This is an exclusive BHB+ story
While workforce woes have begun to improve in the behavioral health industry overall, the idea of mandatory staffing minimums in psychiatric hospitals has started to circulate.
For many of us, 2004 was the year of low-rise jeans, wearing dresses with pants and LiveStrong bracelets. If you were in the health care industry at that time, it was also the year California nurses went to bat against former governor Arnold Schwarzenegger over enforcing numerical registered nurse-to-patient staffing ratios.
Now, 21 years after California Nurses Association v. Schwarzenegger et al., the state’s current governor, Gavin Newsom, is moving to enforce minimum staffing requirements across California’s acute psychiatric hospitals. This came after an investigation by The San Francisco Chronicle that detailed widespread abuse and neglect in these facilities.
While I believe the bulk of the behavioral health industry could, in theory, support staffing minimums, finding the workforce and funds to sustain them could be a more challenging task operationally.
Behavioral health facilities already operate on thin margins and are, in many ways, tied to the legacy reimbursement structures. Recruiting and retaining talent has been one of the biggest challenges for psychiatric hospitals since the COVID-19 pandemic – and across health care in general.
In this BHB+ Update, I team up with senior editor Laura Lovett to explore:
– What’s on the table in the pending proposal from California
– What staffing minimums have looked like in other parts of health care
– The potential impacts of staffing minimums on acute care hospitals’ business model
Setting the stage
Staffing ratios are a contentious topic in the health care field. Nurses feel overworked, understaffed and often unsupported in this feat by hospitals, even when they present research supporting better patient outcomes related to staffing ratios. Hospitals generally take the stance that these ratios are difficult and expensive to enforce and that there are other measures in place to help keep patients safe and support positive outcomes, not just RN-to-patient ratios.
A couple of years back at a different publication, I reported on how things had shaken out two decades into the mandatory nurse-to-patient ratio enforcement in California, and the topic was still met with similar contention from both sides.
The details are still being discussed by the state’s hospital, nurse and public health stakeholders, but one thing is clear: Staffing ratios remain hard for industry experts to talk about.
In my reporting on what California’s new effort may mean for psychiatric hospitals across the country, I reached out to 28 different organizations for comment – and most of my requests went unanswered or were declined.
California is often looked to as a guidepost for policy change and shifts, but still to this day, only two other states, Massachusetts and Oregon, have adopted legally mandated nurse-to-patient staffing ratios. A handful of other states have inched toward a similar approach, but have yet to make enforcement decisions.
If this new mandate goes into effect for psychiatric hospitals, it could become the standard for the behavioral health industry nationwide, with more states becoming eager to create strict staffing guidelines in psychiatric facilities.
But before providers begin posting on Indeed for extra nurses, it’s important to note that right now, this is one proposal in one state for one type of facility. Still, California is the most populous and arguably one of the most progressive states in the country. When California makes changes to its health care system, others tend to follow suit in some manner.
What’s on the table
Before we dive into the weeds of what different stakeholders are advocating for here, it’s critical to mention that, technically, the original California staffing ratios law, AB 394, already established a 1:6 RN-to-patient ratio for standalone psychiatric facilities. But, because the law primarily focused on enforcement of these ratios in general acute care hospitals, “the state sort of dropped the ball on rulemaking for those facilities,” a source told me on background.
Revisiting the staffing mandates for acute psychiatric hospitals (APHs) now would apply to both for-profit and nonprofit operators, as well as general acute care hospitals with psychiatric units.
The regulatory process for establishing and enforcing clear, numerical ratios at these facilities began April 29, with the California Department of Public Health (CDPH) announcing a May stakeholder meeting and releasing a list of six questions to solicit input in advance of it.
Two decades later, coming to the table around this new hyper-focused discussion, the California Hospital Association (CHA) and the California Nurses Association (CNA) are still at odds with what they believe the new psychiatric hospital staffing mandate should include.
In its response to CDPH’s request for input, the CHA recommended a 1:6 ratio for adult patients and a 1:5 ratio for psychiatric facilities that serve children and adolescents, according to a document the association shared with Behavioral Health Business.
However, under the CHA’s recommendation, the group states that this ratio should include a mix of not only registered nurses, but also licensed vocational nurses, licensed psychiatric technicians and mental health workers. The association notes that although a mix of these professionals should be used to meet the staffing requirements, at least 50% of the staff must be either registered nurses or licensed vocational nurses.
This is where the CNA starkly disagrees. Under its proposal, the organization recommends a staffing ratio of 1:6 for adult patients and 1:4 for children and adolescents, but CNA notes that these ratios should exclusively apply to registered nurses. The organization does not support any staffing ratios that include a mix of non-RNs.
