Runaway Patients
Report to the GNC Trust
Len Bowers RMN PhD
Professor of Psychiatric Nursing
Manuela Jarrett RMN BSc
Research Assistant
Nicola Clark MA MSc
Research Assistant
Frank Kiyimba RMN
Research Assistant
Linda McFarlane BSc
Research Assistant
September 1998
Department of Mental Health Nursing
City University
London E1 2EA
1
Contents
Executive summary....................................................................................................1
Introduction to the project.......................................................................................... 5
Literature review ........................................................................................................8
Methodology ............................................................................................................19
Overview of data and analytic methods ...................................................................24
Findings 1: Absconding events and consequences ..................................................30
Findings 2: Assessment of variables impacting on absconding rates ......................37
Findings 3: Characteristics of absconders................................................................42
Findings 4: Going and returning ..............................................................................46
Findings 5: Life on the ward and reasons for leaving..............................................62
Findings 6: Absconding and ethnicity......................................................................87
Findings 7: Nurses' perceptions ............................................................................ 102
Findings 8: Relative and carer perceptions ............................................................114
Discussion of findings............................................................................................120
Conclusions and recommendations........................................................................ 137
Appendices.............................................................................................................140
References..............................................................................................................161
2
Executive Summary
Aims of the project
To discover: the characteristics of absconding patients from acute admission
psychiatric wards; high risk times and places for absconding; how patients left and
returned to the ward; the reasons given by patients for leaving the ward; nursing staff
responses and reactions to incidents of absconding; the responses of patient relatives
or significant others to incidents of absconding; and to investigate the relationship
between rates of absconding, ward atmosphere and ward design.
Literature review
Incidents of absconding from inpatient care are high risk events which have
been linked to serious harm to self and others. Varied definitions of absconding and
methods of calculating the rates of absconding make comparisons between studies
difficult. Nevertheless, it is clear that absconders are more often young, male, from
disadvantaged groups, and suffering from schizophrenia, as compared to admissions
generally. Roughly half of abscondings 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.
Methodology and analysis
The study took place in three NHS Trusts in the East End of London. Twelve
wards were studied, situated in five hospitals at different sites. All absconders from
these wards between 5th January 1998 and 28th May 1998 were identified and
included in the study. A control group was identified by selecting, for each absconder,
the patient on the same ward who followed them in alphabetical order by surname. A
sample of relatives or significant others was assembled by asking absconding patients
for permission to approach somebody close to them, and were interviewed by
telephone. A convenience sample of qualified nursing staff were interviewed,
stratified by ward.
The final sample consisted of 175 absconding patients and 159 controls. There
were 498 absconding events generated by these 175 patients. 52 of these patients were
interviewed on their return to the ward a total of 62 times. 24 ward nurses were
interviewed in person and 6 relatives/carers interviewed by telephone. All interviews
were taped and transcribed except those conducted by telephone. Analysis was
conducted using SPSS and QSR NUD.IST computer software.
1
Key findings
1. A predictive profile of the absconder is: young; male; a firstborn child; from an
ethnic minority group; of the Muslim faith; living with partner or parents; with a
diagnosis of schizophrenia; having had a number of transfers between wards,
refusals of medication and involvement in officially reported ward incidents in the
previous week; considered by nursing staff to be a risk to self or others; someone
who has absconded during previous admissions; and has had previous contact with
the police.
2. Absconding is linked to other forms of patient noncompliance and difficult
behaviour. These behaviours are more likely to arise out of common patterns of
failed relationships between patients and psychiatry, not through individual patient
personality or characteristics.
3. There is indicative evidence that there are at least two different groups of
absconders with differing characteristics, most readily distinguished by age, gender
and marital status.
4. Both ward security/supervision and professional-patient relationships are likely
have an influence upon the rate of absconding, although the efficacy of the former
should not be assumed nor overemphasised.
5. The majority of absconds occur during the first few weeks of admission to hospital,
most patients who abscond do so from the ward, the main route of exit is via the
ward front door, and the most common destination is home.
6. No relationship could be found between absconding and day of the week, number
of days since last ward round, the weather, individual inpatient keyworkers nor any
association with the professional discipline of the patients' community keyworkers.
7. Consultant psychiatrists working on the same ward can differ significantly by the
rate at which their patients abscond.
8. Negative outcomes to absconding are rare (4% of absconding events), but
potentially serious. Predicting which absconds are high risk is a difficult and
almost impossible task.
9. Most absconders return by themselves, some are returned by relatives, and some
are returned by the police.
10.Of those returned by the police, most are brought back by a couple of police
officers who call at the home. A few absconders are brought back by large numbers
of police in riot gear. The numbers of police officers used does not seem to relate
to any reasoned assessment of risk.
11.Patients abscond because they are bored on the ward, frightened of other patients,
feel trapped and confined, have household responsibilities they feel they must
2
fulfil, feel cut off from relatives and friends, or are worried about the security of
their home and property.
12.Psychiatric symptoms also contribute to the decision to leave, but in nearly every
case patients can give additional and rational reasons for their abscond.
13.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. Most are engaged in entirely normal
social and household activities while away.
14.The attitude of absconders to their illness and its treatment divides them roughly
into two groups: "refusers" and "disputers". The Refusers deny that they are ill,
assert that they feel well, and consequently believe that there is no need for them to
be in hospital. The Disputers, on the other hand, did not deny that they were ill and
in need of treatment. Instead they disagreed with the nature of what was being
offered and the way their problems were perceived by psychiatric professionals.
15.Relatives and carers of absconders feel that communication with the hospital staff
is poor, and are either not informed about the abscond, or not informed about the
patients return. In some embarrassing circumstances it is relatives who inform the
ward staff that a patient has absconded.
16.Nurse feel vulnerable to being blamed for absconding and insist that even on the
best run ward patients can still abscond. They often feel blamed by managers or by
medical staff, and frequently blame each other for lapses in procedure and the
supervision of patients.
17.Although patients from ethnic minority groups abscond more frequently, detailed
analysis shows that each ethnic group has a rather different relationship with
psychiatric services that alters the pattern and impact of absconding.
18.Comparison with previous literature and studies leads to the conclusion that
absconding rates in the study districts were not atypical in any way.
19.Different organisational cultures can be detected in the three NHS Trusts of the
study, and these do impact upon absconding, its prevention, the return of patients,
and staff attitudes.
20.Significant differences between absconding rates on wards were detectable. These
could not be accounted for by different ward layouts and numbers of exits, nor by
staffing levels. They are therefore likely to be due to the way the multidisciplinary
teams work with patients on those wards.
Strengths of the study
1. The use of triangulation between different data sets and sources of information
2. Large sample for quantitative analysis covering 5 hospitals and 12 wards
3
3.
4.
5.
6.
7.
Large sample of patient interviews, 62 in all
Interviewer training
Cross checks on coding of interview data
Computer aided qualitative data analysis
Critical review of data interpretation by the research team
Weaknesses of the study
1. The use of case notes for diagnostic and other data is unreliable
2. The East End of London is a special community with high levels of deprivation, a
multitude of ethnic minority populations, and high numbers of refugees
3. Small numbers of women and certain ethnic minorities in interview sample may
have biased the results
Recommendations
1. Some form of home care and home security service for psychiatric inpatients might
be highly valued by those who worry about their property.
2. Nurses may wish to involve relatives and carers (subject to patient agreement) to a
greater degree in the patient's care on the ward, and when seeking their return to
hospital following an abscond.
3. Psychiatric service providers may wish to discuss with the police some form of
prioritisation system for absconders who pose different risks, plus some
communication over which absconders may pose a risk to the police involved in
their return to hospital.
4. There may be a role for Community Mental Health Team staff (perhaps in
conjunction with duty systems) in the return of lower risk absconding patients. This
does not necessarily mean physically returning the patient to hospital, but may
mean a call at the patient's home and persuading them to take a hospital financed
taxi back to the ward.
5. Psychiatric staff (of all disciplines) may wish to renew their efforts to understand
and deal with the patient's worries about home life and responsibilities.
6. Multidisciplinary care teams may wish to consider transfer to a locked intensive
psychiatric care environment, or discharge, for every patient who absconds more
than two or three times during a single admission
7. A controlled trial of an nursing intervention to reduce absconding rates, based upon
the findings of this study, should be undertaken as soon as possible.
4
Introduction
Unauthorised absence of a patient from the ward arouses genuine concern on
the part of the professionals responsible for their care. Yet despite many years of
interest in this topic, what little is known about what patients abscond, why and how
they do so, and what strategies can be used to contain the risks of such behaviour, is
dispersed across a wide body of literature spanning many years. This review seeks to
bring together for the first time the findings of published research to date on the issue
of absconding.
The link of absconding to serious self harm and successful suicide is quite
clear, and has been apparent in the published literature for some time. Crammer
(1984) reported that 26% of British inpatient deaths took place after the patient had
run away. Sundqvist-Stensman (1987) has given a similar figure (30%) for Swedish
inpatient deaths, and Niskanen et al (1974) report 20% for suicides in Helsinki
psychiatric hospitals. The most recent figures from the Confidential Inquiry into
Homicides and Suicides in the UK (Appleby, pers. communication) show that 22% of
inpatient completed suicides took place while the patients concerned were absent
without leave.
Absconding can also result in serious self neglect or death through exposure.
Aspinall (1994) relates the story of a case that ended in the death of a patient after six
days of absence from the ward, and in harsher climates than that of the UK, frostbite
has been reported.
There is a similar, although less direct link, between absconding and violent
behaviour. Powell et al (1994) noted that the act of attempting to abscond could itself
precipitate violence, and Milner (1966) reports that in 3.6% of incidents of absconding
the patients were aggressive to relatives. In addition, there are accounts in recent UK
enquiry reports of homicides perpetrated by patients who have absconded. Kenneth
Grey killed his mother after absconding from an open psychiatric ward in 1994, Jason
Mitchell murdered his father and two neighbours after absconding also in 1994, and
Kevin Rooney stabbed an acquaintance to death after absconding the day after he was
admitted in 1991 (Sheppard 1996). Other risks associated with absconding can be
missed treatment with possible longer duration to remission, or the complete loss of
contact with psychiatric services.
Even without any of the above consequences, absconding may lead to
catastrophic loss of confidence in the psychiatric services by relatives who expect the
hospital to be a 'place of safety'. When things do go wrong, there is a possibility that
legal action may be taken. Molnar et al (1985) identified five cases in the US courts in
which compensation had been sought for the consequences of absconding: two cases
where patients had been struck by cars, one suicide attempt, one assault and one
murder.
Finally, it is worth pointing out that there may be possible benefits to the
patient from absconding, although none of these have been demonstrated or quantified
by research so far. The absconder may gain a sense of independence and liberation
5
from their actions, plus a decrease in paranoia due to no longer being under
observation. If the patient has responsibilities to others, those dependants might gain
companionship and support from the absconder returning home.
