which is essential for an accurate and comprehensive assessment.
In contrast, other nursing staff classifications do not have the scope of practice to make ongoing assessments of acute psychiatric patients and APHs should not use other staff to dilute the RN-to-patient ratios. Some commenters during the stakeholder meeting erroneously asserted that the greater need for observation in psychiatric settings obviates the need for nursing care and that non-RNs may play an even more critical role in patients care. However, while there may be a role for non-RN staff in the care of APH patients, observation is a critical component of the RN’s nursing assessment and nursing process, especially for pediatric and adolescent patients. For example, a recent study found that in cases when a registered nurse decides that a seclusion room is necessary to keep the child or others safe, the child needs the RN to remain in close proximity to observe and help calm them by keeping communication open, thereby avoiding retraumatizing the child.
[10] This nursing intervention requires the RN to stand by the door and inform the child of their whereabouts, coach the child to practice their coping skills through the door, encourage the child by observing calm behavior, and enter the room with the child as soon as it is safe to do so.
[11]
When APHs do not have RNs with specific pediatric development competencies, there can be severe consequences including patient deaths. To reiterate, APHs’ current staffing methods are clearly failing patients as evidenced by the San Francisco Chronicle’s series of investigative articles and the Los Angeles Times’ database documenting patient deaths, sexual assaults, and other incidents. [12]
The current levels of staffing in APHs have also led to unnecessary risks to worker safety and unsafe working conditions for nurses and other mental health workers. The
San Francisco Chronicle investigative series described dangerous understaffing conditions and extreme risks for workplace violence at Aurora Behavioral Healthcare in Santa Rosa that led 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.”
[13]
Research has shown that registered nurses are critical for reducing the risk of violence in acute psychiatric settings for children and adolescents. One study over the course of 16 years showed that the total number of registered nursing staff was
the most significant factor associated with a decreased risk of violent incidents in acute inpatient units for children and adolescents.
[14] The study also found that a staffing mix that substituted registered nurses with unlicensed personnel increased the risk of violence and indicated that registered nurses were more successful in de-escalation.
While collaboration with other health care professionals and staff is important for acute psychiatric care, existing law on ratios must be in accordance with RN scope of practice,
[15] which establishes that
only RNs have the responsibility and authority to provide ongoing, direct nursing assessments.
[16] The law also specifically prohibits unlicensed personnel from performing registered nursing functions.
[17]If non-RNs were to count towards the nurse staffing ratios, this would mean that non-RNs would perform—in clear conflict with RN scope of practice regulations—nursing care and functions that fall only within the RN’s scope of practice and that cannot be delegated to non-RN staff, including the initial and ongoing nursing assessment. However, Health and Safety Code section 1276.4, subdivision (h) mandates that the scope of nursing practice controls if there is a conflict between nurse staffing ratios statute and any provision or regulation defining the scope of nursing practice. To avoid conflicts with registered nurse scope of practice, the regulations on nurse staffing ratios in APHs must be specific to RNs. For these reasons, CDPH must adopt a nurse staffing ratio that requires minimum registered nurse staffing that assigns every patient to an RN, not a ratio that codifies the dangerous status quo APH staffing mixes.
To ensure competent care, as well as safety for both patients and workers, the regulations must require a 1:4 RN-to-patient ratio in pediatric and adolescent units with lower ratios established for patients with higher acuity and greater safety needs.
3. What data should an APH collect to validate their policies and procedures accurately and consistently determine appropriate staffing levels that meet patient needs?
To reiterate the points in CNA’s comments to CDPH in response to the May 2025 stakeholder meeting questions, no patient classification system or data-driven system alone can substitute for the nursing process and validation from RN judgment and assessment. While collecting information and trends is helpful, acute psychiatric hospitals must use the RN direct assessment to determine staffing levels above the minimum ratios.
Even the best patient classification system will not be able to capture all the relevant issues that an RN would identify through their direct and ongoing assessment of the patient. There are known problems with data-driven systems, including data drift which leads to these systems breaking down and degrading.
[18] These problems ensure that there will always be a need for RN direct assessment of individual patients.
