New rules establishing minimum emergency nurse-to-patient staffing ratios at freestanding acute psychiatric hospitals in California took effect June 1. Going forward, there must be one nurse for every five patients younger than 18 and one nurse for every six adult patients, regardless of what other staff are on the unit.
Six weeks later, the nursing workforce is reporting a stretch of near-constant change as hospitals quickly adapt to the new requirements.
Nurses told Becker’s they are having to take on lower-license tasks as counselor and technician positions shrink. Meanwhile, some hospitals are having to hire additional nurses to meet the ratio, which is leading to night-shift instability. Nurses are also being forced to rebid for their positions.
Hospital leaders and nursing union representatives offer different explanations for why the new rules are causing disruptions. Administration generally pointed to meeting the financial burden of having to hire additional nursing staff, while unions said staff reductions were unnecessary.
Changes to the staffing mix
Under the new regulation, hospital leaders said they can no longer use a “team nursing” staffing model, in which different tasks — nursing duties, mental health support, group therapy — were split across disciplines.
“That has probably been the most detrimental to us,” said Jemma Coster, RN, vice president of clinical and regulatory services at Corona, Calif.-based Signature Healthcare Services. “In behavioral health, we use acuity to make sure that we have an appropriate skill mix of staff — they’ve told us we can’t do that.”
John Meier, CEO of Covina, Calif.-based Aurora Charter Oak Behavioral Health Hospital, a Signature Healthcare facility, said this is the first time state regulators have specified a hospital’s staffing licensure mix this directly. In the past, they’ve set broader operational requirements, but this shift limits hospitals’ ability to implement best practices, he said.
Hospital leaders and the CHA support nurse-to-patient ratios but have raised specific concerns about how the current regulation affects nurses and patient care.
Karla Casas, RN, a nurse at Concord, Calif.-based John Muir Behavioral Health Center, said she also supports the ratios but is frustrated by the implementation of ratios and reduction in support staff by hospitals.
“The support staff are professionals — they have bachelor’s degrees, some have master’s degrees, some have their own private counseling practices,” she said. “Every single team member on the floor of a psych unit is valuable — a valuable link in this [team] that we have.”
A distinction was raised between “team-based care” — the multidisciplinary staffing hospitals said they have lost — and “team nursing,” in which licensed vocational nurses or other nursing staff take on duties outside their typical scope of practice, a model not favored by the nursing union.
Ms. Casas said her unit previously had three mental health counselors; that has been cut to one. Smaller units that had two counselors are now down to one as well. Counselors used to chart, pass meal trays, assist nurses and supervise patients during personal hygiene tasks, such as shaving, she said.
“Now all they can do is rounding — making sure patients are where they’re supposed to be,” she said. “That is all they do. By the time they finish rounds, they have to start all over again.”
Hospital leaders pointed to both cost and floor safety as reasons for reducing technician and counselor staffing rather than adding nurses on top of existing staff. Jesse Tamplen, vice president of acute care transitions and behavioral health services at Walnut Creek, Calif.-based John Muir Health, said keeping the same number of techs could complicate care.
“If our unit has more employees than patients, that doesn’t make sense,” he said. “A 10-bed unit, we have 12 staff, 13 staff — that’s not sustainable. That’s not good for the patient, and the more activity you also have in a psychiatric unit, the more it can escalate.”
Ms. Coster and Mr. Meier said the reduction flowed from financial pressure created by the ratio requirement. “Behavioral health operates with razor-thin margins,” Mr. Meier said, describing it as “an unfunded regulation that had millions of dollars of labor costs in a time of massive inflationary pressures and rising costs, greatly outpacing reimbursement rates. At the end of the day, that’s just not a feasible thing for us to do.”
Carmen Comsti, government relations director for the California Nurses Association and National Nurses Organizing Committee, disputed that the regulation required those cuts.
