Design of a Behavioural Risk Monitoring Tool (RutiSafeNet) in an Acute Inpatient Mental Health Unit with Open-Doors Policy: A Qualitative Study

Design of a Behavioural Risk Monitoring Tool (RutiSafeNet) in an Acute Inpatient Mental Health Unit with Open-Doors Policy: A Qualitative Study | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search Design of a Behavioural Risk Monitoring Tool (RutiSafeNet) in an Acute Inpatient Mental Health Unit with Open-Doors Policy: A Qualitative Study View ORCID Profile Laura Miró Mezquita , View ORCID Profile Anna Moreno Orea , View ORCID Profile Joan de Pablo Rabasso , View ORCID Profile Maria Isabel Martínez Segura , View ORCID Profile Marina Delgado Marí , View ORCID Profile Sandra Castro Anso , View ORCID Profile María Jiménez Murcia , View ORCID Profile Ana Ibañez Caparros , View ORCID Profile Tatiana Bustos Cardona , View ORCID Profile Jorge Cuevas-Esteban doi: https://doi.org/10.1101/2025.10.01.25337049 Laura Miró Mezquita 1 INEDIT Research Group on Innovation, Health Economics and Digital Transformation, Institut Germans Trias i Pujol , Badalona, Spain 2 Servei Psiquiatria. Hospital Universitari Germans Trias i Pujol , Badalona, Spain 3 Direcció Estratègia Assistencial i Innovació, Hospital Universitari Germans Trias i Pujol , Badalona, Spain Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Laura Miró Mezquita Anna Moreno Orea 2 Servei Psiquiatria. Hospital Universitari Germans Trias i Pujol , Badalona, Spain 4 NURECARE-IGTP Nursing Research Group, (Institut Germans Trias i Pujol , Badalona, Spain Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Anna Moreno Orea Joan de Pablo Rabasso 2 Servei Psiquiatria. Hospital Universitari Germans Trias i Pujol , Badalona, Spain 3 Direcció Estratègia Assistencial i Innovació, Hospital Universitari Germans Trias i Pujol , Badalona, Spain 5 Departament Psiquiatria. Universitat Autonoma de Barcelona , Barcelona, Spain Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Joan de Pablo Rabasso Maria Isabel Martínez Segura 3 Direcció Estratègia Assistencial i Innovació, Hospital Universitari Germans Trias i Pujol , Badalona, Spain 6 INEDIT Research Group on Innovation, Health Economics and Digital Transformation (Institut Germans Trias i Pujol) Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Maria Isabel Martínez Segura Marina Delgado Marí 2 Servei Psiquiatria. Hospital Universitari Germans Trias i Pujol , Badalona, Spain Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Marina Delgado Marí Sandra Castro Anso 2 Servei Psiquiatria. Hospital Universitari Germans Trias i Pujol , Badalona, Spain Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Sandra Castro Anso María Jiménez Murcia 2 Servei Psiquiatria. Hospital Universitari Germans Trias i Pujol , Badalona, Spain Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for María Jiménez Murcia Ana Ibañez Caparros 2 Servei Psiquiatria. Hospital Universitari Germans Trias i Pujol , Badalona, Spain Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Ana Ibañez Caparros Tatiana Bustos Cardona 2 Servei Psiquiatria. Hospital Universitari Germans Trias i Pujol , Badalona, Spain Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Tatiana Bustos Cardona Jorge Cuevas-Esteban 2 Servei Psiquiatria. Hospital Universitari Germans Trias i Pujol , Badalona, Spain 5 Departament Psiquiatria. Universitat Autonoma de Barcelona , Barcelona, Spain 7 Centro de Investigacion Biomédica en Red de Salud Mental (CIBERSAM) , Madrid, Spain 8 Institut Germans Trias i Pujol , Badalona, Spain Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Jorge Cuevas-Esteban For correspondence: JorgeMiguel.Cuevas{at}uab.cat Abstract Full Text Info/History Metrics Data/Code Preview PDF ABSTRACT Introduction Open-door policies for acute inpatient mental health units (AIMHU) have shown promising results in reducing coercive measures, but concerns remain among patients and staff regarding increased workload, constant surveillance, and potential safety risks associated with these policies. Objectives This study aims to develop a monitoring tool to facilitate safety management in AIMHUs by monitoring behavioural risks and nursing workload. Methods This study employed a qualitative approach using the content analysis method. Data were collected through three in-depth interviews and two focus groups involving staff (n=19) from the AIMHU of the hospital. Results 34 items were identified to define behavioural risks related to self-harm and suicide, aggressiveness, and absconding, alongside factors affecting nursing workload. These items were categorised into three levels of risk: low, moderate, and high. Conclusions The result is a risk monitoring tool based on observational items for daily use in AIMHU that can help to reduce the uncertainty about risk management, especially in open-door units. This innovative tool enables individualized patient monitoring, provides insights into the unit’s status, prioritizes conflict prevention, and upholds the human rights of patients. 