To determine appropriate staffing levels, CDPH must require that APHs implement minimum RN-to-patient ratios as the only method to ensure a safe staffing baseline. Moreover, CDPH should require APHs to determine additional staffing above the minimum ratio based on the RN’s direct assessment of individual patient needs. The regulations should establish RN ratios with lower maximum patient assignments in units with patients who have higher acuity or are at risk of harm to themselves or others—again, based on the RN’s direct and ongoing assessment of the patient.
In cases where RNs must use the most restrictive interventions, CDPH should require a 1:1 registered nurse-to-patient ratio. When patients are at risk of suicide or severe aggression toward others, seclusion and restraint by RNs may be necessary to ensure patient safety and prevent injury to other patients and staff. Federal Centers for Medicare and Medicaid Services (CMS) rules govern most APHs’ use of restraint and seclusion, requiring the use of the least restrictive restraint or seclusion that should be discontinued at the earliest time possible.
[19] Importantly, interpreting the patient’s right to receive care in a safe setting, CMS has issued guidelines stating that patients at risk of suicide, self-harm, or aggression toward others should receive 1:1 monitoring with continuous visual observation.
[20] In these cases, CDPH should adopt a 1:1 registered nurse-to-patient ratios to ensure patient safety and to prevent injury to other patients and staff. In some cases, more than one RN per patient may be necessary based on an RN’s direct assessment.
Ongoing direct observation and assessment by RNs are critically important when seclusion or restraints are necessary. As evidenced by the recent Disability Rights California report, both the use of seclusion and restraints are emergency measures which can lead to death or severe injury if used inappropriately or improperly.
[21] Importantly, research has shown more frequent registered nurse assessments can decrease duration of mechanical restraint episodes.
[22]
In sum, data collection and validation of policies and procedures will not ensure that the appropriate staffing levels are meeting the needs of patients—only the direct and ongoing assessment by the direct care registered nurse can determine the appropriate levels of staffing above minimum numerical RN-to-patient ratios.
4. What barriers, if any, do you see with implementing specific nurse-to-patient ratios in APHs?
Despite what APH employers and others may characterize as barriers to implementing APH RN-to-patient staffing ratios, CDPH must base the acute psychiatric hospital regulations on the law, and the law requires minimum RN-to-patient ratios. After the passage of A.B. 394 (Kuehl) in 1999 and the full implementation of minimum RN-to-patient ratios in 2005, none of the dire predictions that hospitals made about costs and closures in opposition to RN-to-patient staffing ratios ever materialized. Instead, RN staffing ratios regulations for GACHs have led to improved patient care and more RN availability.
After more than two decades of registered nurse-to-patient ratios in GACHs, both California nurses’ experience and the research literature indisputably demonstrate that these legislative and regulatory mandates improve patient care and save lives. Importantly, numerous studies demonstrate that California’s ratios for GACHs have resulted in nurses caring for fewer patients at a time, improving both the working environment and patient care.
[23] Many organizations have taken positions of support for minimum nurse-to-patient ratios, including other nursing organizations like the American Nurses Association, despite claims to the contrary that some commenters made at the June 11, 2025, stakeholder meeting.
[24]
Safe staffing levels in GACHs have attracted and retained nurses to practice in the state. For example, after California implemented our general acute care ratio law, California nurses experienced burnout at significantly lower rates than those in New Jersey and Pennsylvania, and reported less job dissatisfaction.
[25] By improving nurses’ workloads and patient outcomes, ratios have, in turn, led to savings for hospitals. Ratios have reduced hospital spending on temporary RNs and overtime costs and have also resulted in savings from lower RN turnover and costs related to negative patient outcomes.
[26]Requiring a 1:4 RN-to-patient ratio for pediatric and adolescent patients and a 1:6 ratio for adult patients in APHs will increase recruitment and retention just as it did in GACHs. When RN staffing levels are inadequate and unsafe, RNs are unable to provide the care their patients need. Minimum RN-to-patient ratios will reduce the likelihood of moral injury caused by the daily distress of being unable to provide that care.
To meet the RN staffing ratios, acute psychiatric hospitals can hire from California’s robust supply of nurses with active licenses that are not currently working in direct patient care. Despite some employer claims about a nursing shortage, California currently has well over 545,000 registered nurses with active licenses and over a third of RNs are not working as nurses in our state according to the latest data from the U.S. Bureau of Labor Statistics.
