1. The CVI value of the scale items was calculated as 0.98.

2. As a result of factor analysis, the Kaiser Meyer Olkin (KMO) coefficient was found to be 0.833.

3. The final version of the scale includes 27 items and seven sub-dimensions. The sub-dimensions are named as follows: Factor 1, ‘Social Support Resources’; Factor 2, ‘Psychosocial Functioning’; Factor 3, ‘Discharge Readiness’; Factor 4, ‘Treatment Compliance’; Factor 5, ‘Suicide Risk’; Factor 6, ‘Psychotic Feature’; and Factor 7, ‘Insight’.

4. Goodness of fit values: Root Mean Square Error (RMSEA) = 0.052, Normed Fit Index (NFI) = 0.88, Comparative Fit Index (CFI) = 0.93, Goodness of Fit Index (GFI) = 0.90, Adjusted Goodness of Fit Index (AGFI) = 0.87, and $\chi$²/sd = 2.042. Cronbach’s alpha of the scale was found to be 0.833.

5. The ‘Repeated Clinical Hospitalization Risk Assessment Scale in Chronic Psychiatric Diseases’ (RCHRASCPD) is a valid and reliable scale for the Turkish society in terms of measuring risk level.

One in every eight people in the world experiences a mental disorder [1]. Mental disorders are classified according to the International Classification of Diseases (ICD-10) and Diagnostic and Statistical Manualof Mental Disorders, Fifth Edition (DSM-5) published by the American Psychiatric Association (APA) [2]. Chronic psychiatric diseases are mental disorders that last for a long time and often significantly affect a person’s daily life and functionality [3]. Individuals diagnosed with psychiatric diseases can be treated on an outpatient basis or can be followed up through inpatient hospitalization [4]. Individuals receive treatment in psychiatric inpatient services shortly after discharge; it is known that recurrent inpatient hospitalizations occur due to reasons such as familial and individual factors, service provided, and community structure [5, 6, 7]. The return to inpatient treatment of a diagnosed individual within a certain period of time after a previous hospitalization is termed recurrent inpatient services stay [8] and is also called the ‘Revolving Door Phenomenon’ [9].

Although the rate of readmission to psychiatric inpatient services after discharge is unknown, it decreased by 10% in 2022 and 2023, according to the National Mental Health Action Plan of the Ministry of Health of the Republic of Turkey [10].

Many studies both in Turkey and worldwide have investigated risk factors for repeat hospitalization [11]. These risk factors include insufficient social support resources [12, 13, 14], suicide attempt and risk [14, 15], being male [11, 16], early discharge [13], having psychotic symptoms [11], and treatment noncompliance [17].

As psychiatric nurses are important members of the team, they have important duties and responsibilities regarding the identification of risk groups for readmission, the risk factors associated with inpatient readmission, and the care, education, and consultancy specific to each individual in this regard [18]. Mental health nursing is a multidisciplinary field that plays a critical role in the process of protecting, developing, and improving the mental health of individuals. Nurses provide both basic and advanced interventions to individuals experiencing mental health problems [19]. Individuals who are readmitted to psychiatric inpatient services are monitored with the support of nurses from admission to discharge and follow-up in community mental health centers. In this process, nurses play a role in many areas such as improving family and social relationships [20]. Nurses play an important role in preventing repeat hospitalizations by constantly interacting with patients. It is their responsibility to meet the needs of patients and improve their quality of life by creating individualized care plans. They also strengthen patients’ social support networks and help them take their place in society by effectively using community resources [21]. As a result, nurses undertake therapeutic, educational, coordinating, and supportive roles in preventing repeat hospitalizations. In this way, patients’ quality of life increases and repeat hospitalizations, which are a burden on the health system, are reduced.