1. INTRODUCTION Human rights have emerged as a central focus in the evaluation of mental health policies and strategies (Herrman and Swartz, 2007; Patel et al., 2007) with The World Health Organization (WHO) urging all nations to safeguard the rights of individuals hospitalised with mental disorders ( Scobie et al., 2006 ). The structure of psychiatric inpatient wards, significantly influences treatment outcomes and patient experience ( Krückl et al., 2023 ). While traditional closed-door policies are designed to enhance safety and security, they are often perceived by both patients ( Haglund & Von Essen, 2005 ) and staff ( Haglund et al., 2006 ) as restrictive and non-therapeutic environments. These perceptions may contribute to emotional distress and hinder recovery ( Johnson et al., 2022 ). The primary justification for closed-door policies is to ensure safety, particularly for preventing suicide and aggressive behaviour, and reducing the risk of absconding incidents ( Haglund et al., 2007 ; Scobie et al., 2006 ). However, the employment of coercive measures and the lack of freedom of movement undermines patients’ fundamental rights, thus posing significant challenges in hospital management and nursing practice ( Kennedy et al., 2019 ). In response to this issue, new hospitalisation models have been developed that aim to create a safe environment while minimizing the need for such coercive measures ( Gooding et al., 2020 ). Risk factors associated with various conflictive behaviours in mental health units have been extensively investigated. Powell et al. ( Powell et al., 2000 ) conducted a study focusing on suicide risk factors in hospitalised patients, identifying several indicators including suicidal ideation, prior self-harm attempts, recent bereavement, presence of delusions, chronic mental illness, and family history of suicide. In assessing the risk of imminent aggression on a day-to-day basis, the Dynamic Appraisal of Situational Aggression – Inpatient Version (DASA-IV) ( Ogloff & Daffern, 2006 ) scale was developed for adult psychiatric inpatients. Moreover, tools like the Waypoint Elopement Risk Scales (WERS) ( Marshall & Usinger, 2016 ) have been developed to assess the risk of absconding in psychiatric inpatients, taking into account both clinical history, such as abscondment or previous attempts, wandering, substance abuse, self-harm, and harm to others; and day-to-day events, such as absconding threats, substance use, life stressors, current risk to self-harm and medication adherence. It is also deemed essential to monitor the nursing workload required by each patient according to their clinical needs, while establishing risk monitoring to ensure safety. The nursing workload contributes to establishing the global situation in relation to risk management and deciding whether the doors can be opened ( Petrucci et al., 2014 ). In a scoping review published in 2018 ( Sousa & Seabra, 2018 ) on the evaluation of nursing workload in adult psychiatric inpatient units, four studies were identified ( Fanneran et al., 2015 ; Gerolamo, 2009 ; Petrucci et al., 2014 ; Twigg & Duffield, 2009 ). Petrucci et al. ( Petrucci et al., 2014 ) devised a nursing care complexity indicator tool predicated on the personal mental health history extracted from patients’ medical records upon admission. This tool comprises 88 items correlated with Gordon’s 11 functional health patterns ( Gordon, 1982 ). The remaining studies investigate how to assess workload to better distribute workforce planning. The systematic review concludes that few instruments exist to evaluate or measure nursing workload in adult patients hospitalised in mental health units, and those available, lack uniformity. ( Rosen et al., 2018 ; Van Den Oetelaar et al., 2021 ). None of these instruments enable the continuous detection of patient-associated workload changes throughout the entire hospitalisation process. In the context of mental health hospitalisation, especially in open-door policies, it is crucial to assess patients’ behavioural risks and nursing workload to ensure the safety of both patients and staff. To the best of our knowledge, there are no instruments that, based on observation, objectively evaluate both behavioural risks and nursing workload simultaneously and throughout the entire hospitalization process for each patient. Therefore, the aim of the study is to design an inpatient monitoring tool based on objective items for categorising patients’ behavioural risks and nursing workload to ensure the safety of patients and staff while maintaining an open-door policy. 2. METHODOLOGY 2.1. Study Design The aim of this study is to design a monitoring tool for inpatients that allows for the establishment of categories and quantification of the level of behavioural risk and nursing workload to facilitate global security management and offer an objective measure for the decision to open doors. To address the objective of this study, a qualitative investigation was undertaken through individual interviews and focus groups during the first quarter of 2023. Before initiating the qualitative study, the interviewer, that is the first researcher, conducted an observational analysis of the unit to manage interview time effectively, prioritize topics based on their importance, and prevent participant dispersion. An expert panel, composed of psychiatrists, a nurse manager and senior mental health nurses, initially defined the two main categories, behavioural risks and nursing workload. Based on the literature, it was also considered relevant to subdivide the behavioural risk category into subcategories: self-harm and suicide, aggression, and absconding. The tool is designed to monitor each patient in both main categories, behavioural risk and nursing workload, throughout the entire hospital stay. To classify the levels of behavioural risk and nursing workload, the expert committee defined three levels as a starting point: low, moderate, and high, associated with values of 0, 1, and 2, respectively. Each patient receives a score between 0 and 2 for each main category, giving equal importance to both categories. The sum of the scores of all patients enables the therapeutic team to numerically assess the environmental safety. 