Aims of this study
1. To identify the characteristics of absconding patients from acute admission
psychiatric wards
2. To identify high risk times and places for absconding
3. To determine how patients left and returned to the ward
4. To assess the reasons given by patients for leaving the ward
5. To describe nursing staff responses to incidents of absconding
6. To assess nursing staff reactions to absconding
7. To assess the responses of patient relatives or significant others to incidents of
absconding
8. To investigate the relationship between rates of absconding, ward atmosphere and
ward design
Overview of study design
A prospective study of absconding from acute admission psychiatric wards,
comparing absconding patients with a non-absconding control group. Absconders
were interviewed about the incident on their return to the ward. Qualified nursing staff
and patient relatives were also interviewed. Individual wards were assessed for
complexity of layout and ward atmosphere.
The research team
This project took place in the East End of London and was conducted by the
research team in the Department of Mental Health Nursing, St Bartholomews School
of Nursing, City University. It was conceived and initially designed by Prof. Len
Bowers. Further contributions to the study design were made by Nicola Clark, who
also contributed to the analysis, and to interviewer training. Manuela Jarrett was the
full time project research assistant and undertook the majority of the data collection
and inputting. Frank Kiyimba conducted the interviews with nursing staff and took the
lead in their analysis, aided by Nicola Clark. Relative/carer telephone interviews were
conducted by Linda MacFarlane. All those mentioned have contributed to the writing
of this report.
Project management and leadership was provided by Professor Len Bowers,
who is solely responsible for all final decisions about the methodology of the study,
the analysis of the data, and the findings presented in this report.
6
Anonymity
Three NHS Trusts, twelve wards across five hospital sites, took part in this
study. Although all are located in the East End of London, they will not be identified
in this report. Individual wards will be represented by numbers and individual Trusts
by code letters. Interview material will be identified only by a code number. Original
interview tapes will be eventually destroyed, so that there will be no way of
identifying respondents thereafter.
When this report is presented to staff in each of the participating Trusts, they
will be provided with an additional key sheet that identifies (a) the code letter of their
Trust (b) the code numbers of wards in their Trust. Whether they wish to make that
information public will then be a matter for them to decide.
Acknowledgements
The research team would like to thank, first and foremost, all those nurses and
patients throughout the East End of London who co-operated with the research and
consented to be interviewed or otherwise provide data. We have tried very hard to stay
true to what you have told us. We hope that if you read this report, you will recognise
within it an accurate description of yourselves.
We would also like to thank the managers and other clinicians within the
participating Trusts, who gave us full access and supported our data collection in
every possible way.
Funding
This research was funded by the GNC Trust, and we would like to thank the
Trustees for supporting research into psychiatric nursing care.
7
Literature Review
Literature search methodology
The initial literature was identified by conducting electronic searches on
CINAHL (1982-97), PSYCLIT (1974-97) and the Cochrane Database of Clinical
Trials (1997 issue 4). Search terms used were "abscond", "escape", "elope", "AWOL",
"runaway" and variants. This resulted in a small core of papers from which further
references on the topic were identified. All identified literature, post 1950, in English,
was included. Only two non-English publications on the topic were identified.
Definitions of absconding
Much of the published work fails to provide an exact definition of an incident
of absconding. Most studies have used officially produced statistics which have been
created using a variety of criteria. Some studies include failure to return from official
leave, whilst others do not. Some include short temporary absences, others only
absences lasting at least 24 hours, and yet others only those absconds that result in a
discharge. Regrettably, some studies fail to distinguish discharge AMA (Against
Medical Advice) from discharge whilst AWOL (Absent With Out Leave). These
differences make comparisons between studies difficult. In addition, reliance on
official statistics sometimes means that only those absences that arouse concern by
nurses and medical staff are counted, as other absences without permission are 'waited
out', or result in the patient being placed on leave. It is possible, therefore, that the
repeated finding that compulsorily detained patients are more likely to abscond may
only reflect the degree of concern and responsibility felt about these patients by
professionals.
Rates of absconding in different settings
It is not easy to construct a meaningful measure of absconding that can be
extracted from the data available in the published studies, even if the definition
problems described above are ignored. The best suggestion is probably that of Molnar
and Pichoff (1993):
N abscondings
x 10
N patients at risk
where N patients at risk equals the total number of inpatients at the beginning of the
study period plus the number of those admitted in the course of the study.
This index has two drawbacks. Firstly, it fails to treat repeat abscondings
differently from single occasions. Therefore a rate of say, 5%, does not mean that 5%
of patients at risk abscond, as a large part of the rate can be made up by one or two
patients who abscond frequently. Secondly, this measure ignores length of stay with
the result that if the data collection period is short, the rate of absconding produced is
artificially low. However this effect is likely to be small, unless the proportion of long
to short stay patients is extreme.
8
Having arrived at a reasonable measure, the information given in the array of
descriptive studies does not always provide sufficient information for its calculation.
Neither is it always clear by what method individual authors have calculated their own
rates of absconding. A few studies have expressed the rate of absconding as a
proportion of discharges, making comparisons yet more difficult. Tables 1 & 2 show
the rates of absconding by the Molnar and Pichoff formula where possible. Where not
possible or uncertain, the rate given by the author has been used without alteration.
Using this formula, and excluding forensic and adolescent psychiatric services,
the mean rate of absconding for general psychiatric services provided by these studies
is 12.6, with a range of 2 to 44. There is no detectable significant trend over time.
The absconder
Tables 1 & 2 also collate the characteristics of absconders identified by the
many comparative studies which have been carried out. Although no absolutely
consistent picture emerges from these studies, it is very evident that absconders are
generally young, single and male, and tend to come from disadvantaged groups within
the wider society. In London UK this means Afro-Carribean patients abscond more, in
Virginia USA it means lower educational attainment correlates with absconding, and
in Canada, unemployment.
Several studies show a link to compulsory detention, but as has been
mentioned above, this may be an artefact of medical staff and nurses translating their
degree of concern about patients into official absconding procedures. However this is
unlikely to explain the correlation of police or court referral with absconding in
several studies, and Joseph & Potter's (1993) report of the extremely high rate of
absconding among those patients diverted from court.
The studies summarised in the tables span 35 years. It is only relatively
recently that diagnosis has become more rigorously defined, and only a few of the
more recent studies use ICD or DSM categories. It is therefore hard to draw an
obvious lesson from the diagnostic information, however all the recent (post 1980)
western studies of adult psychiatric settings show schizophrenia sufferers to be
significantly over represented in groups of absconders.
How and when patients abscond
There is little in the literature about how patients abscond, and only a few
studies have explored this issue in passing. Richmond et al (1991) report that the
majority of abscondings occurred after patients had been given permission to leave the
ward unaccompanied. However they also report that one in five abscondings happened
while patients were restricted to the unit, doors were locked, and staff stationed at the
doors! Except when patients ran through the door when it was temporarily opened for
someone else "staff could not account for how patients were missing from the unit".
The majority of Kernodle's (1966) absconder respondents said they had simply walked
away from open wards, recreational activities. However some explicitly described
exploiting staff lapses of attention. One proudly described how he had talked his ward
physician into giving him a ride away from the hospital. Kleis et al (1991) and Antebi
9
(1967) also showed that half of abscondings took place whilst the patients were away
from the ward temporarily with permission. However Kleis et al (1991) also describe
some of the methods used by patients to leave the ward, including via the air
conditioning fixture, the window, as well as the door. Nussbaum et al (1994) describe
a series of escapes from their forensic psychiatric facility in which patients tied sheets
together and climbed down from windows on the fifth floor. Both Kernodle (1966)
and Molnar et al (1985) identified instances when patients had been assisted to leave
by visitors, who had, for example, provided street clothes to aid in their escape.
Researchers have sought to relate many general factors to absconding These
include time, day, month/season as well as ward conditions such as staffing levels,
experience of staff, whether the ward is locked or open. Perhaps unsurprisingly, there
is much evidence of seasonal variation influencing absconding patterns. Without
exception these studies have found higher rates of absconding during the warmer
seasons (e.g. Bland and Parker, 1974; Molnar et al, 1985; Falkowski et al, 1990). A
number of studies have also explored patterns relating to days of the week, and with
few exceptions have generally found no significant correlations. Swindall and Molnar
(1985) also reported a higher rate of absconding on Saturdays. Times of day have also
been explored for patterns with little success, although Cancro (1968) found that
absconding usually took place in the evenings, and at mealtimes, but were rare during
activities.
Just one study looked at staffing levels and found that the best staffed ward
had the lowest rate of irregular discharges, but this ward also had the most
experienced medical staff. The ward with the least experienced medical staff had the
second highest rate of irregular discharges, forty-three per cent of which were AWOL
(Siegel et al, 1982).
Why patients abscond
Lewis and Kohl (1962) believed from their study of eleven patients who had
absconded from open units over a one and a half year period that there was no single
factor which caused the person to abscond, but rather three or four factors which
interplayed to act as a trigger. They speculated that one of the possible factors in
absconding is that patients may not necessarily be running away from the hospital so
much as running toward a significant family member. Often the family member would
be someone with whom the patient had an ambivalent relationship. Other explanations
for absconding cited in the literature include the tendency of absconders to be
impulsive (e.g. Meyer et al, 1967; Altman et al, 1972a); a greater inclination towards
non-compliance in general (e.g. Altman et al 1972a; Goodrich and Fullerton, 1984;
Chandrasena and Miller, 1988); fashions or fads within the ward community (Weaver
et al 1978); and a propensity to act out under stress (Altman et al 1972a). Cancro
(1968) speculated on the possibility that patients feel threatened by over caring
doctors who ‘are filled with therapeutic zeal’. He claimed support from this theory
based on the finding that particular doctors had higher rates of absconding patients.
There are very few studies which have given patients the opportunity to
express their reasons for absconding. One of the earliest studies into this topic was
carried out by Muller (1962) and included interviews with patients. Classifying their
10
reasons into categories, he found that "treatment failure" accounted for a major factor
in absconding in fifty per cent of cases. This category encompassed the doctor/patient
relationship; issues to do with medication; and problems concerning active
symptomatology. The next most cited category of reasons related to family troubles.
This included lack of visitors, relatives who were unwell and relationship problems. A
small percentage of patients quoted being influenced by other patients as a factor in
their absconding, others had left to obtain alcohol, and few had left to spend recently
acquired money. There was no clear reason found in just eight per cent of cases.
In a rare qualitative study, McIndoe (1986) interviewed five patients in-depth
about their reasons for leaving without consent. A number of themes emerged which
McIndoe referred to as relating to a "sense of meaninglessness". The patients’ reported
that they did not feel that it was necessary for them to be admitted to hospital. They
felt their problems were manageable without this intervention, but their physicians
had disagreed, leaving them with a lack of understanding as to why they should be
hospitalised. Once in hospital, the patients’ felt their treatment plan was useless,
failing to recognise and address their problems and situation. To further compound
this sense of meaninglessness regarding their stay in hospital, they also were unclear
as to what exactly was the role of the nurse.