[27] By comparison, there were half as many RNs with active licenses in 2004 when ratios were implemented in GACHs.
[28]
The primary barrier to implementation of APH ratios is and has been the ongoing and dangerous practice of APH administration’s prioritization of returns over the safety of patients, nurses, and other health care workers. The absence of mandatory minimum registered nurse-to-patient ratios has effectively allowed APHs to determine staffing levels based on budgeting and revenue rather than safe and effective patient care. Examining current data on RN hours per patient day at APHs demonstrates that additional RN staffing in APHs is feasible but, without minimum numerical safe RN staffing levels, dramatic disparities in staffing levels have persisted, especially between for-profit and non-profit APHs. For example, UCSF Langley Porter, a facility represented by CNA, provided nearly seven times as many RN staffing hours for patients than Aurora Behavioral Healthcare Santa Rosa, a for-profit APH.
[29]
Although non-profit APHs may also have issues, for-profit APHs especially have engaged in nurse staffing cuts to save money, leading to adverse patient outcomes and in some cases death. Requiring APHs to provide minimum RN staffing ratios will prevent these hospitals from putting profit above patients and ensure all hospitals have appropriate baseline staffing levels.
5. Do you have any other comments/suggestions regarding the APH staffing ratios that you would like the Department to consider?
- Dangerous understaffing in APHs require urgent action from CDPH to implement mandatory minimum RN staffing without further delay.
CNA raises the urgency of the situation in our state’s APHs and the dire need for CDPH to issue emergency regulations establishing minimum RN staffing ratios in our acute psychiatric hospitals with all due haste. Recent reports of patient harm and death by the San Francisco Chronicle and others plainly show that patients in APHs need minimum numerical RN-to-patient ratios, and they need it now. There is a crisis of dangerous understaffing in California’s acute psychiatric hospitals and CDPH has the responsibility to fulfill its obligation under the law to issue these regulations. CDPH and hospitals have had over two decades to prepare for staffing ratios in acute psychiatric hospitals. There is no reason to delay any further.
Despite some commenters’ assertions that CPDH is “too focused” on nurse staffing, CDPH must establish mandatory minimum RN-to-patient staffing ratios in APHs because the Department is simply required to under the law. Long-standing statute, in Health and Safety Code section 1276.4, lawfully requires the establishment of minimum registered nurse-to-patient staffing ratios regulation for APHs. Importantly, this legal requirement that CDPH establish RN-to-patient ratios does not obviate CDPH’s ability to consider additional staffing requirements above this baseline.
Fortunately, over two decades ago, CDPH’s predecessor agency developed the regulatory language for RN-to-patient ratios in GACHs that fulfills the statutory mandate in Health and Safety Code section 1276.4. In other words, the work of determining what unit-specific RN-to-patient staffing ratios are minimally required to provide safe and effective care for patients in acute care hospitals has already been done for our GACHs. Indeed, the GACH rulemaking on minimum RN-to-patient ratios was the largest rulemaking in department history and spanned more than 10,000 pages.
[30] With the GACH regulations on minimum RN-to-patient staffing ratios as a clear model and baseline, there is no reason for CDPH to further delay the process of implementing emergency rulemaking for minimum RN-to-patient staffing ratios for APHs.
- CDPH must ensure that APH patients receive the same standard of care as patients in GACHs at all times.
To ensure an equal standard of care for all acute care patients regardless of whether they are receiving care in a GACH or APH, CPDH must require APHs to provide patients with the same staffing protections that, at the very least, match the staffing ratios in GACHs and that these minimum staffing ratios are mandated at all times. Nurse staffing ratios at APHs must be specific to RNs to ensure that patients in APHs receive the same standard of care as patients in psychiatric units within GACHs. These minimum RN staffing requirements have been in place in GACHs for over 20 years, establishing the minimum staffing standard of care for acute care patients.
As we described in further detail in our May 20, 2025, comments to CDPH, CNA reemphasizes here the need for CDPH to require minimum RN-to-patient ratios at acute psychiatric hospitals
at all times and on every shift. Under hospital licensing regulations, “[a]ll hospitals shall maintain
continuous compliance with the licensing requirements.”