2.2. Setting The present study was conducted at the Acute Inpatient Mental Health Unit of Germans Trias University Hospital (GTUH), Badalona, Barcelona, Spain, a general multispecialty hospital affiliated to the University Autonoma of Barcelona. At the time of the study, GTUH catchment area was of 350.530 adults distributed across four community mental health areas in the North Barcelona health district, with a mean of 313 adult discharges per year. The acute inpatient psychiatric unit at GTUH consists of one ward with 20 beds and are staffed by multidisciplinary teams of senior and junior psychiatrists, nurses, psychologists, and social workers. The unit provides multidisciplinary acute specialist clinical care for patients admitted with serious mental illnesses, in the form of pharmacotherapy, psychotherapy, social work and occupational care, and a recovery program. Since 2019, the unit has progressively implemented the Safewards care model. Safewards is a set of ten interventions designed to enhance safety by preventing conflict and containment ( Bowers, 2014 ). Electro-convulsive therapy is available when the study was carried out. Most of the patients (90-95%) are admitted from the emergency room. They usually suffer from severe primary psychiatric disorders with acute disturbances or risk of self-harm. The remaining of patients are referred from community mental health providers. The ward has open-door policies, meaning that door was open during daytime, and at night-time the door was closed. These policies have been conducted from October 2021. 2.3. Rigour This research was conducted according to the guidelines in the Standards for Reporting Qualitative Research (SRQR) ( O’Brien et al., 2014 ). To establish credibility, independent coding of the data was done by two researchers, followed by a collaborative consensus on emerging codes. Transferability was addressed by providing detailed descriptions of the AIMHU setting and the open-door policy context, allowing readers to assess the applicability of findings to their own environments. To ensure dependability, we have clearly outlined the data collection and analysis processes, including the interviews and focus groups methodologies. The study adhered to ethical guidelines, receiving approval from the local research ethics committee (PI-23-143). 2.4. Participants The inclusion criteria for participants were as follows: (1) be working in the hospital ‘s acute mental health unit, and (2) having experience, at least six months, working on Open-doors policies. The participants were selected using the purposive method. The individual interviews included 3 participants (66% female) from different areas of work, and they were contacted face-to-face. For the focus groups, a total of 29 participants were contacted by email and 16 agreed to take part in the study. Informed consent was obtained from all subjects involved in the study. Two focus groups were conducted, with 8 participants per session. The participants included 8 nurses, 5 nursing assistants, 1 psychiatrist, 1 psychologist and 1 social worker. Of the participants, 81.25% were females, while the rest were males. The focus groups were held at the hospital facilities. The sociodemographic data for all the participants is shown in Table 1 . View this table: View inline View popup Download powerpoint Table 1. Descriptive statistics of participants in the qualitative study. 2.5. In-depth semi-structured interviews The data were collected through face-to-face semi-structured interviews conducted in a designated room within the AIMHU of the hospital. Only the researcher and the interviewee were present in the room. Prior to the interviews, an interview guide was developed by the expert panel. Each interview was structured into two sections according to the categories: behavioural risks and nursing workload. Behavioural risk section was subdivided in the three different subcategories. Each section started with the following question: “Do you think it is appropriate to differentiate it into low, moderate and high level?”. It was followed by an open-ended query depending on the subtheme addressed: “What observations would you employ as criteria to delineate whether a patient is categorised as low, moderate, or high risk?”. These initial prompts were succeeded by further exploratory inquiries for each behavioural risk, such as: “What behavioural characteristics are exhibited by patients at risk of aggression?” “What common traits do patients who attempt to abscond share?”. To objectively assess nursing workload, the inquiries included the same initial questions for the levels of categorisation and initial items. Moreover, workload disparities between voluntary and involuntary inpatients were discussed and identifying physical care needs that require increased staff attention was a crucial issue. The influence of the mental status in the nursing workload was also explored. The duration of the interviews averaged approximately 45 minutes for each participant. They were audio-recorded using two distinct devices, with participants providing verbal consent prior to commencement. Subsequently, the interviews were meticulously transcribed. Initial line-by-line coding was performed according to the content analysis method and descriptive codes were identified by two researchers independently. These “codes” are referred to as items throughout the article and, subsequently, in the developed tool. In accordance with the methodology of qualitative studies, the term “categories” will refer to themes, and “subcategories” will denote subthemes. Categories were defined in advance, that is, behavioural risks and nursing workload, and subcategories for behavioural risks were validated. 