The issues raised in this study differ from those which emerged from the study
carried out by Falkowski et al (1990) in which three quarters of the absconders agreed
to be interviewed about the reasons they left. Nineteen per cent of the patients in this
study referred to being disturbed by other patients as a reason for leaving the ward. A
further seventeen per cent described the stigma of being in a psychiatric hospital as a
major factor influencing their decision to go AWOL. Other reasons reported were:
disliking the staff (13%); disliking the food (11%); disliking the ward (8%); lack of
privacy (7%); and responding to hallucinations (5%). Interestingly, this study revealed
that in over half of the cases there were no changes made in the management of care
of the patient on their return to the ward.
Evaluative studies
Table 3 summarises the few evaluative studies of interventions impacting
upon the rate of absconding. These studies are generally methodologically weak and
badly described. There is little that can be concluded from them with great confidence.
Two studies (Cancro 1968, Molnar et al 1985) have examined the impact of
decreasing security by the unlocking of ward doors, and both of these have found that
the rate of absconding increased as a result of these measures. It is therefore possible
(although untested as yet) that locking wards may significantly reduce absconding,
although this is likely to be unpalatable to many, and may have negative consequences
in other areas.
Battle & Zweier (1973) and Maratos & Kennedy (1974) both sought to
evaluate the impact of the introduction of groups to the ward situation. The study
designs do not inspire confidence, as Battle et al had only a very small sample, and the
Maratos et al study was unfortunately confounded by the researcher moving from one
11
ward to the other at nearly the same time as the conditions crossed over. For what it is
worth, both these studies managed to demonstrate decreases in the rate of absconding.
Richmond et al (1991) devised a battery of measures to reduce absconding,
implementing these on one ward while reserving others as controls. This design
appears to have lacked randomisation, and the data provided is scant and hard to
interpret. Nevertheless a demonstrable effect was shown, although it is impossible to
know which of the elements of the combined intervention were significant.
Finally, Gudeman et al (1985), in their study evaluating a set of changes made
to admission wards towards less restrictive care, found a significant decrease in
absconding. Although this final study was uncontrolled, the trial period was lengthy,
which would appear to rule out short term experimental effect as a cause of the
improvement.
In short, there are no thoroughly convincing, well designed, rigorously carried
out trials of interventions to reduce absconding. However, on currently available
evidence it does seem likely that open wards are likely to have more absconds than
those that are locked, that group activities giving patients a voice on the ward may
decrease absconding, as may any one of a range of measures like: partial
hospitalisation, regular checking by nurses, use of a sign-out book, patient
involvement in treatment planning, contracting with patients about off-unit privileges,
and early discharges for patients who clearly intend to leave.
Discussion
The potentially serious outcomes of absconding indicate that further research
is a priority. The findings reviewed above do not lead to sufficiently firm conclusions
upon which to base inpatient care. Future research in this area should be more
rigorous in its design, use a clear definition of an incident of absconding, and provide
sufficient data for the Molnar and Pinchof formula to be calculated. Such research
needs to address several related issues.
It would seem likely that the rate of officially notified absconds may be
substantially lower than the true rate. When the risk is judged to be low, quite often
the psychiatric team will wait to see if the patient returns, or phone them at home to
ask them to return, before invoking the official abscond procedure. Identification of
the true rate of absconding and its relationship to the official rate would enable us to
discover whether officially notified absconds really are more likely to result in
negative outcomes than those which are not. It might well be, for instance, that the
repeated finding that compulsorily detained patients abscond more frequently is only
an artefact of the fact that these are the patients whose absconds are most likely to
result in official procedures. Also, using a wider definition of absconding that includes
failure to return from leave, would help to find out whether these patients shared the
same characteristics, or were equally at risk as those who departed from the ward.
Although some studies have attempted to solicit the patient's point of view on
absconding, these have either used extremely small samples (McIndoe 1986) or have
analysed responses into pre set categories (Falkowski et al 1990). Advances in
12
understanding the motivation of patients who abscond may help us to devise strategies
to reduce the associated risks, as may more detailed information on exactly what
methods they use to leave the ward. In addition, no study has yet reported on the
impact of absconding upon staff and the organisation of the psychiatric hospital, nor
upon patients' relatives and their trust in the professionals.
The statistical methods used in the published studies are basic and can be
improved upon. A more certain profile of the absconder could be developed allowing
better prediction, by using more sophisticated statistical techniques that address not
just single variables, but also interactive effects. Greater research focus upon patients
whose absconding is at a high risk of negative outcome may enable more specific and
useful profiling.
Lastly, interventions to reduce absconding need to be devised and tested in
rigorous clinical trials, using control groups, blinding, and randomisation if possible.
Only then will we have nursing strategies to reduce absconding risk in which we can
have confidence.
13
Table 1 Descriptive studies - U.K.
Study
Type of Service
Antebi (1967)
One
1000
bed
Psychiatric Hospital
(All Saints)
Falkowski et
al. (1990)
One 670 bed Psychiatric
Hospital
(Springlield
Hosp.,
London)
One Psychiatric Hospital
Joseph &
Potter (1993)
Milner, G.
(1966)
Muller (1962)
District General Hospital
Psychiatric Unit of 220
beds
(Oldham DGH)
1000 bed psychiatric
hospital
(Powick Hospital)
Neilson et al
(1996)
Acute psychiatric wards
in Sheffield
Tomison
(1989)
316
bed
psychiatric
hospital
(Barrow Hospital, Bristol)
Type of
Study
Abscond
definition
Absconder
Characteristics
Diagnoses
Abscond
Rate*
Prospective
identification
of
absconders followed by analysis of
case notes. Compared to total
Hospital population.
Interviews of 100 absconded
patients
Leaving the Hospital
grounds
without
permission, or failing to
return from leave.
Absent
without
permission and cause
for serious concern
Young,
Male,
Criminal
record
(No significance tests)
Psychopathic personality
(No significance tests)
2.8 (?)
Male, older, Compulsorily
detained,
Afro-Caribbean
background
Schizophrenia
most
frequent
(No significance tests)
Not reported
Admissions arising from a Court
Diversion scheme
Prospective
comparison
of
absconders over 18 months with a
control group
Not defined
Prospective
analysis
of
all
absconders over 9 month period
with interviews of the absconders
and staff, compared to total
hospital population
Retrospective case note analysis
of a random sample of 246
admissions
Prospective contingency table
analysis of absconders over one
year compared to sex matched
control
group,
and
to
all
admissions that year
Official reports, leaving
the grounds without
permission
46
Not defined
History of absconding, Poor
work
record,
Frequent
suicidal attempts, Antisocial
behaviour
Compulsorily detained
Absence of a patient
sufficient
to
cause
concern on the part of
trained nursing staff
Male, Young, admitted via
police
or
courts,
compulsorily detained
14
7
Schizophrenia, Paranoid
psychosis, Psychopathic
personality
(no significance tests)
Not provided
* See text for method of calculation, except where otherwise stated
No significant findings
34.5
Schizophrenia
or
Personality Disorder (in
females)
8.7
Table 2 Descriptive studies - other countries
Study
CounType of Service
try
Altman et al
(1972a)
U.S.
Altman et al
(1972b)
U.S.
Atkinson
(1971)
U.S.
Bland &
Parker (1974)
Cancro.
(1968)
Chandrasena
(1987)
5 State Mental Hospitals, 3
Community Mental Health
Centres, 2 Schools for the
Mentally Handicapped
(Missouri)
5 State Mental Hospitals,
acute
treatment
centres
excluded
(Missouri)
4, 24 bed open psychiatric
wards
(Neurpsychiatric
Institute,
UCLA)
Canada
One 700-1000 bed Psychiatric
Hospital
(Alberta Hospital)
U.S.
One 100-200 bed Psychiatric
Hospital
(Menninger Memorial Hospital)
145 bed Psychiatric Hospital
(Royal Ottawa Hospital)
Canada
Coleman
(1966)
U.S.
One Veterans Adminstrations
Hospital
(Salem, Va.)
Cooke &
Thorwarth
(1978)
U.S.
Regional Forensic Psychiatric
Centre
(Norristown State Hospital)
John et al
(1980)
India
One 805 bed Psychiatric
Hospital
(NIMHANS, Bangalore)
Type of
Study
Abscond
definition
Retrospective
contingency
table analysis. Some analyses
statistically invalid
Official
returns
of
absence
without
permission
Retrospective
discriminant
analysis of two sets of
Hospital statistical returns
Absconder
Characteristics
Diagnoses
Abscond
Rate*
Male, Caucasian, Single
Acute brain syndrome,
Personality Disorder.
3.6
Official
returns
of
absence
without
permission
Single, Catholic, Male,
Student, Court referral
Personality disorder
sexual deviation
4.4
Retrospective
contingency
table analysis of hospital
records over six years of
absconders
vs.
AMA
discharge
vs.
regular
discharge
Retrospective analysis of case
notes of absconders for two
separate one year periods
Official
discharge
classification
(i.e.
absconders
who
returned not included?)
Young, Female aged 5160 years
Personality disorder
Not defined
Young,
Male,
Compulsorily detained
(No significance tests)
Personality
disorder,
Alcohol and drug abusers,
Adolescent
adjustment
reaction
(No significance tests)
Unclear. Four years data in
all, spanning 1957-66
Not defined
Young, Male
(No significance tests)
Retrospective
contingency
table analysis of the case
notes of AMA vs. AWOL vs.
Regular discharges
Retrospective
contingency
table analysis of case records,
absconders
compared
to
control group (matched?)
Retrospective analysis of case
notes of absconders vs
randomly selected control
group
Retrospective
contingency
table analysis of case notes of
absconders over one year vs
all Hospital admissions
Only those discharged
while absent without
leave
No
fixed
abode,
unemployed, Single
Official reports
Previous
absconds,
rejected
by
family,
Catholic, Caucasian
Not defined
Missing from the ward
without permission for
more than 24 hours
15
3.5
(of
discharges)
13.1
20.4-28.4 (?)
Schizophrenia Dysthymia
2.9
(of
discharges)
2
Agitated,
paranoid,
symptoms
Young, Male,
or
anxious,
psychotic
Mania, Schizophrenia
15
3.3
Kashubeck et
al (1994)
U. S.
Residential treatment centre
for adolescents
Kernodle
(1966)
US
One 2500 bed State Mental
Hospital
(Eastern
State
Hospital,
Virgnia)
Kleis et al
(1991)
U.S.
Acute care, 170 bed, private
psychiatric hospital (More than
30% of patients adolescent)
Levy (1972).
U.S.
Lewis & Kohl
(1962)
U.S.
Residential 10 bed treatment
centre for adolescent girls
Two open psychiatric wards in
a large General Hospital
(Payne Whitney Psychiatric
Clinic, The New York Hospital)
Description of absconders
over nine year period
Analysis of records, plus
interviews with absconding
patients, their relatives, and
members of the treatment
team. 11 cases in total.
Meyer et al
(1967)
U.S.
25 bed open psychiatric unit in
a University Hospital
Miller et al
(1983)
U.S.
Molnar et al
(1985)
U.S.