“The suggestion by hospital representatives during the May 13 stakeholder meeting that the APH staffing ratio should be composed of 50% RNs and licensed vocational nurses and 50% psychiatric technicians and unlicensed mental health workers would dangerously codify the current failing staffing mix at APHs,” the CNA response states.
CNA argues that this mix of staff, which has been “the status quo,” actually “has led to unnecessary patient deaths, sexual assaults, other negative patient outcomes, and unsafe working conditions for nurses and other mental health workers in APHs.”
The state of staffing minimums in health care
A vast amount of research has been devoted to exploring the impact of staffing ratios on patient outcomes, with some even exploring specifics on how this affects psychiatric care.
Many studies have found that nurse-to-patient ratios were linked to improved patient care and lower patient mortality rates.
Others, however, have found that nurse-to-patient ratios have “mixed effects on quality.”
Research aside, staffing ratios continuously spark heated debate across the medical community.
Since the 2004 enforcement of the California staffing ratios mandate – aside from Massachusetts and Oregon which implemented their mandates ten years apart in September 2014 and June 2024, respectively – other states have slowly attempted to make similar moves toward this.
Seven states – Connecticut, Nevada, New York, Ohio, Oregon, Texas and Washington
– have adopted requirements for hospitals to form committees made up of 50% nurses to address staffing.
Three states – New Jersey, Rhode Island and Vermont – do not have staffing mandates or committees in this vein, but do require reporting on annual staffing plans.
Illinois falls into both of these categories, requiring committees to address staffing and a submission of annual staffing plans.
Minnesota is the only state where chief nursing officers are specifically charged with developing hospital staffing plans.
Additionally, Colorado and New York have passed laws that require more nurse oversight into staffing ratios, but are not mandates on staffing levels.
On the federal level, the Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act seeks to set “mandatory minimum registered nurse-to-patient staffing ratios,” nationwide. It was first introduced in the House in 2023, and was recently reintroduced this May to Congress by Senators Alex Padilla (D-Calif.) and Jeff Merkley (D-Ore.).
If passed, hospitals, including psychiatric ones, would be required to adhere to certain procedures about how staffing ratios are determined and “post a notice regarding nurse-to-patient ratios in each unit and maintain records of actual ratios for each shift in each unit.”
As of May 14, the 2025 reintroduction of the bill was referred to the Committee on Energy and Commerce and the Ways and Means Committee for consideration.
Other subsectors of health care have already implemented mandatory minimums. For example, The Centers for Medicare & Medicaid Services (CMS) mandated staffing requirements for skilled nursing facilities to improve quality and safety measures.
The feasibility
I think most in the industry can agree that in a perfect world, lower patient-to-staff ratios are the gold standard. However, the behavioral health industry is still digging out from massive staffing shortages, and staffing mandates could feel more like a double-edged sword operationally.
In the early 2020s, earnings calls were plagued by disappointing results due to a challenging labor market following the COVID-19 pandemic. In 2021, Universal Health Services (NYSE: UHS) – one of the largest for-profit acute care behavioral health providers in the country – reported it was forced to turn away patients because it couldn’t fill gaps in its nursing workforce.
Since then, the workforce market has improved. UHS even attributed improved staffing retention and recruiting to its increase in earnings during its Q1 2025 earnings call.
If mandatory minimums were to go into effect, we might find ourselves back in a situation where they need to turn away patients due to nursing ratios.
In this case, I can foresee for-profit psychiatric hospitals with a national footprint pulling back on expansion efforts in states that do enforce mandatory staffing minimums.
We’ve already seen behavioral health organizations, especially psychiatric and substance use facilities, carefully choose their state presence based on certificate of need (CON) laws. With the workforce frequently at the center of expansion conversations, state regulations surrounding staffing could be a determining factor in which projects receive the green light.
Still, it’s essential to acknowledge that staffing shortages have been a contributing factor to dangerous situations for patients and clinical teams. Nurses – regardless of their specialty – increasingly face violence in their workplace. Ratios could help protect them, other staff and patients.
For now, flexibility may be key when talking about staffing minimums. The behavioral health workforce is dynamic and includes a broad team. If staffing ratios include a mix of the workforce beyond nurses, such as therapists, social workers and occupational therapists – the idea becomes more feasible, but to the nurse’s point, a mix to meet the mandate may not be the safest clinically.
Even though none of these issues are yet fully developed, I believe that behavioral health providers should at the very least consider how their organization might be able to accommodate staffing ratios should they ever come into effect.