[31] Because acute psychiatric hospitals provide 24-hour care, minimum staffing protections should apply at all times for hospitals to maintain continuous compliance. This requirement means that there should be one (1) registered nurse to six (6) patients or fewer
at all times in adult units, and one (1) registered nurse to four (4) patients or fewer
at all times in pediatric and adolescent units.
- CDPH should implement minimum staffing levels in supplemental service settings.
CDPH should exercise its authority to adopt minimum staffing standards for supplemental service units in APHs, including skilled nursing services (SNS) and intermediate care service beds (ICS). Psychiatric patients at the SNS and ICS level require nursing care for their moderate to high-acuity needs typically for a longer duration.
[32] Research has shown that lower nurse staffing is a significant factor associated with negative patient outcomes, including increased falls.
[33] To meet the nursing care needs of SNS and ICS patients in psychiatric settings, CDPH should issue regulations that require minimum staffing standards with safe RN staffing levels.
- Minimum registered nurse-to-patient ratios ensure the safety of patients and staff, not automated worker surveillance systems and technology.
No automated decision-making tool (ADMT), clinical decision-support system, predictive technology, or other data-driven system will ever replace the human expertise and clinical judgement that is essential for providing the safe, effective, and equitable nursing care that all patients deserve. There simply is no substitute for direct, hands-on nursing care. Some employers have proposed that worker surveillance technology and a system of alerts can prevent patient harm and adverse outcomes. But nurses know that safe, minimum RN staffing levels are the only method that actually allows RNs to provide the continuous, direct nursing assessment to closely monitor patients and ensure their safety. The critical role of RNs in patient care is clear. In implementing the APH RN-to-patient staffing regulations, CDPH must not allow APHs to subvert or substitute RN’s clinical judgment and direct patient assessment through the use of data-driven surveillance or acuity tools.
The data-driven process of surveillance, routinization, and interference with professional judgment in health care can lead to inappropriate or harmful recommendations on patient care, putting nurses’ health and safety and patients’ lives at risk. These data-driven tools are deployed without regard to individual patient care needs or the professional judgment of RNs. Hospital employers may use a computer-generated acuity level to require nurses and other health care professionals—in order to reduce staffing costs and increase net revenue—to work faster, accept more patients per nurse, and reduce their use of independent professional skill and judgment without regard to quality of care and health care outcomes for patients.
Concerningly, data-driven technologies and ADMTs in health care have been demonstrably prone to serious inaccuracies and biases.[34] Many data-driven clinical tools in health care have been found to produce outputs with racial and ethnic bias only after the tool has been implemented, regardless of whether race and ethnicity have been explicitly factored in as inputs.[35] Bias in algorithmic recommendations may not only impact nurses’ workload but, significantly, conflict and interfere with nurses’ and other health care clinician professional judgment.
Finally, the level of opacity of ADMTs and other data-driven clinical tools makes it technically difficult, and potentially impossible, for health care facilities, systems, or users to assess their functionality. Whether trained on static data taken at one point in time about a patient or patient population or trained on data generated by ADMT systems, the validity of these data-driven tools and their outputs degrades in quality over time and can perpetuate bias or other problems with earlier models.
[36]
As described throughout CNA’s comments, the RN’s use of their professional judgment to conduct the initial and ongoing direct assessment of each patient’s unique needs is key to determining the safe and effective staffing levels needed to provide high-quality patient care.
For all of the reasons above and for the reasons described in CNA’s April 15, 2025, letter to Governor Newsom and May 20, 2025, comments to CDPH, CNA urges CDPH to adopt our proposed regulatory language, through emergency regulations, which would establish mandatory, minimum, safe registered 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: 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
[2] Cal. Code Regs., tit. 22, § 70217, subd. (a)(6).
[3] Brière, F. N., Rohde, P., Seeley, J. R., Klein, D., & Lewinsohn, P. M. (2015). Adolescent suicide attempts and adult adjustment. Depression and anxiety, 32(4), 270-276.