As seen in the literature, clinical data collection forms created by the study owners are used as data collection tools in studies examining the risk factors affecting recurrent clinical hospitalizations in psychiatric diseases. In order to evaluate the risk of repeated hospitalization of individuals diagnosed with chronic psychiatric diseases, we aimed to provide a comprehensive scale specific to individuals diagnosed with chronic psychiatric diseases. It is expected that the risk of repeated hospitalization of individuals diagnosed with chronic diseases who are admitted to a psychiatric inpatient service will be evaluated using this developed scale and measures will be taken to prevent readmission, thus reducing costs. We intend for the scale to be used as a data collection tool in determining the risk of repeated hospitalization during the process that begins with admission to psychiatric inpatient services. We believe that the developed scale can be applied to predict the risk of repeat hospitalization of individuals followed in community mental health centers.

In this study, Explanatory Factor analysis determined the KMO value to be 0.833. As a result of the Bartlett Sphericity test, it was determined that there was a significant relationship between the variables. Accordingly, it was concluded that the data were suitable for applying factor analysis [28]. The RCHRASCPD explained 64.142% of the total variance. In multi-factor models, it is considered sufficient for the total variance to be between 40% and 60%. It is considered a valid and strong analysis if the variance is between 50% and 75% [29]. Since the total variance explanation rate is over 50%, it seems to be at an acceptable level [30].

The risk assessment scale for repeated inpatient hospitalization in chronic psychiatric diseases has 29 items and the reliability level is 83.3%. Additionally, when reliability levels were examined on the basis of factors, they vary between 89.1% and 72.4%. As Cronbach’s alpha of the scale and its sub-dimensions is over 70%, it can be said that the reliability analysis findings are at an acceptable level. When looking at the literature, it is stated that an internal consistency value of Cronbach’s alpha coefficient between 0.60 and 0.80 is considered reliable for the scale, and a value between 0.80 and 1.00 indicates that the scale is highly reliable [31].

The fit index values and good fit values of the measurement model of the RCHRASCPD include criteria that show how well the measurement model fits the data set [32]. The index values obtained as a result of the analysis show that the measurement model has an acceptable fit in general, but there are areas of potential improvement.

The minimum score that can be obtained from the RCHRASCPD developed within the scope of this research is 29 and the maximum score is 124. While the increase in the score obtained from the scale indicates that the risk of repeated inpatient hospitalization increases for individuals with chronic psychiatric diseases, it can be said that the decrease in the score received from the scale by the patients in the study indicates a decrease in the risk of repeated inpatient hospitalization. Considering the number of psychiatric hospitalizations within 18 months, 53.8% of the participants admitted once, 27.9% twice, 10.5% three times, 5.1% four times and 2% (n = 6) of them had more hospitalizations. It is stated in the literature that 17.0% of individuals with chronic psychiatric diseases have been hospitalized three times and 29.8% have been hospitalized four times or more [33]. In another similar study, it was reported that 24.2% (n = 64) of individuals with alcohol and substance addiction were readmitted in the first 6 months. In another study, the overall incidence of readmissions was 16.04%; the readmission rate within 30 days was found to be 6.26% and the readmission rate between 31 and 180 days was 9.44% [34].

Factor 2 includes items that question the individual’s psychosocial functionality. An increase in the score means a decrease in functionality. When the findings were examined, it was seen that the number of repeated hospitalizations increased as the score received increased. When the literature was examined, similar findings were found. It has been reported that low functionality of the patient is an important risk factor for repeated hospitalization [9]. In a study examining individuals who were readmitted within 30 days after discharge, the importance of psychosocial functionality was emphasized [35].

Factor 3 includes items related to readiness for discharge. As the score increased, it was seen that the individual was not ready for discharge and the number of repeated hospitalizations increased. Similar findings were found when the literature was examined. A study reported that individuals with repeated hospitalizations need a more comprehensive discharge plan and support for the transition to society after psychiatric hospitalization [35].

