Sometimes, when patients who are mentally ill are admitted to hospital, they leave without the agreement of the staff, or go missing. This is a serious concern, because many patients are brought into hospital in the first place because they are at risk of harming others or themselves in some way. One of the gravest of these concerns is that patients might kill themselves, and it is known that about a third of those inpatients who complete suicide do so following absconding from the hospital.
Since 1996, when our research into this topic started we have reviewed the literature (and recently updated that review); conducted an exploratory study on who absconds, in what circumstances, and why; successfully devised and tested a nursing intervention to reduce the numbers of patients absconding; audited that intervention across wards in multiple hospitals; and produced a training package to allow wards to implement it.
Because of rising concerns in the UK about absconding rates, many wards and units which previously operated with open doors have now become permanently locked. We have shown that door locking only reduces absconding by 25% - precisely the same proportion by which our nursing intervention reduces absconding. We have thoroughly investigated staff, patient and visitor perceptions of locked doors, and their outcomes. The details of that research can be found on another page [link to locked doors page]. Below you can find a summary of our research into absconding, followed by a list of our publications and links to some of our research.
The literature review
A systematic search identified forty-five empirical studies, dating from the 1960s to the present day. Varied definitions of absconding and methods of calculating the rates of absconding made comparisons between studies difficult. Nevertheless, it is clear that absconders were more often young, male, from disadvantaged groups, and suffering from schizophrenia, as compared to admissions generally. Previous reports show that many absconding events take place while the patient is temporarily off the ward with permission; the remainder of absconding patients use an assortment of means to make their escape. A large variety of reasons for absconding have been elicited from patients or advanced as possibilities by researchers. Only six evaluative studies of interventions impacting upon absconding have been reported in the literature, but no firm conclusions can be drawn from them.
The exploratory study
Twelve acute wards monitored their absconds for a period of five months. Demographic details of absconders were compared to a control group on non-absconding patients with both nurses and patients interviewed.
Interviews of patients who returned to their wards showed that they abscond because they are bored, frightened of other patients, feel trapped and confined, have household responsibilities they feel they must fulfil, feel cut off from relatives and friends, or are worried about the security of their home and property. Psychiatric symptoms also contribute to the decision to leave, but in nearly every case patients can give additional and rational reasons for their abscond. Some patients leave impulsively and in anger following unwelcome news about delayed permission for leave or discharge. Others leave specifically in order to carry out some activity outside the hospital.
In contrast to the findings in previous studies, the vast majority of absconders leave from the ward directly, mostly via the front door. Some are known to be at risk of absconding, and although more than half declare their intention to leave, they still succeeded in getting away. On some occasions they circumvent locked or guarded doors, or special nursing observation. Shift handovers are a peak time for absconds, possibly due to decreased nursing surveillance of the ward. Most absconds occur during the first few weeks of admission, and most absconders simply go home and engage in normal, everyday activities.
Absconders are considered by staff to be high risk patients, and many have histories of violence and/or suicide attempts. Nevertheless nurses only request the aid of the police in returning patients on 47% of occasions. The actions of the police are very variable, and range from two policemen calling at the patient's house, to an entire team in riot gear appearing at the patient's door in the early hours of the morning. Although most absconds result in no harm to anyone, four percent result in harm to the patient or others. Most absconders return by themselves, but relatives and carers also play a significant role in persuading the patient to return or bringing them back.
Interviews of staff revealed that the assessment of the level of risk which a patient posed varied considerably, with some wards using standard risk assessment tools and others talking about their own methods. There was some evidence of conflict with medical staff about what measures should be put in place to manage the risk (observation level, leave). The interviewees were aware of serious consequences of absconding, and this made them worry when patients absconded. Following an abscond most nurses look for an explanation, and this can lead to blame of other members of the team. A sizable minority spoke of feeling unsupported by their managers, and that their jobs could be at risk following an abscond.
The trial of an intervention to reduce absconding
The aim of this trial was to evaluate the impact of an intervention to reduce absconding by patients from partially locked acute psychiatric wards (wards where the door is locked from time to time at the discretion of the nurse in charge, but not always open or always locked). Five acute psychiatric wards in one hospital were entered into a stepped, before-and-after controlled trial. Following 3 months at baseline, nursing staff on the wards were trained in the intervention and monitored in its execution for the next 3 months. Absconding and violent incidents were recorded by nursing staff through shift reports and validated against officially collected forms.
Absconding reduced by 25% overall during the intervention period, a fall which was statistically significant. The wards also significantly reduced the amount of time the ward door was kept locked. Three out of the five wards implemented the intervention effectively and two of these achieved decreases in their absconding. The other two wards were not able to consistently implement the intervention, and their absconding rates remained unchanged. The findings support the efficacy of the intervention in reducing absconding.