Two general psychiatric wards
and one alcohol and drug
abuse treatment unit, in a rural
community
mental
health
facility
80 bed psychiatric ward in a
county general hospital
Prospective analysis of case
notes
&
interview
of
therapists, over two years,
compared to a control group
matched for age, sex and race
Retrospective
discriminant
analysis of case note data,
100 AWOL vs 100 non AWOL
discharges
Prospective comparison of
absconders over one year with
a control group
Molnar et al
(1993)
U.S.
Any
unauthorised
departure of a patient
from
the
hospital
grounds
Official incident reports
500 bed urban state hospital
(Buffalo Psychiatric Centre)
Retrospective analysis of case
notes of absconders over five
years compared to control
group matched for age, sex,
and race over same period.
Case note analysis and 160
interviews
of
absconding
patients, over one year,
compared to total hospital
population
Retrospective analysis of case
notes
Retrospective
case
note
analysis of absconders over a
one year period
Not defined
Not defined
History of absconding,
suspected
history
of
sexual abuse, parents
whose rights had been
terminated
Young, Male, Divorced or
Separated,
Lower
Educational Achievement
(no significance tests)
Leaving the Hospital
grounds
without
permission, or failing to
return from leave.
Not defined
Young, Male.
(no significance tests)
Not defined
Previous absconds, poor
impulse control, history of
poor
motivation,
compulsorily
detained,
pressure from relatives to
leave, psychotherapeutic
stress,
mistakes
in
medical judgement
Affective disorder
Personality disorder
(no significance tests)
Affective disorder, Alcohol
or Drug use
(no significance tests)
Not reported
4.2
1.8
(of
discharges)
38
Paranoid ideation
Not recorded
Any
unauthorised
absence necessitating
staff intervention
Psychotic disorder
44
Those discharged while
absconded
Depression,
use
16
Young,
detained
compulsorily
Young, Male, Involuntary
criminal legal status
(no significance tests)
Schizophrenia
Substance
Not recorded
5.5
32
Morrow
(1969)
U.S.
280 bed maximum security
building in the grounds of a
state hospital
(Fulton
[Missouri]
State
Hospital)
One 805 bed Psychiatric
Hospital
(NIMHANS, Bangalore)
Psychiatry department of a
Medical College
(K.G.'s, Lucknow)
Mubarak et al
(1989)
India
Narottam et al
(1977)
India
Nicholson et
al (1991)
U.S.
Nussbaum et
al (1994)
Canada
Medium Secure Forensic Unit
(METFORS, Toronto)
Richmond et
al (1991)
U.S.
Sommer
(1974)
U.S.
Two 30 bed acute admission
wards and one 30 bed
psychogeriatric ward
(VA Medical Centre, Memphis)
State Mental Hospital
(Bronx State Hospital)
State forensic unit
(Oklahoma)
Retrospective
contingency
table analysis of records of
absconders compared to a
control group matched for type
of admission and age
Comparison of all absconders
in 1977 with all in 1987
Escapes,
no
clear
definition provided
Unemployed, History of
alcoholism,
Oldest
children,
Young,
Transfers from prison
Official reports - escape
register
Young,
Male,
admission
Retrospective
contingency
table analysis of case notes of
absconders over one year
compared to all regular
discharges
Retrospective analysis of all
records of 'Insanity Acquitees'
over six years, absconders
compared
to
regular
discharges
Retrospective
contingency
table analysis of case notes of
absconders over 15 years,
compared to all other patients
Prospective
analysis
of
absconders over one month
Missing from the ward
without permission for
more than 24 hours or
not returned from leave
Young, Male, Single,
literate, moderately well
off, urban dweller (if male,
opposite if female)
Acute schizophrenia
Not provided
Previous hospitalisations,
Prior Arrests, Fewer years
of education
No significant findings
Contingency table analysis of
absconders in one month
compared to two control
groups: regular discharges
and patients granted home
leave
First
Not provided
Mania, Organic psychosis
Antisocial
Disorder
Personality
Not provided
Previous absconds
(no significance tests)
Schizophrenia
(no significance tests)
Leaving
the
ward
without
consent
official definition
Young, Puerto Rican,
Previous
absconds,
Previous home leave with
consent
Psychosis,
schizophrenia
* See text for method of calculation, except where otherwise stated
17
paranoid
3.3(1977)
2.6(1987)
11.6
(of
discharges)
8.2
< 0.002
9.3
2-3 (?)
Table 3 Evaluative studies
Study
Design
Sample
Intervention
Outcome
Prospective
timesample, ABA, 10 weeks
for each phase
Natural
experiment,
before and after, no
control
Before and after, no
control
Non random sample of 8 men who
had absconded at least three times
since admission
All patients in one 100-200 bed US
psychiatric hospital
Twice weekly group psychotherapy (client centred)
50% lower rate of absconding during treatment
periods (p < 0.05 by chi square)
Absconding rate (as % of admissions) increased
from 20.4 to 28.4, i.e. by 39%.
Maratos
&
Kennedy (1974)
Crossover trial
Two acute admission wards over 22
weeks, crossover at end of week 9.
Before = closed hospital with elaborate and
intensive searches for missing patients. After =
open hospital (no further detail given).
Before = 2 standard wards to which patients were
admitted, with a 25 bed day hospital programme.
After = all patients admitted to day hospitals (100
places) with an Inn (if required) and an Intensive
Care Unit
Weekly, hour long, community meetings
Molnar
(1985)
Before and after,
control
Battle & Zweier
(1973)
Cancro (1968)
Gudeman et al
(1985)
et
al
Richmond et al
(1991)
Before
and
controlled trial
All patients admitted to a 70 bed
mental health centre attached to a
teaching hospital over 38 months
no
All patients on one 80 bed psychiatric
ward over two years
after
All patients on three wards. After one
month, one ward introduced the
intervention with the other two serving
as controls for 7 months. No
information on how experimental ward
chosen.
Before (year one) = doors frequently and on one
zone always, locked. After (year two) = doors
unlocked except for temporary high risk situations.
Identification those at risk of absconding with hourly
checks by nurses with written records. Use of a
sign-out book for those with off-unit privileges.
Increased patient involvement in treatment
planning. Formal contracting over off-unit privileges.
Early discharges with intensive follow up.
18
Numbers of absconds decreased by 54% (p <
0.001 by t test)
Number of abscondings decreased by more than
50% under the experimental condition (possibly
results confounded by the experimenter working on
both wards during the experimental condition)
Absconding rate increased from 2.5% of all
admissions to 7% of all admissions
50% reduction in absconding from the experimental
ward.
(No statistical tests given)
Methodology
Sample
The study took place in three NHS Trusts in the East End of London. Twelve
wards were studied, eleven were mixed gender, sectorised acute admission wards with
bed numbers ranging from 15 to 25. The twelfth was a combined female only acute
care ward and mother and baby unit. The wards were situated in five hospitals at
different sites throughout the East End of London.
All absconders from these wards between 5th January 1998 and 28th May
1998 were identified by the researcher (MJ) and included in the study.
A control group was identified by selecting, for each absconder, the patient on
the same ward who followed them in alphabetical order by surname. A small number
of these became eventually absconded themselves, in which case they became part of
the absconding sample and were deleted from the control group.
A sample of relatives or significant others was assembled by asking
absconding patients for permission to approach somebody close to them.
A convenience sample of qualified nursing staff were interviewed, stratified by
ward. A minimum of two staff per ward were interviewed. The sample of staff was
opportunistic, in that the researcher (FK) visited each ward on a regular basis, seeking
a time when the ward was quiet enough for a staff member to be released for
interview, and seeking consenting volunteers from those staff on duty at the time.
Definition of absconding incident
For the purposes of this study, an incident of absconding was defined as the
absence of a patient from the ward, without permission, for more than one hour. All
absconding patients were included in this study, regardless of whether they went on to
become officially reported, placed on leave, discharged, or otherwise processed.
Preparation for the study
Prior to commencement of the study managerial support and permission were
obtained from Directors of Nursing, Nurse Advisors, and and those with operational
management responsibility for the wards. Following appointment of the lead Research
Assistant on this project (MJ) further meetings took place with these same managers,
and subsequently with the ward managers and other ward staff in the different
hospitals.
Police liaison officers were also visited by the Research Assistant (MJ) and
informed about the study.
19
Training in conducting research and telephone interviews was provided by a
Senior Research Assistant (NC), who also reviewed and gave feedback on pilot
interviews and interviews conducted early in the study.
Data collection
Quantitative data on absconders and the control group
Using the literature previously reviewed, plus discussion and thinking around
the topic, the research team (LB, MJ, NC) identified those characteristics of patients
which might be relevant to absconding, and additional data about absconding
incidents that it would be useful to collect and explore. This list was then refined into
a smaller number of variables that were both of interest and feasible to collect.
A data collection instrument was designed for use by ward staff to identify
incidents of absconding, and what nursing actions were taken when (see appendix 1).
The same form was used by ward staff to note when and how the patient returned to
the ward. Staff were encouraged to ring the absconding hotline to notify the researcher
(MJ) of a new incident of absconding. The researcher also made visits to the wards,
initially three time per week, getting to know the staff, asking about absconds,
checking official reports and bed states, and instructing on how to complete forms
correctly.
Compliance with the submission of data was fair. Inner London psychiatric
wards are known to be under extreme pressure, with high morbidity, bed occupancy,
levels of patient violence, and difficulties with recruitment and retention of nursing
staff (Johnson et al 1997, Gournay et al 1997). With this in mind, the burden placed
upon nursing staff to submit data was kept as small as possible. On some wards there
was some initial suspicion about the motivation of the researchers, however this
evaporated as the study continued, aided by the fact that the researcher doing the data
collection (MJ) was herself a psychiatric nurse. Continued compliance with the study
over the data collection period was assisted by feedback of the interim report to ward
managers.
Once an abscond was identified, the researcher would collect information
about the patient and the identified non-absconding control (see appendix 2). This was
composed of 32 variables:
Ward
Consultant
Keyworker (ward nurse)
Community keyworker discipline (Community Psychiatric Nurse, Social Worker, etc.)
Current Mental Health Act status (if detained and under which section of the act)
Mental Health Act status on admission to hospital
Date of admission
Age
Gender
Marital status
Ethnic origin
Religion
20
Sibling order (order of birth in family of origin)
Accommodation (e.g. public housing, private housing, etc.)
Living group (who the patient lives with, e.g. spouse, parents, etc.)
Occupation (full time, part time, unemployed etc.)
Duration since last employment
Highest level of educational achievement
Source of referral
Diagnosis (casenote diagnosis by ICD 10 categories)
Current medication
Risk as identified in care plan (e.g harm to self or others, etc.)
Number of ward transfers of patient in previous week
Number of official ward incident reports for patient in previous week
Number of medication refusals by patient in previous two days
Whether patient absconded on a previous admission
Previous contact with the police
Previous contact with forensic psychiatry or the courts
Previous admissions to psychiatric hospital
History of suicide attempts
History of self mutilation
Whether patient expressed intention to leave the ward in 24 hours prior to abscond
A further 9 items of additional information about the absconding incident were also
collected:
Date and time of abscond and return
Location of incident (where the patient absconded from)
Security status of the ward at time of abscond (whether locked, etc.)