“There’s nothing in the staffing ratios that says ancillary staff have to be lessened in order to meet the nurse-patient ratios,” she said. “The standard itself contemplates that the assigned registered nurse is able to create a nursing care plan with the full necessary staffing needs of ancillary staff within the facility …. The ratios don’t mean that nurses do all jobs within the facility — it’s recognizing that there’s a minimum floor for safety.”
Tasks outside the nursing scope
Kirsten Barlow, vice president of public policy for the California Hospital Association, said mental health counselors and technicians — traditionally the “eyes and ears” for nurses on a unit — are seeing their hours reduced or positions eliminated as hospitals work due to limited resources.
As a result, she said, nurses are increasingly handling tasks such as escorting patients to activities, assisting with hygiene, doing laundry, retrieving items for patients, or accompanying a group of patients to meals.
“[Those are] things that are not nursing-level-of-care,” she said. “Nurses are now being asked to do things that, frankly, are below their training level and below what they became licensed nurses to perform.”
Ms. Coster said these tasks were not part of standard nursing training. “We’re not taught how to interact with patients every minute of every day, how to give therapy to patients,” she said. “A lot of how staff interact with patients to build rapport quickly, to de-escalate crises — it’s something you learn on the job. It really isn’t always something we can train.”
Ms. Comsti said the source of nurse frustration is being mischaracterized.
“Nurses aren’t getting frustrated because they’re not practicing at the top of their license,” she said. “They’re getting frustrated because they’re being given more tasks than they had previously …. They don’t have the support that they needed to do things like, sitting [with] a patient who may be on suicide watch or to do some of the periodic mental health checks.”
Working on the night shift
At John Muir, Ms. Casas said the hospital hired roughly 30 nurses — including several travelers — largely to meet ratio requirements overnight. The units continue to operate under a state waiver that allows a lower staffing level at night than during the day and evening.
“[John Muir] opens the units. However, they’re still using the waiver to continue keeping the night shift skeleton crew. All of these nurses that were hired for full time [are] not working full time,” she said. “I’m not talking about [John Muir] canceling the shifts of one or two nurses per shift — it’s multiple, four, five, six, seven nurses every night. Maybe it’s not going to affect patient care tomorrow or next week, but it will.”
Kristen Pace, RN, executive director of behavioral health at John Muir Health, said psychiatric care at night is structured to promote uninterrupted sleep rather than the active daytime treatment that shapes most nursing tasks. Ms. Pace said this has led to declining job satisfaction among night-shift nurses, making retention more challenging.
The California Hospital Association is asking the state to adopt a 1-to-12 nighttime ratio, citing research on sleep as part of psychiatric treatment. “Sleep is actually the most effective intervention you can have, even more than therapy or medication,” Ms. Barlow said. “So we really are continuing to urge the state to provide a different ratio of 1-to-12 at nighttime, when patients are sleeping.”
Ms. Comsti disagreed with that premise. “It’s a little bit of a fallacy that the patient population is different at nighttime,” she said. “That’s just not how acute psych hospitals operate …. It is keenly important to be able to continuously monitor patients who have psychiatric conditions, particularly patients who are on watch for suicide or other types of potential for self-harm.”
New grads and extended training
Much of the recent hiring has skewed toward recent graduates. Ms. Pace said John Muir’s standard orientation runs one week of classroom training followed by one week on the unit. For its most recent cohort of night-shift hires, the hospital extended the on-unit portion from one week to three. Leaders also provide more frequent check-ins on competencies.
Ms. Coster described a similar dynamic in her personal experience. “Much of what I learned to become a psych nurse was on the unit as a new grad, and learning from the experienced nurses,” she said. “But we’re now flooding the place with new grads because we have to meet a ratio, and there’s not as many experienced nurses to do the on-the-job training.”
Hospitals are hiring nurses across a wide range of experience levels and backgrounds, he said, “some coming from med-surg, ER, or general acute settings with little or no prior psychiatric experience, others with psychiatric experience but unfamiliar with the new nursing model and unit-specific protocols” — and each group needs a different depth of orientation before they can function safely and independently.