2.6. Focus groups Two focus groups were conducted in a hospital training room, guided by two researchers (LMM and MIMS). Based on insights extracted from the analysis of interview data, a comprehensive guide was developed to direct the focus groups toward relevant topics. No additional individuals were present in the interview room aside from the participants and the researchers. During the discussions, items and the corresponding levels extracted from individual interviews were first introduced and deliberated upon. After that, other situations were exposed while researchers diligently documented field notes and identify new items as necessary. It was considered highly relevant to collect information on the appropriate duration of alert maintenance for each item. Each focus group extended over a duration of 1.5 hours, and data saturation was achieved in both instances. As in the interviews, the recordings were made with two different devices and transcribed after the session. The analysis of the information mirrored the content analysis methodology used in the interviews. After the interviews and focus groups, coding was compared and categorised according to similarities and differences. Finally, it was decided to convene the expert panel to refine, consolidate, and validate the items for each level. 3. RESULTS The result of this study is a tool for monitoring acute patients in mental health units during admission, which will be called RutiSafeNet. 3.1. Behavioural risks First, the debate revolved around which types of situations should be included in the tool. Collectively, they agreed that, since the tool aims to monitor changes during hospitalization, it should focus more on clinical presentation and individual behaviours rather than clinical history and intrinsic patient information. “I believe it’s more about the clinical presentation than the patient.” (P9) Regarding self-harm and suicide risk, all participants unanimously agreed that constant verbalization of suicidal ideation poses a high risk, while a punctual verbalization of self-harm wishes represented a moderate risk. Any type of self-injury or medication overdose was also agreed upon to merit a high score. “And a high risk, well, that it comes from a well-structured suicidal thought, or because it has been carried out or is manifesting that it is going to do it already without telling you how. Also, that directly during the shift it is evidenced that self-injury or medication overdose has been performed.” (P1) Picking up dangerous objects such as sharp objects, lighters, and belts was identified as posing a high risk of aggressiveness to both themselves and others. Additionally, there was discussion about the severity of verbal threats, with the minimum score being moderate risk. “When in doubt, I would always mark it as red because you never know what could happen, but the type of verbal threat should be considered.” (P2) Regarding absconding risk, hypervigilance with access points and requests for personal documentation were mentioned as indicators of considerable risk. Previous absconding attempts were considered high risk in involuntary inpatients. “If they come in very decompensated and have a lot of history of absconding, it’s more likely that they will leave than if they come in for a change in treatment or because they are awaiting another device.” (P6) 4.2. Nursing workload The definition of nursing workload score revolved around the cognitive status of patients and their demands. “Very high is a person who is all the time in the control room, asking for our attention, that you have to be with him during the shift, that is very invasive, very reiterative.” (P5) “Medium level, would be a depression for example that needs us to be there doing reconductions.” (P1) Patients requiring moderate demands such as assistance with hygiene or meal companionship were deemed to impose a moderate workload. Patients with a high degree of dependence and those requiring constant redirection were identified as posing the highest burden, warranting a score of two. Finally, Table 2 presents the 34 items and their corresponding score and duration for categorising risks associated with self-harm and suicide, aggressiveness, and absconding, as well as the nursing workload attributed to patients. View this table: View inline View popup Table 2. Items, score and duration for self-harm and suicide, aggressiveness and absconding risk and nursing workload extracted from the complete qualitative study. 4. DISCUSSION This study presents the development of a clinical risk score tool for managing patient safety in mental health hospitalisation. The tool has been successfully designed to provide a rapid and efficient assessment of the therapeutic climate and environmental safety through a total score within AIMHUs. The tool is based on 34 items, differentiated into two main categories, behavioural risks and nursing workload and specifically assesses self-harm and suicide, aggression and absconding risk. Categories and subcategories were considered appropriated in the study, aligning with the risk division defined by the National Health Service (2006) ( Scobie et al., 2006 ) and Haglund et al. ( Haglund et al., 2007 ). The distinction into three levels— low, moderate, and high— was also regarded as suitable for each category and subcategory, and