Factor 4 includes the treatment noncompliance subscale. When the scores obtained from the scale were examined, it was seen that the number of repeated hospitalizations increased as the individual’s level of non-compliance with treatment increased. In a study examining the risk factors for repeated hospitalization, it was reported that increasing treatment compliance will reduce the risk of repeated hospitalization [9]. Another study showed that rehabilitation services and medication monitoring carried out in Community Mental Health Centers (CMHC) increase compliance with treatment and thus contribute to a decrease in the frequency of hospitalization [34]. It seems that the findings in the literature are contradictory, but parallel findings related to our research appear to be in the majority.

Factor 5 includes the individual’s past suicide history and current suicide risk. When the findings were examined, it was seen that as the number of repeated hospitalizations increased, the risk of suicide and the presence of a past suicide history increased. It is reported in the literature that the risk of rehospitalization is high in individuals with chronic psychiatric diseases who attempt suicide [36]. In another similar study, it was reported that those with a history of suicide attempt and previous hospitalization were hospitalized twice or more [37]. In another study, the rate of rehospitalization due to suicide risk or suicide attempt ranged between 7.96% and 11.24% [38]. In a similar study, suicide risk was found to be a determinant of early hospital admission [39]. In another study, 94.8% of patients who applied to the emergency department attempted suicide 1–3 times in the last year. It was found that 42.2% of patients who presented with a suicide attempt were referred to intensive care, while only 3.7% were admitted to the psychiatric ward [40].

Factor 6 includes items questioning the presence of psychotic symptoms. When the findings were examined, it was seen that the number of repeated hospitalizations increased as the presence of psychotic symptoms increased. When the literature was examined, contradictory findings were found. In one study, the average number of repeated hospitalizations of individuals diagnosed with schizophrenia showing psychotic symptoms was found to be 7.41 [41]. In another study, it was found that individuals with repeated hospitalizations had higher scores related to psychotic symptoms [9]. Another study reported that the findings of people who were hospitalized three or more times in 12 months were accompanied by psychotic symptoms [42]. In another study examining individuals with repeated hospitalizations, it was reported that 23% of individuals had repeated hospitalizations and that the individuals’ findings were accompanied by psychotic symptoms [43]. It is thought that the results of the studies may vary due to factors such as the diversity of psychotic symptoms within themselves, whether individuals have insight into the process, the different levels of coping with symptoms in individuals, and the stage at which individuals are in the treatment process.

Many studies have been conducted emphasizing the importance of repeated hospitalizations in psychiatric inpatient services. There is a need for studies that contribute to the planning and implementation of interventions aimed at preventing and reducing these repeated hospitalizations. This research aimed to develop a comprehensive scale to be used in this process. We believe that this scale will support the detection of individuals at risk of repeated psychiatric hospitalization and the prevention of hospitalization, as well as reducing the rate of repeated hospitalizations by providing early intervention in the process. The importance of the scale can also be emphasized in terms of contributing to the reduction of the financial burden of repeated hospitalizations on the health system.

Data were evaluated with SPSS 21.1 Applied Biostatistics. The tax package and applied statistical methods and findings package of the research are stored individually by the authors. The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Conception–NŞ, BÖ; Design–NŞ, BÖ; Supervision–BÖ; Fundings–BÖ; Materials–NŞ; Data Collection and/or Processing–NŞ; Analysis and/or Interpretation–NŞ, BÖ; Literature Review–NŞ; Writing–NŞ; Critical Review–BÖ. Both authors read and approved the final manuscript. Both authors have participated sufficiently in the work and agreed to be accountable for all aspects of the work.

The study was conducted in accordance with the Declaration of Helsinki. This study was approved by the ethics committee responsible for the adult psychiatry inpatient services of Ankara City Hospital affiliated with the Ministry of Health in Turkey (ethics committee decision no: 23.12.2022-3) and Ankara Yildirim Beyazit University Faculty of Health Sciences ethics committee (ethics committee decision no: 2022-1054, 06.10.2022-14). During the collection of research data, verbal and written permission was obtained from participating individuals and, when necessary, from their appointed guardians, by informing them about the research, and them signing an ‘Informed Consent Form’.

This research received no external funding.

The authors declare no conflict of interest.