Level of observation of the absconding patient
Number of other patients on high level observations at time of abscond
Whether patient was confined to the ward at time of abscond
Risk outcome (whether any harm came to the patient or anyone else during the incident)
Staff on duty at the time of abscond (by grade and agency/non agency)
Changes in care following the abscond
Most of the above items were obtained by scrutinising ward records, medical notes
and nursing notes. Where gaps existed, nursing staff on duty were asked verbally for
information about the patient, or the ward situation at the time of the abscond.
Interviews of absconders
Using the literature previously reviewed, plus discussion and thinking around
the topic, the research team (LB, MJ, NC) identified suitable questions for inclusion in
an interview schedule for patients who had absconded. This was then piloted and
modified as appropriate. The final schedule may be found in appendix 3.
These interviews were conducted on the ward following the patients return.
Ward staff were asked to indicate whether patients were well enough to consent to be
interviewed. Interviews were taped and fully transcribed.
21
Interviews of nursing staff
Using the literature previously reviewed, plus discussion and thinking around
the topic, the research team (LB, MJ, NC) identified suitable questions for inclusion in
an interview schedule for nursing staff around the topic of absconding. Interviews
were semi-structured, and focused on the procedure taken when patients abscond, how
staff feel about absconding, risk assessment and observation policies on the ward,
team management of absconding. Interviews were designed to last 30 minutes. The
interview schedule was then piloted on two wards and modified as appropriate. The
final version may be found in appendix 4.
These interviews were conducted on the wards during April, May and June
1998. Interviews were taped and fully transcribed.
Interviews of relatives / significant others
The research team (LB, MJ, NC, LM) developed an interview schedule
suitable for conducting by telephone with the relative or a significant other of patients
who had absconded. Patients were asked, after having been interviewed themselves,
whether they would give permission for an appropriate person to be approached for a
telephone interview. If they did so consent, the person was contacted by phone and
asked for their consent for the telephone interview to take place. These interviews
were conducted between April and August 1998 by a member of the team (LM). The
final schedule may be found in appendix 5.
Ward data
Information on admission and bed occupancy rates for the study period were
provided by managers and IT departments in the three NHS Trusts.
Two of the research team (LB and MJ) composed a simple measure of ward
observability. These rating were made in conjunction with the ward managers during
early 1998. A copy of this scale can be found in appendix 6.
During April - July 1998, a minimum of five nursing staff from each ward
included in the study completed the staff version of the Ward Atmosphere Scale
(Moos 1974).
Data analysis
Quantitative data was entered on to SPSS for computerised statistical analysis.
All interviews were taped and fully transcribed using the system detailed in
appendix 8. They were then imported into QSR NUD.IST, a qualitative data analysis
computer package, for coding and analysis. The vast majority of coding for patient
22
interviews was determined in advance. Further codes were developed and discussed in
the research team during analysis, before they were introduced and used.
The coding system for the staff interviews was developed by the researcher
who carried them out (FK), after discussion with the team.
Ethical approval
Ethical approval for the study was obtained from the ELCHA research ethics
committee on 4th August 1997, reference P/97/180.
No patient was approached for interview unless the ward staff confirmed that
they were well enough to take part. Signed consent was sought from patients and
others prior to interview by the researcher. Full information about the study was given
to respondents at the time of consent. Notices about the study were put up in the wards
so that patients and staff would be aware in advance that they may be asked for
interviews.
23
Overview of Data and Analytic Methods
Quantitative data on absconders
The final sample consisted of 175 absconding patients and 159 controls. There
were 498 absconding events generated by these 175 patients. The mean number of
absconding events per patient was 2.9 and the median 1. The distribution was skewed
and is presented in the chart below:
Number of absconds per patient
100
80
60
No. of patients
40
20
0
1
2
3
4
5
6
7
8
9
10 11 13 16 26 34 40
No. of absconds
Data collected on these patients can be explored using two different varieties
of comparisons with the control group. The patient based approach enters each
absconding patient only once into the analysis, regardless of the number of times they
have absconded. This method is probably most useful to illuminate the reasons why
patients abscond. The event based approach enters all absconding episodes into the
analysis, and disregards the fact that some events are generated by the same patients.
The strength of this approach is that it can help determine the risk factors for
absconding in a population of psychiatric patients. Both approaches have been used in
this study.
Variables collected on absconders and their controls were of different types.
Some were nominal (e.g. diagnosis), and some interval (e.g. absconding rates). A
variety of statistical approaches to exploring the data have thus been used. Chi square
tests have been used to assess differences between absconders and their controls, and
the z test of equality between the proportions (Cohen 1988) to assess variations
between wards and hospitals. Pearson correlations have been used to further explore
the relationship between rates of absconding and other variables. SPSS was used for
the majority of the statistical work, but for the z tests a reusable spreadsheet
calculation was devised.
24
Ethnic categories used in this study
Any set of ethnic minority groupings or categories are, to varying degrees,
artificial. Those chosen for this study are no different, with some groupings spanning
a wide range of cultural diversity (e.g. African) and others being determined by a
narrow definition by national origin (e.g. Bangladeshi). The categories chosen for this
study were selected with a view to assembling adequate numbers in each set so that
some more generalised statements could be made, and were based on local knowledge
of the population in the East End of London. Even so, some groups whom the research
team initially hoped to discover more about (e.g. Turkish) were hardly represented in
the wider study at all.
In this study ethnic tags were taken from medical and nursing case notes. The
adequacy of this procedure is open to question, as it is unclear how these judgements
were made in the first place and whether they would be representative of self
definitions of ethnicity by the patients concerned. Nevertheless staff in the East End of
London are well aware of ethnic issues, many are themselves from various minority
communities, and it is general policy to seek the patients own definition of their ethnic
background. In the light of this, it was considered that case note definitions would be
good enough for the purposes of this study.
No solution to these problems is satisfactory. Each study has to make its own
compromises about definitions in order to proceed. The choices made during this
study are presented here so that the interpretations and conclusions reached can be
accurately assessed by the reader.
Interviews of absconders
Fifty two people (which constituted 29% of the total number of absconders in
the study) were interviewed a total of sixty two times (some were interviewed more
than once following repeat absconds). Interviews were conducted when the patient
returned to the ward, if they gave consent, and if there were no language barriers.
Their ages ranged from nineteen to sixty three years old, with most being thirty
five years old or under. There were forty one men and eleven women. Almost two
thirds had a diagnosis of schizophrenia and half of the sample were admitted
involuntarily but by the time of the absconding incident a further seven were being
detained under the Mental Health Act.
Trust
E
O
S
total
awol patients
(%)
80 (46)
59 (33.9)
35 (20.1)
174 (100)
awol
episodes (%)
213 (42.8)
202 (40.6)
83 (16.7)
498 (100)
25
pts interviewed
(%)
21 (40)
23 (45)
8 (15)
52 (100)
ward
1
2
3
4
5
6
7
8
9
10
11
12
totals
pts awol
(%)
12 (6.9)
12 (6.9)
14 (8.0)
17 (9.8)
13 (7.5)
12(6.9)
8 (4.6)
17 (9.8)
18 (10.3)
4 (2.3)
23 (13.2)
24 (13.8)
174 (100)
Gender
MHA status
Diagnosis
Age
Ethnicity
episodes
(%)
30 (6.0)
50 (10.0)
23 (4.6)
36 (7.2)
80 (16.1)
69 (13.9)
13 (2.6)
25 (5.0)
47 (9.4)
6 (1.2)
45 (9.0)
74 (14.9)
498 (100)
Patients interviewed
Number
Male
41
Female
11
pts interviewed
(%)
3 (5.8)
5 (9.6)
5 (9.6)
2 (3.8)
4 (7.7)
4 (7.7)
1 (1.9)
7 (13.5)
6 (11.5)
3 (5.8)
6 (11.5)
6 (11.5)
52 (100)
% of total
78.8
21.2
Involuntary
Informal
33
19
63.5
36.5
Schiz.
Other
32
20
57.7
42.3
35 & under
36 & over
30
22
57.7
42.3
Patients interviewed
Number
afro-carrib.
12
bangladeshi
5
other african
5
somali
3
other asian
1
white eur.
25
other)
1
% of total
23
9.6
9.6
5.7
1.9
48.1
1.9
The interview sample is representative of absconders by Trust, ward, age,
diagnosis and Mental Health Act status. The sample of men is on the whole
representative of the men in the total absconding study in all respects. However, the
sample of women being only 11 forms just 16% of the total number of women in the
study. This in turn affected the ethnic representation of the female interviewees in that
women from Bangladeshi backgrounds were not represented at all, while all other
groups were under represented. The reasons for this were twofold (a) less women than
men absconded (36 compared to 64%) and (b) there were different outcomes or
consequences for women who absconded compared to men. Women were far more
26
likely to be placed on leave or discharged while absent, whereas men were much more
likely to be required to return to hospital.
Much of the data presented in this study is based upon 62 interviews of 52
absconders. Although this is a large number for any qualitative interview survey, and
does well represent the views of absconders, the numbers from some ethnic minority
groups are small. Numbers from all ethnic groups except white european and afro
caribbean were very small. Therefore any general conclusions reached from the
interview data of this study about the smaller groups of ethnic minority absconders
must be considered to be highly tentative, even bordering on the speculative.
Nevertheless, the data does raise interesting and important questions which will be
presented here.
All interviews were transcribed in full and analysed using the software
package QSR NUD*IST. Codes for the content analysis of this material were devised
in advance in conjunction with the design of the interview schedule. These codes were
of two kinds, factual and referential (Seidel & Kelle 1995). The factual codes used
denoted NHS Trust, gender, age group, diagnosis, Mental Health Act status and
ethnicity. The referential codes were linked to specific interview questions and
covered various topics such as how the patient left, the reason they gave for leaving,
where they went, what they did, their thoughts about ward life and psychiatric
professionals, etc. A small number of additional referential codes were introduced
during the data analysis, following discussion with the full research team. The
majority of coding was completed by the project research assistant. Checks for
accuracy and comprehensiveness of the coding were made by the project leader. Some
additional coding based on searches for key words was also conducted.
Analysis of the data then proceeded mainly by intersecting the referential and
factual codes and examining the data so generated. For example, reasons for leaving
were intersected with Mental Health Act status to explore the different reasons for
leaving given by those who were compulsorily detained on the ward, versus those who
were informal patients. This approach enabled the summary of large amounts of data
by the use of matrix analysis (Miles and Huberman 1994) and resulted in the tables
presented in subsequent chapters of this report. The matrices produced were examined
jointly by the research team for interpretation. In turn this lead to the identification of
areas of further interest, where more detailed content analysis was undertaken by
examining the transcripts in more detail.
Occasional chi square tests were used to test the significance of quantified
qualitative data (Kelle 1995).