the majority consider it acceptable. Regarding self-harm and suicide risk, it was concluded that verbalization of suicidal ideation, moderate or severe self-harm, and suicide attempts address high risk, coinciding with the conclusions drawn by Powel et al. ( Powell et al., 2000 ). In the present study it has been reported that the severity of suicidal ideation can be differentiated into two risk levels depending on the severity. Passive death wishes and non-suicidal self-injury have been considered of moderate risk. Furthermore, events that are not intrinsic to the patient have not been taken into consideration, such as previous family history of suicide or recent bereavement because the tool is designed to be based on observational items. Items of the aggressive category that score as high risk are aggressive behaviour towards people, towards objects and recently unrestrained patient. Verbal aggressiveness and threatening behaviour are considered medium risk. The DASA-IV ( Ogloff & Daffern, 2006 ) scale item ‘Verbal threats’ is directly related to verbal aggression, but the four remaining items extracted from this qualitative study do not have an equivalence in the DASA-IV scale. In respect to absconding risk subcategory items, explicit verbal expression was considered a high risk, as also defined in the WERS scale ( Marshall & Usinger, 2016 ). Hypervigilance with access points, which has been concluded to pose a high risk of absconding, is not included in the WERS scale. On the other hand, within this subcategory, it has been established that previous absconding attempts only represent a risk in patients with involuntary admissions, whereas the WERS scale considers them regardless of the type of admission. F Although the WERS scale does not address this issue, Georgieva et al. ( Georgieva et al., 2012 ) reported that it had high predictive power for seclusion and the use of coercive measures. The medium risk item ‘refusal to take medication’ is also included in the WERS scale, while ‘acute cognitive change’ can be reflected in the WERS item ‘behaviours.’ The remaining items from this qualitative study that indicate a medium risk of absconding—namely, constant demands for discharge, moderate to severe cognitive impairment with ambulation, and involuntary admission—do not have equivalents in the aforementioned scale. Finally, the nursing workload category includes items related to patient care, excluding those associated with administrative tasks. In this study, different levels of workload (low, moderate, and high) have been distinguished, while in the tool developed by Petrucci et al. ( Petrucci et al., 2014 ), all items receive the same score. One of the major differences between this tool and the scale developed by Petrucci is that the latter only considers the nursing workload at the time of admission, whereas ours assesses it during each shift. This enables the acquisition of current information regarding patient needs and the associated workload. In the “health management” category of Petrucci’s tool, acute somatic pathology care and management of patients with oppositional behaviours are included; in the “Activity/exercise” category, items related to dependency on basic activities of daily living are considered; and in “Nutritional,” patients irregularly consuming food or liquids are scored, although it may not be related directly to an eating disorder. The oppositional behaviours are also included in the DASA-IV scale. Some situations covered in the 88-item tool are also found in the one extracted from this qualitative study; however, they are not included in the nursing workload category. Items related to supervision (constant and intermittent accompaniment and demanding patient) are not considered in the Petrucci’s tool. The remaining items, patients in mechanical or environmental restraint, or with a contagious condition, have been classified in different levels in the nursing workload category. This designed tool could facilitate the reduction of negative perceptions and emotions related to staff burnout, safety, and excessive responsibility, and it would help alleviate the uncertainty associated with security. This tool directly addresses the safety concerns raised by staff and patients regarding open-door policies, as highlighted in several qualitative studies ( Indregard et al., 2024 ; Kalagi et al., 2018 ; Muir-Cochrane et al., 2012 ; Sollied et al., 2023 ). Since the tool provides numerical values, algorithms can be developed to generate a score that reflects the overall climate of the unit. The aggregation of both parameters offers insight into environmental safety and allows for the establishment of a cut-off point to guide decisions regarding the opening of doors. One of the strengths of the current study is that it was based on two focus groups, and 3 in-depth interviews with the collaboration of a wide variety of mental health professionals. Employing qualitative techniques like semi-structured interviews enables participants to elaborate on their answers, leading to a comprehensive data gathering process that captures depth and intricate details beyond what a quantitative method can achieve. To the best of our knowledge, it is the only study that simultaneously considers the behavioural risks of hospitalized patients and the workload they generate for the nursing staff. This innovative tool manages to include factors not only considered in the past patients’ history and enhances existing scales. It is worth noting that RutiSafeNet, may be modifiable and adaptable to other types of patients and