Getting your
Trinity Audioplayer ready...Hospital executives in California say new staffing standards intended to make psychiatric hospitals safer for patients are having the opposite effect: reducing access to treatment for people with the most serious cases of mental illness.
Emergency regulations adopted by the California Department of Public Health require 35 psychiatric hospitals throughout the state to assign one nurse for every six adult patients, and one for every five youth patients, starting June 1.
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Until this month, there were no staffing ratios for nurses in locked psychiatric hospitals. Meanwhile, general hospitals have been required to assign a minimum number of nurses per patient for more than two decades.
Executives at John Muir Health Psychiatric Hospital in Concord said they hired dozens of nurses to comply with the standards, but were still short of the personnel needed to operate all of their 71 patient beds. The hospital shuttered its 10-bed unit for children in mental health crisis this month and temporarily closed a separate ward with 11 beds for adults.
Three other hospitals in the Central Valley and Southern California also closed a total of 44 beds in June, according to the California Hospital Association.
“It’s a major hit,” said Gigi Crowder, CEO of the Contra Costa County chapter of the National Alliance on Mental Illness. “We definitely still need the beds.”
Without space in psychiatric hospitals, people who need care may go without or be left waiting in emergency rooms or other facilities that lack the staff to properly help them.
To keep beds open, the public health department has approved temporary rule waivers for 23 hospitals, including John Muir Health, Fremont Hospital and San Jose Behavioral Health Hospital.
While hospital operators say they can’t hire or staff enough nurses to comply with the required ratios, forcing them to close beds, nurses argue the new rule is being used as an excuse to fire other unlicensed workers and reduce patient access to care. In a letter to California’s health secretary, the California Hospital Association estimated that 760 unlicensed staffers would lose their jobs as nurses take on their responsibilities. That’s alarmed the National Union of Healthcare Workers, which represents about 400 nurses and staff at two psychiatric hospitals in Sacramento.
“Employers have made their intent plain,” the union wrote the health secretary in its own letter. “The result is a shell game: licensed nurses will be added on paper, unlicensed direct-care staff will be removed and most patients will experience little or no improvement in care, while for some, conditions will grow less safe.”
If unresolved, the loss of beds could complicate a key priority for Newsom, who has championed an expansion of behavioral health care, poured billions of dollars into improving access to treatment and charted new court pathways for people with acute mental illnesses. Patients with serious mental illnesses arrive at psychiatric hospitals because first responders have committed them for involuntary treatment or emergency room staff have transferred them there for care. Families may also check in loved ones. Patients stay there for a few days to a week at a time, often until their involuntary commitment expires.
The facilities are a critical part of the behavioral health safety net, but a spate of injuries and 17 deaths drew scrutiny from state lawmakers last year. The California Nurses Association, which represents 100,000 nurses, pushed to extend nurse-to-patient staffing ratios to psychiatric hospitals, arguing they were critical for the health and safety of patients and staff. Gov. Gavin Newsom and lawmakers agreed.
Directed by a new state law passed last year, the state public health department set daily fines of $15,000 to $30,000 for hospitals in violation, beginning June 1.
When unveiling its new rules, the department said short staffing of nurses was a particular problem in psychiatric hospitals.
“Nursing services are the number one type of deficiency identified during facility surveys,” the department wrote.
The nurses’ association celebrated the staffing ratios as “historic” when they went into effect. The higher standards “should dramatically improve the care behavioral health patients receive and that registered nurses can provide,” the union wrote.
A month after going into effect, those rules are transforming workforces at psychiatric hospitals. Managers hired 1,000 new nurses statewide in a blitz, the hospital association said, but also terminated or cut hours for unlicensed mental health staffers who perform important roles in these intense settings, like routine visual checks of patients who may be suicidal. Nurses’ associations say those management decisions are bucking the intent of the higher staffing standards.
At John Muir Health Psychiatric Hospital on Wednesday, management had still closed patient admissions to its ward for children 12 and younger, and the section was empty of patients or staff. Children had been treated there from all over the state, he said, and the unit accounted for about 10% of California’s acute psychiatric treatment beds for kids.
At another section of the hospital, teens in hospital scrubs walked the quiet halls of the adolescent unit with their lunch trays. Older adults made their beds or sat in a common area near windows of frosted glass, tinted for privacy from onlookers.
All furniture and artwork is designed to prevent suicide, and patients swap their clothing for scrubs if any articles have buttons or threads that could be used for self-harm. Teams of doctors, psychiatrists, nurses and social workers carry out treatment plans that may involve medication, therapy and group social gatherings. A patient stays for about six days on average, said Jesse Tamplen, John Muir Health’s behavioral health administrator.
“These are some of the most acute psychiatric patients in the state of California,” he said. “These are people who need life-saving care.”
The hospital has hired 31 nurses to comply with the ratios, Tamplen said. But it has also terminated the positions of 22 unlicensed mental health staff — workers who are vital, but do not count toward the state ratio requirements, he said.
Those workers hand out meals, run therapeutic group meetings and perform patient safety checks. Now, nurses are trying to do more of those tasks while juggling their own work, said Karla Casas, a registered nurse who has worked there for eight years.
“There are less staff on the floor. Less eyes on everything. And there’s definitely more work for nurses on the floor,” she said.
Overall, though, the nurses are glad for the staffing standards, Casas said.