Staff interviews
Twenty four interviews with staff members from the twelve wards in the study
were conducted between April and June 1998. These were tape recorded and
transcribed by secretarial staff. Each tape was then listened to again by a member of
the research team who corrected any errors in the transcript. Documents were then
imported into QSR NUD*IST for analysis.
27
Factual codes were determined in advance, referential coding was devised
using simple content analysis following scrutiny of the transcripts. Matrix analyses
were examined by the research team for interpretation and further analysis.
Relative/carer interviews
Patients who had absconded from the ward were approached to request their
consent to interview one of their relatives/carers. The conditions and aim of the
interview were explained both verbally and on the consent form. The conditions being
that the interview would take place over the phone, would last fifteen minutes to half
an hour, and the information would be treated confidentially. In addition, no
information revealed by the patient in their interview would be passed on. This was
doubly ensured by the fact that the two different researchers were involved in
interviewing patients and relatives respectively. It was explained that the purpose of
the interview was to ascertain the relatives views about the ward, the care that the
patient was receiving, and in what way, if any, had the absconding incident impacted
on the relatives’ perception of the staff and treatment afforded to the patient.
The recruiting of relatives began in mid April. However, the task emerged to
be much more difficult than initially anticipated. The reason for this was a) some
patients simply did not have relatives/carers around or were not in contact with them
b) some said their relatives had no idea they were presently in a psychiatric ward and
they did not want them to find out c) some did not wish their carers to be contacted
since they felt their relatives already had too much to worry about d) and some refused
on the grounds that they felt sure that the relatives would refuse.
Once consent was obtained, a different researcher (LM) for them to contact the
relative or carer and see if they would agreed to be interviewed. Nine clients gave the
name and telephone number of a relative they were happy for us to interview. Of those
no contact was made with 2, due to wrong phone numbers and a phone number no
longer in service being given by the clients. A number of attempts were made to elicit
other contact numbers but to no avail. None of those who were actually contacted
refused, although one person consented but was unavailable for interview during the
data collection period. At the end of this process, six carers were interviewed between
April and September 1998. Notes were taken of the responses during these phone calls
and the small amount of material produced dealt with via simple content analysis.
CLIENT
RELATIVE/CARER
GENDER
5 male
1 female
3 male
3 female
RELATIONSHIP
2 brother /1 father
1 sister, 1 mother, 1 partner
28
Sequence of analysis
Transcription of patient interviews began with the commencement of data
collection and continued until some weeks after data collection had finished. Coding
of that data followed at the same pace and to the same schedule. Informal results and
feedback were therefore provided to the team quickly and continuously. Similarly, the
quantitative data were inputted onto SPSS immediately and some interim charts and
tables were explored three months into the data collection period.
Following the close of data collection, the quantitative data was the first to be
thoroughly analysed. The results of that analysis shaped the preliminary questions that
were addressed in the qualitative analysis of patient interviews. Some themes elicited
from the qualitative results have lead to further quantitative analyses. Analyses of the
nurse interviews and patient/carer interviews took place last and was informed by
previous results.
A triangulation (Denzin 1977) strategy has thus been followed. The different
data sets from the different strategies have informed the analysis and interpretation of
each other. This strategy works well with an exploratory study such as this.
29
Findings 1:
Absconding events and consequences
Leaving the ward
At the time of the absconding event, 35% of absconders were confined to the
ward, and were more likely to be confined to the ward, even at time of first
absconding, than were the controls. 15% had a risk of absconding noted in the care
plan (as opposed to 4% of the controls who did not abscond), and 15% were on
regular intermittent nursing observations. In short, a significant but apparently small
proportion of patients who abscond are recognised as an absconding risk, and nursing
action is taken to prevent absconding, but is not always successful.
58% of absconders expressed to staff their intention of leaving the ward within
the 24 hours preceding the abscond. Again this underscores the fact that even when
the absconding risk is known, effective nursing action is not always taken. This could
be due to a range of factors, and is not necessarily an indication of the inefficacy or
inefficiency of nurses.
On 1% of absconding incidents the ward door is locked when the patient
absconds, and for a further 11% of incidents a nurse is stationed at the door to oversee
people leaving and entering. For the remaining 88% of occasions the ward is open at
the time of absconding.
In contrast to the previous literature which reports that about half of
absconders leave whilst temporarily off the ward with permission, in this study 82%
of absconders left directly from the ward, 14% whilst temporarily off the ward, and
3% failed to return from leave. This indicates that any effort directed towards the
reduction of absconding does not need to focus primarily upon the granting of leave or
permission to leave the ward.
Staff issues
There is no association between the individual inpatient keyworkers and absconding,
nor any association with the professional discipline of the patients' community
keyworkers.
Simple contingency table analysis of numbers of controls vs. absconders by consultant
shows that some consultants do have significantly greater numbers of absconders than
others. At first sight, consultants 2, 7, 8 and 10 appear to have high levels of absconds.
30
Consultant * Control vs absconds Crosstabulation
Consultant
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Total
Count
% within
Consultant
Count
% within
Consultant
Count
% within
Consultant
Count
% within
Consultant
Count
% within
Consultant
Count
% within
Consultant
Count
% within
Consultant
Count
% within
Consultant
Count
% within
Consultant
Count
% within
Consultant
Count
% within
Consultant
Count
% within
Consultant
Count
% within
Consultant
Count
% within
Consultant
Count
% within
Consultant
Count
% within
Consultant
Count
% within
Consultant
Count
% within
Consultant
Count
% within
Consultant
Count
% within
Consultant
Count
% within
Consultant
Control vs absconds
Absconder
Control
9
7
Total
16
56.3%
43.8%
41
7
100.0%
48
85.4%
14.6%
100.0%
24
8
32
75.0%
25.0%
100.0%
26
14
40
65.0%
35.0%
100.0%
2
3
5
40.0%
60.0%
100.0%
30
13
43
69.8%
30.2%
100.0%
66
4
70
94.3%
5.7%
100.0%
8
1
9
88.9%
11.1%
100.0%
13
7
20
65.0%
35.0%
100.0%
46
6
52
88.5%
11.5%
100.0%
3
2
5
60.0%
40.0%
100.0%
36
11
47
76.6%
23.4%
100.0%
11
6
17
64.7%
35.3%
100.0%
72
19
91
79.1%
20.9%
100.0%
38
18
56
67.9%
32.1%
100.0%
48
13
61
78.7%
21.3%
100.0%
10
3
13
76.9%
23.1%
100.0%
10
11
21
47.6%
52.4%
100.0%
3
4
7
42.9%
57.1%
100.0%
1
2
3
33.3%
66.7%
100.0%
497
159
656
75.8%
24.2%
100.0%
p < 0.001 by chi square
However this effect might be confounded by ward. Most consultants work on only one
ward, thus any high or low rate visible in the table below may well be due to the
impact of particular ward nursing teams, rather than the individual consultant. There
are, however, several consultants who share wards, and their absconding rates can be
31
contrasted. The effect of the individual ward is thus controlled, and using the z test of
equality between the proportions, the different admission rates of these pairs of
consultants can also be taken into account. When pairs of consultants absconding rates
are examined as a proportion of their admissions over the study period, the following
table is produced:
Sig. difference
Events
Patients
!
"
!
"
"
"
!
"
"
"
"
"
Pair 1
Pair 2
Pair 3
Pair 4
Pair 5
Pair 6
This table shows that there can be significant differences between consultants in the
numbers of their patients who abscond. The fact that these differences only emerge at
the event level is probably due to the small numbers in the patient based data.
Timing of absconding
Most absconds occur during the first three weeks following admission, as the
following chart shows:
Duration from admission to abscond
(Event based)
30
No. of absconds
20
10
0
.00
16.00
8.00
32.00
24.00
48.00
40.00
65.00
56.00
85.00
74.00
123.00 162.00 323.00
96.00
141.00 178.00 423.00
No. of days from admission to abscond
Patient based data is even more positively skewed, with 66% of all first
absconds occurring in the first two weeks following admission. This would indicate
that there is either a "settling in" period for patients, or a phase when the patients
illness is at its most acute, during which nurses need to be most aware of the risk of
32
absconding. However the risk of absconding never goes away completely, and some
patients still abscond for the first time after having stayed more than six months.
On 51% of occasions absconders returned to the ward the same day, and a
further 31% returned the next day. Those who go for less than a full day tend to return
quite quickly, with half of them being back on the ward within six hours. Of the 498
absconding events monitored during this study, 9% of the patients involved failed to
return at all. Two of these were still missing at the time data collection terminated,
most of the rest had been placed on leave or discharged. It can therefore be seen that
few patients, if any, are permanently lost to follow up after absconding from the ward.
Most absconds occur towards the middle of the day, however the chart below
shows two isolated peaks at 13.00 hrs and 21.00 hrs. These tally with nurse shift
change times when the ward is relatively unobserved due to the presence of the
nursing team in the office, patients are checked, return from therapeutic activities, or
are expected to return from temporary leave.
Absconds by time of day of departure
70
60
50
No. of absconders
40
30
20
10
0
.00
6.00
3.00
8.00
7.00
10.00 12.00 14.00 16.00 18.00 20.00 22.00
9.00
11.00 13.00 15.00 17.00 19.00 21.00 23.00
Time of day of abscond
Patients returning from absconding episodes do so in gradually increasing
numbers throughout the day. They are, as would be expected, least likely to return
during the small hours of the morning (see chart below).
Absconds by time of day of return
50
40
No. of absconders
30
20
10
0
.00
4.00
2.00
9.00
6.00
13.00
11.00
Time of day of return
33
17.00
15.00
21.00
19.00
23.00
63% of absconders returned of their own accord, 2% were brought back by
ward staff, 8% by relatives or friends, and 13% were brought back by the police. This
latter 13% represents 66 occasions when police were involved in the physical return of
patients to the ward. On many other occasions they were involved administratively or
in searching for the patient unsuccessfully, as they were officially notified about 47%
or 230 absconding incidents. This represents a considerable investment of police
resources.
Saturday is the most popular day to abscond, and Sunday the least, as the chart
below indicates. However there is not a great deal of variation in absconding over the
course of the week.
Absconds by weekday
100
80
No. of absconds
60
40
20
0
Sunday
Tuesday
Monday
Thursday
Wednesday
Saturday
Friday
Day of the week
In order to test whether there was any tendency for patients to abscond
following unpalatable news being given in a ward round (e.g. refusal of leave), the
duration between each absconding episode and the relevant ward round was
calculated. Patients of those consultants holding more than one ward round per week
were excluded from this analysis. No relationship with the ward round day was found
(see chart below).
No. of absconds by days from ward round
60
50
40
No. of absconds
30
20
10
0
.00
1.00
2.00
3.00
4.00
Duration in days from ward round to abscond
34
5.00
6.00
Nursing action on discovering an abscond
The most common first nursing responses to the discovery of an abscond are to
search the ward (65% of absconding events) or to wait to see if the patient returns
(76%). Several people are notable for the way they are not informed about absconds. It
is very rare, for example, for nurses to contact the patient's general practitioner (0.4%),
consultant (7%), community keyworker (7%), or the duty doctor (17%). Relatives
were only informed on 23% of occasions, and the patient's home contacted on 15% of
occasions. When relatives were called, 73% were contacted within the first hour of the
abscond being discovered. However sometimes relatives were not contacted until up
to 24 hours later. A similar pattern is visible in data about the police. Police were
officially informed on 58% of occasions. When they were informed, on 62% of
occasions it was within the first hour, however sometimes they were not contacted
until up to 48 hours later.