[5] Health & Saf. Code, § 1276.4, subd. (a). These regulations include California Code of Regulations, title 22, sections 70053.2, 70215, and 70217 and title 16, section 1443.5 as they were in effect when A.B. 394 was signed into law on October 10, 1999. For more detailed discussion of how the law establishes the specific role of the RN in the nurse-to-patient ratios, see
CNA’s May 20, 2025 comments to CDPH (PDF).
[6] Cal. Code Regs, tit. 16, § 1426, subd. (d) (listing pediatrics and “mental health/psychiatric nursing” as required nursing areas in prelicensure nursing curriculum). Business & Professions Code, § 2786, subd. (a) requires all Board of Registered Nursing approved school of nursing or nursing program provide “a minimum of 30 hours of supervised direct patient care clinical hours dedicated to each nursing area” in a “board-approved clinical setting[.]”
[7] Bus. & Prof. Code, § 2786, subd. (a).
[8] See Cal. Code Regs., tit. 16, § 1443.5.
[9] Tushe, M., Karagjozi D. (2025). The Commonalities and Specificities of Nursing Care in Mental Health for Children, Adolescents, and Adults in Psychiatry. Current Research Journal of Social Sciences and Humanities. 2025 8(1).
[10] Adrian, M. & McCaffrey, G. (2024). Pediatric psychiatric inpatients' perspectives of aggression management: Discernment in the doorway. Journal of child and adolescent psychiatric nursing, 37(3): e12477.
[13] Palomino, J. and Dizikes, C. (2025, March 19), supra, note 12.
[14] Panagiotou, A., Mafreda, C., Moustikiadis, A., & Prezerakos, P. (2019). Modifiable factors affecting inpatient violence in an acute child and adolescent psychiatric unit: A 16‐year retrospective study. International journal of mental health nursing, 28(5), 1081-1092.
[15] Health & Saf. Code, § 1276.4, subd. (a).
[16] Cal. Code Regs., tit. 22, § 70215.
[17] Bus. & Prof. Code § 2725.3, subd. (a).
[19] 42 C.F.R. § 482.13(e) et seq.
[21] Diaz, R. et al. (2025, March 21). “Let Me Go: Excessive Restraint of Patients at College Hospital.” Disability Rights California, Investigations Unit.
[22] Allen, D., Fetzer, S., & Cummings, K. (2020). Decreasing duration of mechanical restraint episodes by increasing registered nurse assessment and surveillance in an acute psychiatric hospital. Journal of the American Psychiatric Nurses Association, 26(3), 245-249.
[23] Aiken, L. H. (2010). The California nurse staffing mandate: implications for other states. LDI Issue Brief, 15(4), 1-4.
McHugh, M. D., Rochman, M. F., Sloane, D. M., Berg, R. A., Mancini, M. E., Nadkarni, V. M., ... & American Heart Association’s Get with the Guidelines-Resuscitation Investigators. (2016). Better nurse staffing and nurse work environments associated with increased survival of in-hospital cardiac arrest patients. Medical care, 54(1), 74-80.
[25] Aiken, L. H. (2010). The California nurse staffing mandate: implications for other states. LDI Issue Brief, 15(4), 1-4.
[26] Jones, C. B. (2008). Revisiting nurse turnover costs: Adjusting for inflation. JONA: The Journal of Nursing Administration, 38(1), 11-18.
[27] California Board of Registered Nursing (Apr. 1, 2025). “
Monthly Statistics.” Department of Consumer Affairs. (Accessed June 13, 2025).
[30] 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.
[31] Cal. Code Regs., tit. 22, § 71127 (emphasis added).
[32] McBain, R. K., Cantor, J. H., Eberhart, N. K., Huilgol, S. S., & Estrada-Darley, I. (2022). Adult psychiatric bed capacity, need, and shortage estimates in California—2021. Rand Health Quarterly, 9(4), 16.
[33] Weinberg, A. D., Lesesne, A. J., Richards, C. L., & Pals, J. K. (2002). Quality care indicators and staffing levels in a nursing facility subacute unit. Journal of the American Medical Directors Association, 3(1), 1-4.
Glocker B. et al. (2023). Risk of bias in chest radiography deep learning foundation models. Radiology: Artificial Intelligence, 5(6): e230060.