At the same time, Mr. Meier said, hospitals are under real pressure to get new hires through training and onto the floor quickly to help close the staffing gap. “We’re not shortening training to hit that timeline, as completion is competency-based, not time-based, so nurses aren’t cleared for independent assignment until they’ve actually demonstrated the required skills,” he said.
That also means the timeline to full autonomy varies from person to person, he said, which makes workforce planning harder to predict than it would be under a uniform training pipeline.
Ms. Comsti also challenged the framing that hospitals are drawing from a small pool of nurses, stating the issue is working conditions rather than overall supply.
“There isn’t a nursing shortage. There’s a shortage of good nursing jobs in California and nationwide,” she said. “There are plenty of nurses who are ready and willing, particularly now that we have mandatory minimum nurse-to-patient ratios to work at psych hospitals. It’s just a matter of ensuring that employers are actually hiring them and putting them on the job.”
Job changes for existing staff
Ahead of the June 1 implementation date, John Muir required its nurses to rebid for their positions, which Ms. Casas said reduced part-time openings and shifted most night-shift nurses to full-time status.
“[The system] gave us two or three weeks advance notice back in April — making all nurses rebid for their jobs,” Ms. Casas said. “They significantly reduced the amount of part-time positions. Almost everyone on the night shift is now full-time. They reduced the amount of part-time nurses and made every nurse change to full-time equivalent.”
Some nurses who had been working part-time had to increase their hours, disrupting existing schedules.
Retention
Ms. Barlow said the CHA is seeing “an unprecedented level of nurses asking for leaves of absence, taking vacation time, or even resigning from their positions.” Because the regulation requires the ratio to be met at all times, she said, a single nurse calling in sick or taking leave can put a unit out of compliance, forcing a hospital to reduce capacity until it’s back in ratio.
Ms. Coster said Signature’s internal reports show an increase in resignations systemwide. “[Nurses] have less patients, so they have less nursing tasks to complete, but they have significantly more tasks to complete that don’t require a license, and we’ve received quite a lot of dissatisfaction in regards to that,” she said.
Ms. Casas said retaining nurses with psychiatric experience specifically is a concern. “You can’t just take an ICU nurse, even an ED nurse, and put them in a psychiatric unit and say ‘go ahead,’” she said. “It is specialized care, and it requires different skills …. You want good nurses with experience, and you want to retain them.”
Ms. Comsti attributed nurse turnover to a different cause.
“Nurses tend to leave the bedside, and there’s high attrition when they experience moral distress,” she said, “On-site staffing is the top reason for nurses to experience moral distress because they can’t take care of their patients in the way that they know they ought to be providing care.”
Travel nurses
Ms. Barlow said travel nurses can cost up to 150% more than staff nurses and typically sign contracts of just 12 to 13 weeks, with the biggest concern being quality of care. Hospitals often finish orienting a traveler not long before their contract ends, making it “not a practical solution, nor a long-term one,” she said.
Ms. Pace said John Muir has used a limited number of travel nurses to fill gaps while continuing to recruit and train staff, though the statewide pool of psychiatric travel nurses is small. The hospital now reviews its staffing and clinical capacity every eight hours, she said, to determine how many patients it can safely care for on a given shift.
Ms. Coster said several Signature facilities also brought in contract labor to meet the compliance deadline. When bringing in a wave of new nurses at once while adding travel nurses — who may not be aware of the organization and its culture — there is a learning period where facilities must navigate maintaining quality throughout the process.
“[Travel nurses] don’t come with the same level of training. They’re not organic, they don’t learn from us — they’re fillers,” she said. “In psych, teamwork is everything: you have to trust your team, and everyone has to be trained the same way, with the same moral and ethical mentality.”
Ms. Coster echoed that acute psychiatric hospitals support the ratios.
“We just ask that it incorporate the different types of staff who work with our patients every day,” she said. “By limiting it to a nurse-to-patient ratio, and requiring that it be primary nursing, that’s the model we have to transition to. As other facilities have experienced, more bodies doesn’t mean safer. It’s to the detriment of the best practice of how psychiatric care is provided.”
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