Risk and absconding
21% of absconding patients had a recorded history of at least one suicide
attempt, and 5% had a history of self mutilation of one form or another. 32% of
absconders were considered by staff to be at risk of self harm, and were noted as such
a risk in their nursing care plans. In addition, 27% were considered to be at risk from
the use illicit drugs, and 16% at risk of self neglect. (These percentages and those in
the following paragraph overlap slightly, as some patients were considered at risk in
more than one category)
20% of absconders were considered to pose a risk to others, and 23% had a
history of contacts with forensic psychiatry, courts, or prison. In addition, 5% of
absconders had been involved in officially reported ward incidents.
As other studies have reported, the vast majority of absconding incidents
resulted in no harm. In this study, 2.4% of incidents resulted in a patient harming
themselves, and 1.6% in them harming someone else.
Risk outcome
Valid
Total
None
Harm to
self
Harm to
others
Property
damage
Other
Drug use
Total
Frequency
441
Percent
88.6
Valid
Percent
88.6
Cumulative
Percent
88.6
12
2.4
2.4
91.0
8
1.6
1.6
92.6
4
.8
.8
93.4
3
30
498
498
.6
6.0
100.0
100.0
.6
6.0
100.0
94.0
100.0
Perceptions of risk appear to differ sharply for different genders of patient and
for different ethic origins. It is impossible to say whether this is due to these differing
backgrounds producing different kinds of psychiatric problems, or to stereotypical
35
views on the part of staff assessing risk, or to some combination of both these factors.
The relationship is far from simple and certainly does not support the explanation that
psychiatric professionals perceive ethnic minority patients as "big, black and
dangerous".
Consider the following two tables:
Perceived risk to others
Current risk to others * ethnic origin Crosstabulation
ethnic origin
Current risk
to others
Yes
No
Total
Count
% within ethnic origin
Count
% within ethnic origin
Count
% within ethnic origin
Afro-Carribean
15
39.5%
23
60.5%
38
100.0%
Bangladeshi
9
56.3%
7
43.8%
16
100.0%
Other
African
1
5.0%
19
95.0%
20
100.0%
Somali
4
50.0%
4
50.0%
8
100.0%
Other
Asian
1
12.5%
7
87.5%
8
100.0%
White
European
14
18.4%
62
81.6%
76
100.0%
Turkish
2
100.0%
2
100.0%
Other
2
33.3%
4
66.7%
6
100.0%
Total
46
26.4%
128
73.6%
174
100.0%
p = 0.003 by chi square
Perceived risk to self
Current risk to self * ethnic origin Crosstabulation
ethnic origin
Current
risk to self
Yes
No
Total
Count
% within ethnic origin
Count
% within ethnic origin
Count
% within ethnic origin
Afro-Carribean
6
15.8%
32
84.2%
38
100.0%
Bangladeshi
3
18.8%
13
81.3%
16
100.0%
Other
African
5
25.0%
15
75.0%
20
100.0%
Somali
1
12.5%
7
87.5%
8
100.0%
Other
Asian
8
100.0%
8
100.0%
White
European
23
30.3%
53
69.7%
76
100.0%
Turkish
2
100.0%
2
100.0%
Other
2
33.3%
4
66.7%
6
100.0%
Total
42
24.1%
132
75.9%
174
100.0%
p = 0.073 by chi square
Both these tables show statistically significant relationships between ethnicity and
perceptions of risk. However it is quite clear that solely being black is associated with
being considered a risk to others. For why are 'Other African' patients considered to be
less a risk to others than Afro Caribbean patients. And if Asian patients are
supposedly viewed differently and more positively than those of African and AfroCaribbean origin, why are the Bangladeshi patients so frequently considered a risk to
others?
Instead it is clear that each ethnic community (the white majority included)
interacts with psychiatry to produce different groups of patients with different
diagnoses, different problems, with different causes.
Consequences of absconding
On 73% of occasions, the absconding incident made no change to the care
provided to the patient upon their return. The most common alternative was for the
patient to be granted leave or discharged, however this occurred to twice as many
women as men.
36
Findings 2:
Assessment of variables impacting on absconding rates
Relationship of absconding to the weather
Absconding rates were available for a total of 143 days (5/1/98 - 27/5/98).
Weather data for those days was obtained from the Climatological Observers Link
(http://www.met.rdg.ac.uk/~brugge/col.html). No significant correlation could be
found between daily absconding rates and the main features of the reported weather.
Daily weather
Pearson correlation with
numbers of absconds/day
0.076
-0.045
-0.027
0.094
-0.056
Sunshine hours
Rain (mm)
Rain (hours)
Maximum temperature
Frost (hours)
Significance
0.368
0.609
0.747
0.264
0.504
All these figures are low, but all are in the direction of positive correlations
between absconding and good weather. However even when these weather variables
are taken together in a linear regression equation, they fail to produce a significant
result.
It must therefore be concluded that, in the UK at least, weather has no
significant impact upon the rate of absconding.
Variations between wards
Ward
1
2
3
4
5
6
7
8
9
10
11
12
Beds
17
18
15
25
18
22
16
16
25
18
20
16
Staff
4
4
4
4
4
4
5
4
4
7
4
5
Adms
108
104
115
98
77
74
34
71
94
97
94
96
Bedocc
2477
2539
1521
3227
2256
2899
1816
1921
2488
2620
3054
2616
Events
29
49
23
35
79
69
13
24
47
5
47
73
Patients
12
12
14
18
13
12
8
17
18
4
22
23
LoS
22.94
24.41
13.23
32.93
29.30
39.18
53.41
27.06
26.47
27.01
32.49
27.25
Each Trust involved in the study kindly provided numbers of admissions and
bed occupancy by ward for the study period, enabling the calculation of absconding
rates for patients (counting each absconder only once, regardless of the number of
times they absconded) and events (counting each abscond separately, regardless of the
37
smaller number of patients producing these absconding events). Each ward was then
compared with the total of the remaining wards, using the z test of equality between
proportions (Cohen 1988). Differing methods of calculating the rates of absconding
were used.
Proportions of absconds by beds: This method of calculation fails to take into account
whether all beds were occupied for all of the study period, nor is it sensitive to patient
throughput.
Proportions of absconds by admissions: The number of admissions ignores the
patients who were already on the ward at the time the study commenced, and no
distinction has been made between admissions and readmissions. Trust O operates a
system where many patients are first admitted to a holding ward before being
transferred to beds on other wards. In this case, these transfers have been counted as
admissions to the destination ward, and have therefore been included twice in the
admission figures.
Proportions of absconds by bed occupancy: This figure includes those on leave at any
time during the study period. It is perhaps the best number by which to judge real
differences in absconding rates.
Ward
Beds
1
2
3
4
5
6
7
8
9
10
11
12
z
1.42
-1.35
1.91
3.15
-4.49
-2.51
5.66
2.10
1.06
14.17
-0.48
-4.44
sig.
0.0778
0.0885
0.0281
0.0010
0.0000
0.0060
0.0000
0.0179
0.1446
0.0000
0.3156
0.0000
Ward
Beds
1
2
3
4
5
6
7
8
9
10
11
12
z
-0.60
-1.03
1.59
-0.57
-0.45
-2.56
-2.60
2.91
-0.57
-5.67
3.70
6.58
sig.
0.2743
0.1515
0.0559
0.2843
0.3264
0.0052
0.0047
0.0018
0.2843
0.0000
0.0001
0.0000
Event based analysis
Adms
z
sig.
-4.30
0.0000
0.15
0.4404
-6.02
0.0000
-2.23
0.0129
10.26
0.0000
8.37
0.0000
-0.97
0.1660
-2.21
0.0136
0.73
0.2327
-8.55
0.0000
0.73
0.2327
6.10
0.0000
Bedocc.
z
sig.
-2.04
0.0207
1.05
0.1469
-0.51
0.3050
-2.77
0.0028
7.04
0.0000
3.12
0.0010
-3.29
0.0004
-1.50
0.0668
0.87
0.1922
-6.20
0.0000
-0.62
0.2676
4.66
0.0000
Patient based analysis
Adms
z
sig.
-1.54
0.0618
-1.38
0.0838
-1.27
0.1020
0.58
0.2810
0.15
0.4404
-0.02
0.4920
1.16
0.1230
1.81
0.0351
0.79
0.2148
-3.40
0.0002
1.96
0.0250
2.13
0.0166
Bedocc.
z
sig.
-0.70
0.2420
-0.79
0.2148
1.74
0.0409
-0.24
0.4052
-0.07
0.4721
-1.29
0.0985
-0.85
0.1977
1.76
0.0392
0.93
0.1762
-3.05
0.0013
1.01
0.1562
2.04
0.0207
38
Ward
Beds
1
2+
3
4
5+
6+
7
8
9
10
11
12+
+ location of
Event based
Adms
Bedocc
Low
Low
Low
Low
High
High
Low
Low
Low
Low
High
High
Low
Low
Beds
Patient based
Adms
Bedocc
High
Low
High
High
Low
Low
Low
Low
Low
High
Low
High
High
High
High
High
4 most frequently absconding patients
Low
High
High
Low
High
High
Low
High
These apparent differences between the wards should be treated with caution.
They may reflect differences in willingness to report absconds to the researchers,
rather then real differences in rates of absconding. Or they may reflect differences in
deprivation and morbidity of the localities served by the wards. If these two sources of
variation can be assumed to be minimal (and that is a large "if"), then the following
deductions may be made:
Ward 1 has a similar number of patients who abscond, but is good at
intervening to reduce subsequent repeats.
Ward 3 is a temporary holding ward. It therefore has patients at their peak time
for absconding in the early days of their admission. Because many patients are
subsequently transferred to other wards, they have a low rate of repeat absconds.
Ward 4 has a similar number of patients who abscond, but is good at
intervening to reduce subsequent repeats (like ward 1).
Wards 5 and 6 have high absconding rates by event based figures. This appears
to be due to a poor responses to first absconds (in contrast to ward 1) and the presence
of some of the patients most prone to abscond repeatedly. The low patient based
figure for Ward 6 reflects a high length of stay on this ward. In other words, Ward 6
has a low number of one time absconders and a high number of repeat absconders.
Ward 7 is a female only ward, and the relatively low rates of absconding are
due to the fact that women abscond much less than men.
Ward 8 has a high patient based and a low event based rate. This indicates that
although patients abscond initially at a high rate from this ward, they rarely repeat,
possibly due to post abscond intervention by the staff.
Ward 10 has a low rate of absconding for unknown reasons. This ward has a
low rate of incidents of all types (Bowers and Clark 1998).