The distributed audit
In this project, the anti-absconding intervention was encapsulated in a self-training package, and offered freely to wards across the UK who agreed to implement it and audit the results. Fifteen wards completed this distributed audit, and achieved overall a 25.5% decrease in their absconding rates, as measured by official reports. The results support the efficacy of the intervention, and indicate that significant reductions can me made in absconding rates from unlocked or partially locked acute psychiatric wards.
We estimate that by using this intervention an average 20 bed acute ward would decrease its officially reported absconds by 11 over the course of one year. On a larger scale, an NHS Trust with 10 acute wards of 20 beds each would decrease officially reported absconds by 110 over the course of a year meaning a reduction of 4 adverse incidents per year for that Trust. Absconds that are not officially reported (because the patient is informal or the staff wait for the patient to return) also decrease, increasing the benefit from the intervention.
There is strong support for the efficacy of the intervention in reducing absconding. All tests have been conducted on generic acute admission psychiatric wards that were always open, or locked only at times at the discretion of the nurse in charge. The outcome of applying of the intervention on locked wards, psychiatric intensive care units, forensic wards, elderly care wards, and in child and adolescent mental health units, is not known. We are aware that patients still manage to abscond from locked wards, and we believe that the principles underpinning the intervention are widely applicable. Nevertheless the evidence we have only relates to acute care for adults.
Contributors to this research: Len Bowers, Nicola Clark, Manuela Jarrett, Jane Alexander, Cathe Gaskell, Alan Simpson
Links to online material
Runaway Patients: report to the GNC Trust The report to the funders of the original exploratory study, containing additional material not otherwise published.
Literature review on absconding
Bowers, L. (2000) The Expression and Comparison of Ward Incident Rates. Issues in Mental Health Nursing 21(4)365-386
Bowers, L. (2003) Runaway Patients. Mental Health Practice 7(1)10-12
Bowers, L., Alexander, J. and Gaskell, C. (2003) A Controlled Trial Of An Intervention To Reduce Absconding From Acute Psychiatric Wards. Journal of Psychiatric and Mental Health Nursing 10:410-416
Bowers, L., Douzenis, A., Galeazzi, G., Forghieri, M., Tsopelas, C., Simpson, A., and Allan, T. (2005) Disruptive and dangerous behaviour by patients on acute psychiatric wards in three European centres. Social Psychiatry and Psychiatric Epidemiology 40:822-828
Bowers, L., Jarrett, M. & Clark, N. (1998) Absconding: A Literature Review. Journal of Psychiatric and Mental Health Nursing 5:343-353
Bowers, L., Jarrett, M. Clark, N., Kiyimba, F. & McFarlane, L. (1999) 1. Absconding: why patients leave. Journal of Psychiatric and Mental Health Nursing 6(3)199-206
Bowers, L., Jarrett, M. Clark, N., Kiyimba, F. & McFarlane, L. (1999) 2. Absconding: how and when patients leave the ward. Journal of Psychiatric and Mental Health Nursing 6(3)207-212
Bowers, L., Jarrett, M. Clark, N., Kiyimba, F. & McFarlane, L. (1999) 3. Absconding: outcome and risk. Journal of Psychiatric and Mental Health Nursing 6(3)213-218
Bowers, L., Jarrett, M. Clark, N., Kiyimba, F. & McFarlane, L. (2000) Determinants of absconding by patients on acute psychiatric wards Journal of Advanced Nursing 32(3)644-649 Also reproduced in: Pryce, A. (Ed) (2002) Diverse Practices: Elements in the Formation of a Health Care Research Unit. London: City University.
Bowers, L., Simpson, A. and Alexander, J. (2003) Patient-staff conflict: results of a survey on acute psychiatric wards. Social Psychiatry and Psychiatric Epidemiology 38:402-408
Bowers, L., Simpson, A. and Alexander, J. (2005) Real world application of an intervention to reduce absconding. Journal of Psychiatric and Mental Health Nursing 12:598-602
Clark, N., Kiyimba, F. Bowers, L., Jarrett, M. & McFarlane, L. (1999) 4. Absconding: nurses views and reactions. Journal of Psychiatric and Mental Health Nursing 6(3)219-224
Gerace, A., Muir-Cochrane, E. and Bowers, L. (2010) The profile of absconding psychiatric inpatients in Australia. Journal of Clinical Nursing
Simpson, A. and Bowers, L. (2004) Runaway Success. Nursing Standard 18(19)18-19
Stewart, D. and Bowers, L. (under review) Absconding and locking ward doors: evidence from the literature. Journal of Psychiatric and Mental Health Nursing