units, such as locked door wards. Moreover, due to the way the information in the tool is structured, organised into categories and subcategories, and the concise nature of the items, it is a user-friendly tool that requires minimal prior training. Limitations This study has some limitations. One of the primary limitations of this study is that the developed instrument has not yet been validated through quantitative studies or comparisons with established scales. While the tool has been designed based on qualitative evidence and expert consensus, its validity and reliability still need to be evaluated in future research. Specifically, further studies are required to assess the instrument’s internal consistency, temporal stability, and its relationship with other measures of risk and workload in mental health units. Without these analyses, the application of the instrument should be considered preliminary, and its clinical use should be approached with caution until empirical data support its effectiveness and accuracy. Secondly, it’s possible that there might be a bias in opinions among the professionals since all of them are members of the same acute unit staff. Since open-door policy had been recently implemented, the participants’ experience might not be enough. Thirdly, in the nursing workload category, non-patient related activities, such as training other nurses and organisational and administrative work, have not been considered, but their impact on the overall level of nursing workload could be analysed. More evidence and the conduct of new studies in other AIMHUs with different policies would be necessary to verify the congruence of the items. 5. CONCLUSIONS This study underscores the importance of structured risk assessment in AIMHUs, particularly in the context of open-door policies. By identifying and categorizing 34 key items related to behavioural risks and nursing workload, we have developed a practical monitoring tool that facilitates daily risk management. This tool provides a standardized approach to evaluating self-harm, aggressiveness, and absconding risks, supporting clinical decision-making and enhancing patient safety. The implementation of this monitoring tool enables individualized patient monitoring and provides a real-time overview of unit dynamics, contributing to conflict prevention. Further research is required to validate the scale, enhance its applicability across diverse healthcare settings, and assess its long-term impact on reducing coercive therapeutic measures. Nevertheless, the standardization of risk control and workload monitoring represents an advancement in the management of AIMHUs, with the potential for broader implementation at higher levels. Data Availability All data produced in the present study are available upon reasonable request to the authors Acknowledgments The authors would like to thank the participants of the qualitative study for giving their precious time in assisting the sessions. Footnotes lmirom.germanstrias{at}gencat.cat amoreno.germanstrias{at}gencat.cat jdepablo.germanstrias{at}gencat.cat mimartinezs.germanstrias{at}gencat.cat mdelgadom.germanstrias{at}gencat.cat secastro.germanstrias{at}gencat.cat mjimenezm.germanstrias{at}gencat.cat aibanezc.germanstrias{at}gencat.cat tatianabustos.germanstrias{at}gencat.cat Conflicts of interest: The authors declare no conflict of interest. Funding: This work was supported by a grant from the JMC Legacy Research Fund of Germans Trias i Pujol University Hospital. It was also supported by the Fundació Llegat Roca i Pi. The sponsor had no role in the study design, data collection and analysis, interpretation of results, the preparation of the manuscript, the decision to submit the manuscript for publication, and the writing of the manuscript. REFERENCES Allen , J. J. , & Anderson , C. A. ( 2017 ). Aggression and Violence: Definitions and Distinctions . The Wiley Handbook of Violence and Aggression , 1 – 14 . doi: 10.1002/9781119057574.whbva001 OpenUrl CrossRef Andreu , M. , Balcells , M. , Graell , M. , Bueno , L. , Gual , A. , & Barrio , P. ( 2024 ). Like cheese and chalk or cross-fertilization? A qualitative exploration of how addiction patients perceive treatment in a general psychiatry ward . Addiction Research and Theory , 0 ( 0 ), 1 – 9 . doi: 10.1080/16066359.2024.2331762 OpenUrl CrossRef ↵ Bowers , L. ( 2014 ). Safewards: A new model of conflict and containment on psychiatric wards . Journal of Psychiatric and Mental Health Nursing , 21 ( 6 ), 499 – 508 . doi: 10.1111/jpm.12129 OpenUrl CrossRef PubMed Efkemann , S. A. , Bernard , J. , Kalagi , J. , Otte , I. , Ueberberg , B. , Assion , H. J. , Zeiß , S. , Nyhuis , P. W. , Vollmann , J. , Juckel , G. , & Gather , J. ( 2019 ). Ward atmosphere and patient satisfaction in psychiatric hospitals with different ward settings and door policies. Results from a mixed methods study . Frontiers in Psychiatry , 10 ( AUG ), 1 – 11 . doi: 10.3389/fpsyt.2019.00576 OpenUrl CrossRef ↵ Fanneran , T. , Brimblecombe , N. , Bradley , E. , & Gregory , S. ( 2015 ). Using workload measurement tools in diverse care contexts: The experience of staff in mental health and learning disability inpatient settings . Journal of Psychiatric and Mental Health Nursing , 22 ( 10 ), 764 – 772 . doi: 10.1111/jpm.12263 OpenUrl CrossRef PubMed ↵ Georgieva , I. , Vesselinov , R. , & Mulder , C. L. ( 2012 ). Early detection of risk factors for seclusion and restraint: A prospective study . Early Intervention in Psychiatry , 6 ( 4 ), 415 – 422 . doi: 10.1111/j.1751-7893.2011.00330.x OpenUrl CrossRef PubMed ↵ Gerolamo , A. M. ( 2009 ). An Exploratory Analysis of the Relationship Between Psychiatric Nurses’ Perceptions of Workload and Unit Activity . Archives of Psychiatric Nursing , 23 ( 3 ), 243 – 250 . doi: 10.1016/j.apnu.2008.06.005 OpenUrl CrossRef PubMed Gill , N. , Drew , N. , Rodrigues , M. , Muhsen , H. , Morales Cano , G. , Savage , M. , Pathare , S. , Allan , J. , Galderisi , S. , Javed , A. , Herrman , H. , & Funk , M. ( 2024 ). Bringing together the World Health Organization’s QualityRights initiative and the World Psychiatric Association’s programme on implementing alternatives to coercion in mental healthcare: a common goal for action . BJPsych Open , 10 ( 1 ), 1 – 7 . doi: 10.1192/bjo.2023.622 OpenUrl CrossRef ↵ Gooding , P. , McSherry , B. , & Roper , C. ( 2020 ). Preventing and reducing ‘coercion’ in mental health services: an international scoping review of English-language studies . Acta Psychiatrica Scandinavica , 142 ( 1 ), 27 – 39 . doi: 10.1111/acps.13152 OpenUrl CrossRef PubMed ↵ Gordon , M. ( 1982 ). Functional health paterns, nursing diagnosis process and application . New York : Mc Graw-Hill Book Comp . ↵ Haglund , K. , Van Der Meiden , E. , Von Knorring , L. , & Von Essen , L. ( 2007 ). Psychiatric care behind locked doors. A study regarding the frequency of and the reasons for locked psychiatric wards in Sweden . Journal of Psychiatric and Mental Health Nursing , 14 ( 1 ), 49 – 54 . doi: 10.1111/j.1365-2850.2007.01042.x OpenUrl CrossRef PubMed ↵ Haglund , K. , & Von Essen , L. ( 2005 ). Locked entrance doors at psychiatric wards - Advantages and disadvantages according to voluntarily admitted patients . Nordic Journal of Psychiatry , 59 ( 6 ), 511 – 515 . doi: 10.1080/08039480500360781 OpenUrl CrossRef PubMed Web of Science ↵ Haglund , K. , Von Knorring , L. , & Von Essen , L. ( 2006 ). Psychiatric wards with locked doors - Advantages and disadvantages according to nurses and mental health nurse assistants . Journal of Clinical Nursing , 15 ( 4 ), 387 – 394 . doi: 10.1111/j.1365-2702.2006.01489.x OpenUrl CrossRef PubMed Huber , C. G. , Schneeberger , A. R. , Kowalinski , E. , Fröhlich , D. , von Felten , S. , Walter , M. , Zinkler , M. , Beine , K. , Heinz , A. , Borgwardt , S. , & Lang , U. E. ( 2016 ). Suicide risk and absconding in psychiatric hospitals with and without open door policies: a 15 year, observational study . The Lancet Psychiatry , 3 ( 9 ), 842 – 849 . doi: 10.1016/S2215-0366(16)30168-7 OpenUrl CrossRef PubMed ↵ Indregard , A. M. R. , Nussle , H. M. , Hagen , M. , Vandvik , P. O. , Tesli , M. , Gather , J. , & Kunøe , N. ( 2024 ). Open-door policy versus treatment-as-usual in urban psychiatric inpatient wards: a pragmatic, randomised controlled, non-inferiority trial in Norway . The Lancet Psychiatry , 11 ( 5 ), 330 – 338 . doi: 10.1016/S2215-0366(24)00039-7 OpenUrl CrossRef PubMed ↵ Johnson , S. , Dalton-Locke , C. , Baker , J. , Hanlon , C. , Salisbury , T. T. , Fossey , M. , Newbigging , K. , Carr , S. E. , Hensel , J. , Carrà , G. , Hepp , U. , Caneo , C. , Needle , J. J. , & Lloyd-Evans , B. ( 2022 ). Acute psychiatric care: approaches to increasing the range of services and improving access and quality of care . World Psychiatry , 21 ( 2 ), 220 – 236 . doi: 10.1002/wps.20962 OpenUrl CrossRef PubMed Jungfer , H. A. , Schneeberger , A. R. , Borgwardt , S. , Walter , M. , Vogel , M. , Gairing , S. K. , Lang , U. E. , & Huber , C. G. ( 2014 ). Reduction of seclusion on a hospital-wide level: Successful implementation of a less restrictive policy . Journal of Psychiatric Research , 54 ( 1 ), 94 – 99 . doi: 10.1016/j.jpsychires.2014.03.020 OpenUrl CrossRef PubMed ↵ Kalagi , J. , Otte , I. , Vollmann , J. , Juckel , G. , & Gather , J. ( 2018 ). Requirements for the implementation of open door policies in acute psychiatry from a mental health professionals’ and patients’ view: A qualitative interview study . BMC Psychiatry , 18 ( 1 ). doi: 10.1186/s12888-018-1866-9 OpenUrl CrossRef ↵ Kennedy , H. , Roper , C. , Randall , R. , Pintado , D. , Buchanan-Hagen , S. , Fletcher , J. , & Hamilton , B. ( 2019 ). Consumer recommendations for enhancing the Safewards model and interventions . International Journal of Mental Health Nursing , 28 ( 2 ), 616 – 626 . doi: 10.1111/inm.12570 OpenUrl CrossRef PubMed Kowalinski , E. , Hochstrasser , L. , Schneeberger , A. R. , Borgwardt , S. , Lang , U. E. , & Huber , C. G. ( 2019 ). Six years of open-door policy at the University Psychiatric Hospital Basel . Nervenarzt , 90 ( 7 ), 705 – 708 . doi: 10.1007/s00115-019-0733-3 OpenUrl CrossRef PubMed ↵ Krückl , J. S. , Moeller , J. , Imfeld , L. , Schädelin , S. , Hochstrasser , L. , Lieb , R. , Lang , U. E. , & Huber , C. G. ( 2023 ). The association between the admission to wards with open-vs. closed-door policy and the use of coercive measures . Frontiers in Psychiatry , 14 ( October ), 1 – 7 . doi: 10.3389/fpsyt.2023.1268727 OpenUrl CrossRef Lebel , J. L. , Duxbury , J. A. , Putkonen , A. , Rittmannsberger , H. , Sartorius , N. , Brad , M. , Burtea , V. , Capraru , N. , Cernak , P. , Dernovçek , M. , Dobrin , I. , Frater , R. , Hasto , J. , Hategan , M. , Haushofer , M. , Kafka , J. , Kasper , S. , MacRea , R. , Nabelek , L. , … Huber , C. G. ( 2018 ). Locked doors in acute inpatient psychiatry: A literature review . Journal of Psychiatric and Mental Health Nursing , 73 ( 1 ), 1 – 8 . doi: 10.4414/smw.2018.14616 OpenUrl CrossRef Lima , D. W. da C. , Paixão , A. K. R. , Bezerra , K. P. , Freitas , R. J. M. de , Azevedo , L. D. S. , & Morais , F. R. R. ( 2021 ). Humanização no cuidado em saúde mental: compreensões dos enfermeiros . SMAD Revista Eletrônica Saúde Mental Álcool e Drogas (Edição Em Português) , 17 ( 1 ), 58 – 65 . doi: 10.11606/issn.1806-6976.smad.2021.164401 OpenUrl CrossRef ↵ Marshall , L. E. , & Usinger , S. ( 2016 ). The Waypoint Elopement Risk Scales (WERS) . Missouridou , E. , Fradelos , E. C. , Kritsiotakis , E. , Mangoulia , P. , Segredou , E. , & Papathanasiou , I. V. ( 2022 ). Containment and therapeutic relationships in acute psychiatric care spaces: the symbolic dimensions of doors . BMC Psychiatry , 22 ( 1 ), 1 – 11 . doi: 10.1186/s12888-021-03607-2 OpenUrl CrossRef PubMed Missouridou , E. , Xiarhou , P. , Fradelos , E. C. , Mangoulia , P. , Kasidi , K. , Kritsiotakis , M. , Stefanou , E. , Liapis , C. , Dimitriadis , A. , Segredou , E. , Dafogianni , C. , & Evagelou , E. ( 2021 ). Nurses’ Experiences of Psychiatric Care in Acute Care Units with an Open Door Policy . Advances in Experimental Medicine and Biology , 1337 ( January ), 127 – 135 . doi: 10.1007/978-3-030-78771-4_15 OpenUrl CrossRef PubMed Molin , J. , Strömbäck , M. , Lundström , M. , & Lindgren , B. M. ( 2021 ). It’s Not Just in the Walls: Patient and Staff Experiences of a New Spatial Design for Psychiatric Inpatient Care . Issues in Mental Health Nursing , 42 ( 12 ), 1114 – 1122 . doi: 10.1080/01612840.2021.1931585 OpenUrl CrossRef PubMed ↵ Muir-Cochrane , E. , Van der Merwe , M. , Nijman , H. , Haglund , K. , Simpson , A. , & Bowers , L. ( 2012 ). Investigation into the acceptability of door locking to staff, patients, and visitors on acute psychiatric wards . International Journal of Mental Health Nursing , 21 ( 1 ), 41 – 49 . doi: 10.1111/j.1447-0349.2011.00758.x OpenUrl CrossRef PubMed ↵ O’Brien , B. C. , Harris , I. B. , Beckman , T. J. , Reed , D. A. , & Cook , D. A. ( 2014 ). Standards for reporting qualitative research: A synthesis of recommendations . Academic Medicine , 89 ( 9 ), 1245 – 1251 . doi: 10.1097/ACM.0000000000000388 OpenUrl CrossRef PubMed ↵ Ogloff , J. R. P. , & Daffern , M. ( 2006 ). The dynamic appraisal of situational aggression: An instrument to assess risk for imminent aggression in psychiatric inpatients . Behavioral Sciences and the Law , 24 ( 6 ), 799 – 813 . doi: 10.1002/bsl.741 OpenUrl CrossRef PubMed Web of Science ↵ Petrucci , C. , Marcucci , G. , Carpico , A. , & Lancia , L. ( 2014 ). Nursing care complexity in a psychiatric setting: Results of an observational study . Journal of Psychiatric and Mental Health Nursing , 21 ( 1 ), 79 – 86 . doi: 10.1111/jpm.12049 OpenUrl CrossRef PubMed ↵ Powell , J. , Geddes , J. , Deeks , J. , Goldacre , M. , & Hawton , K. ( 2000 ). Suicide in psychiatric hospital inpatients: Risk factors and their predictive power . British Journal of Psychiatry , 176 ( MAR .), 266 – 272 . doi: 10.1192/bjp.176.3.266 OpenUrl Abstract / FREE Full Text ↵ Rosen , M. A. , Dietz , A. S. , Lee , N. , Jeng Wang , I. , Markowitz , J. , Wyskiel , R. M. , Yang , T. , Priebe , C. E. , Sapirstein , A. , Gurses , A. P. , & Pronovost , P. J. ( 2018 ). Sensor-based measurement of critical care nursing workload: Unobtrusive measures of nursing activity complement traditional task and patient level indicators of workload to predict perceived exertion . PLoS ONE , 13 ( 10 ). doi: 10.1371/journal.pone.0204819 OpenUrl CrossRef Schneeberger , A. R. , Kowalinski , E. , Fröhlich , D. , Schröder , K. , von Felten , S. , Zinkler , M. , Beine , K. H. , Heinz , A. , Borgwardt , S. , Lang , U. E. , Bux , D. A. , & Huber , C. G. ( 2017 ). Aggression and violence in psychiatric hospitals with and without open door policies: A 15-year naturalistic observational study . Journal of Psychiatric Research , 95 , 189 – 195 . doi: 10.1016/j.jpsychires.2017.08.017 OpenUrl CrossRef PubMed ↵ Scobie , S. , Minghella , E. , Dale , C. , Thomson , R. , Lelliott , P. , & Hill , K. ( 2006 ). With safety in mind: Mental health services and patient safety . National Patient Safety Agency ; ↵ Sollied , S. A. , Lauritzen , J. , Damsgaard , J. B. , & Kvande , M. E. ( 2023 ). Facilitating a safe and caring atmosphere in everyday life in forensic mental health wards - a qualitative study . International Journal of Qualitative Studies on Health and Well-Being , 18 ( 1 ). doi: 10.1080/17482631.2023.2209966 OpenUrl CrossRef ↵ Sousa , C. , & Seabra , P. ( 2018 ). Assessment of nursing workload in adult psychiatric inpatient units: A scoping review . Journal of Psychiatric and Mental Health Nursing , 25 ( 7 ), 432 – 440 . doi: 10.1111/jpm.12468 OpenUrl CrossRef PubMed Steinauer , R. , Krückl , J. S. , Moeller , J. , Vogel , M. , Wiesbeck , G. A. , Walter , M. , Lang , U. E. , & Huber , C. G. ( 2020 ). Opening the Doors of a Substance Use Disorder Ward—Benefits and Challenges From a Consumer Perspective . Frontiers in Psychiatry , 11 ( September ), 1 – 6 . doi: 10.3389/fpsyt.2020.580885 OpenUrl CrossRef PubMed ↵ Twigg , D. , & Duffield , C. ( 2009 ). A review of workload measures: A context for a new staffing methodology in Western Australia . International Journal of Nursing Studies , 46 ( 1 ), 132 – 140 . doi: 10.1016/j.ijnurstu.2008.08.005 OpenUrl CrossRef PubMed ↵ Van Den Oetelaar , W. F. J. M. , Roelen , C. A. M. , Grolman , W. , Stellato , R. K. , & Van Rhenen , W. ( 2021 ). Exploring the relation between modelled and perceived workload of nurses and related job demands, job resources and personal resources; A longitudinal study . PLoS ONE , 16 (2 Febuary ). doi: 10.1371/journal.pone.0246658 OpenUrl CrossRef View the discussion thread. Back to top Previous Next Posted October 02, 2025. 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