39
Ward 12 has a high rate of absconding by all possible calculations. Again the
reason is unknown.
Ward observability
A simple scale to assess the observability of a ward was devised (see appendix
6). The scale scored complexity of layout, ease of visibility for nurses, and number of
exits. Scoring was completed by a researcher (MJ) in conjunction with the ward
managers.
Bivariate Pearson correlation coefficients were calculated for the observability
scores and rates of absconding for wards, using both patient and event based data. No
significant correlation was found. The calculation was repeated using number of ward
exits in place of the observability score, with the same result. In fact, there was a
nonsignificant trend towards absconds decreasing on those wards that were less
observable or which had more potential exit points.
No firm conclusion can be drawn from this, as only twelve cases were
available for analysis, and the effect of ward observability/exits on absconding would
have to have been very strong to be statistically significant with this small sample.
Nevertheless, the presence of a trend in the opposite direction does call into question
(i) whether level of ward security has anything to do with absconding rates, and (ii)
whether higher staffing levels to improve observation of patients would have any
impact upon absconding rates.
However there is a small amount of support in the data for the supposition that
higher staff/patient ratios reduce absconding rates. There is no correlation between
typical daytime numbers of nurses and absconding rates. However when staff to bed
number ratios were calculated and tested for correlation with absconding rates, there
was a nonsignificant trend in the direction of fewer absconds on better staffed wards.
Variations between Trusts
The same statistical
differences between Trusts.
reliable. However it would
absconding by admissions,
occupancy.
Trust
E
O
S
Beds
87
89
50
method used to assess ward differences was applied to
With only three cases to compare, the findings are less
appear that Trust S has a higher patient based rate of
and a lower event based rate of absconding by bed
Adms
436
434
192
Bedocc
12502
11217
5715
40
Events
211
200
82
Patients
77
60
36
LoS
28.67
25.85
29.77
Trust
Beds
E
O
S
z
-1.78
-0.49
3.01
sig.
0.0375
0.3121
0.0044
Event based analysis
Adms
z
sig.
1.08
0.1401
-0.18
0.4286
-1.14
0.1271
Bedocc.
z
sig.
0.15
0.4404
1.13
0.1292
-1.58
0.0571
N.B. Numerators and denominators for beds reversed.
Trust
Beds
E
O
S
z
3.36
-2.61
-0.86
Trust
E
O
S
Beds
High
Low
sig.
0.0004
0.0045
0.1949
Patient based analysis
Adms
z
sig.
1.01
0.1562
-1.81
0.0351
1.02
0.1539
Event based
Adms
Bedocc
Beds
High
Low
Bedocc.
z
sig.
0.54
0.2946
-0.93
0.1762
0.46
0.3228
Patient based
Adms
Bedocc
Low
Low
No highly consistent picture merges out of this data. There is indicative (but
not convincing) evidence that absconding might be higher in Trust E than in the other
two Trusts. These differences could, however, be due to variation in nursing cooperation with the research, slightly differing admission policies, or a number of other
factors.
41
Findings 3:
Characteristics of absconders
Characteristics of absconders
The table below shows the results of statistical tests for differences. The most
relevant set of results for nursing practice are those which compare all absconding
with the control group. Those variables which are statistically significant may be used
by nurses to predict the patients who are most likely to abscond. The profile of an
absconder is someone who is: young; male; a firstborn child; from an ethnic minority
group; of the Muslim faith; living with partner or parents; with a diagnosis of
schizophrenia; having had a number of transfers between wards, refusals of
medication and involvement in officially reported ward incidents in the previous
week; considered by nursing staff to be a risk to self or others; someone who has
absconded during previous admissions; and has had previous contact with the police.
In contrast to previous studies, these results do not show that compulsorily
detained patients are more likely to abscond. Previous studies have relied heavily on
the use of statistics generated through the production of official reports. The definition
of an abscond used in this study (absent from the ward without permission for at least
one hour) has shown that only 47% of absconds are officially reported. These official
reports are more likely to be made if the patient is compulsorily detained (they are
completed for 58% of detained patients who abscond, but only for 35% of informal
patients who abscond). The fact that previous studies report detained patients
absconding more frequently is thus an artefact of their methods.
Event based analyses are excellent for the identification of risk factors for use
as practical predictors in the ward setting. Patient based analyses show that when
absconders are examined in detail, their characteristics are not very different from the
control group. This may indicate that the propensity to abscond is not a derivative of
patients enduring psychological or personality characteristics, but is instead a product
of other factors, such as the social context within which they find themselves.
About half (55% in this study) of all patients who abscond do so only once in
the course of their admission to hospital (in this report these are called single
absconders). The remainder abscond more than once, and some abscond many times
(in this report these are called multiple absconders).
Neither single nor multiple absconders considered separately are any more
readily distinguished from controls than when they are considered together. However
when they are compared with each other (in an event based analysis), it can be seen
that single absconders are more likely to be female, older (over 35 years old), and not
single. These are preliminary indications that the type of patient who absconds only
once may be different, and do so for different reasons.
42
All analyses confirm that absconding during a previous admission is strongly
associated with the propensity to abscond during the current admission.
Variable
Absconds
vs
controls
(event
based)
+++
+++
Absconds
vs
controls
(patient
based)
Single
absconds
vs
controls
Multiple
absconds
vs
controls
Age
++
Gender
+
Marital status
Sibling order
+
Ethnic origin
+++
Religion
+++
Education
Living group
+
Accommodation
+
Employment
++
Time since last employment
+
Diagnosis
+++
No. ward transfers in past 7
+++
days
MHA status on admission
No. of medication refusals in
++
+
+
past 2 days
No. of incident report forms in
+++
past 7 days
Previous admission
Previous contact with the
+++
+
police
Previous contact with courts or
prisons
History of self mutilation
AWOL on previous admission
+++
+++
+++
+++
Previous suicide attempt
Risk (self neglect)
++
+
+
Risk (to others)
++
Risk (to self)
+
All results by chi square test, + = p < 0.05; ++ = p < 0.01; +++ = p < 0.001
Single
absconds
vs
multiple
absconds
+
+
+
The strongest variables were selected from the above list, and collapsed into
dichotomous variables for preliminary logit loglinear analysis with control group vs.
Absconders as the dependent variable. First results showed significant higher order
combined effects for female gender, young, schizophrenia, white European and
Christian. Comparing these results with the previous contrast between single and
multiple absconders, it would appear that gender might be the most significant
variable. Chi square tests were thus used again, but this time treating male and
females as separate populations. The statistical power of this analysis is lower due to
the smaller sample sizes. Yet significant differences can be seen, and the following
results were obtained.
43
Variable
Female
absconds
vs. Female
controls
Male
absconds
vs. Male
controls
+++
+
Male vs.
Female
absconds
Age
+++
Marital status
+++
Sibling order
++
Ethnic origin
+++
+++
Religion
+++
+++
Education
Living group
+
+
Accommodation
++
+++
Employment
+
+
Time since last employment
+++
Diagnosis
+++
+++
No. ward transfers in past 7
+++
++
days
MHA status on admission
++
++
No. of medication refusals
++
in past 2 days
No. of incident report forms
++
+
in past 7 days
Previous admission
Previous contact with the
++
++
++
police
Previous contact with courts
+
or prisons
History of self mutilation
AWOL
on
previous
+++
+++
+++
admission
Previous suicide attempt
Risk (self neglect)
+
++
Risk (to others)
++
Risk (to self)
All results by chi square test, + = p < 0.05; ++ = p < 0.01; +++ = p < 0.001
In contrast to female controls, female absconders had a history of absconding
on previous admissions, were more likely to live alone, and have had previous contact
with the police, forensic psychiatric services, prison and the courts.
In contrast to their controls, male absconders were more likely to live in
council accommodation, be under 35 years of age, have a history of absconding on
previous admissions, suffer from schizophrenia, be from a Bangladeshi, Somali, or
other African ethnic background, unemployed, living with a partner or with parents,
married with a stable partner, refused medication, been transferred from another ward,
or been involved in an officially recorded incident within the previous week,
compulsorily admitted under the Mental Health Act, have had previous contact with
the police, be of the Muslim or Sikh faith, be considered at risk of self neglect and/or a
risk to others.
The sharpest contrast is produced by comparing the male and female
absconders with each other. In case these were usual differences between male and
female psychiatric patients, not connected with absconding behaviour, males and
females in the control group were contrasted on the same variables. Similar
44
differences were found for previous contact with the police and diagnosis, and these
may therefore be considered typical differences between male and female patients,
regardless of the propensity to abscond. For other variables however, either no
differences exist between male and female controls, or the differences are in the
opposite direction. The following table summarises the results:
Male
In council accommodation or homeless
Female
Private rented, or housing association
accommodation
Aged 36 years and older
Not absconded on a previous admission
Afro-Caribbean or white European
In some form of employment
More recently employed
Living alone
Separated/divorced
Compulsorily admitted for assessment
Christian or no religion
Not at risk of self neglect
Not a risk to others
An only child
Not transferred between wards in past week
No official incident report in past week
Aged 35 years and under
Absconded on a previous admission
Bangladeshi or Somali
Unemployed
Less recently employed
Living with parents or partner & children
Single
Compulsorily admitted on a treatment order
Muslim or Sikh
At risk of self neglect
Risk to others
A first born child
Transferred between wards in past week
Official incident report in past week
These findings indicate that female patients who have a difficult relationship
with inpatient psychiatry and who are prone to break the rules are different from males
who exhibit the same behaviour pattern. They may therefore have different reasons for
absconding, and different remedies may be appropriate. The issue of gender will be
returned to when consideration is given to the outcome of absconding incidents, their
official reporting, and risk management.
Unfortunately, this study was not powerful enough to establish separate
predictive profiles for male and female absconders, as the female absconders do not
differ sufficiently from the female controls.
45
Findings 4:
Going and returning
The findings presented in this chapter are based upon the 62 interviews of 52
returned absconding patients, except where otherwise stated. Analyses of the
interview data have been summarised in matrices which can be found in Tables 1 - 7
at the close of the chapter.
Leaving the ward
The majority of absconders found it easy to just walk off the ward, as
illustrated in Tables 1 - 5. Just under 60% of interviewees had absconded in this way.
pt: I just walked through the door ..I went round that way so I
walked past the office ..no one was about so I walked out the
door. (P10811)
pt: I just walked out. (P10902)
pt: just walked out (P11909)
pt: the door was open ...that door wasn't locked ..I just
opened it and left ..that's it ... (P12703)
Seeing the unlocked door was interpreted by some patients as a message that they
were free to leave, or that leaving without permission would be easy, or that they were
being dealt with unfairly because other patients could come and go as they pleased.
pt: the door was open .. I knew the opportunity had presented
itself (P62311)
pt: well it wasn't that .. I was standing next to the door .. and I
was watching all these people walk in and out freely .. like
you know .. I thought to myself like you know .. I can't ..you
know ..( P21306)
pt: I just wake up and saw there was nobody sitting near the
door ..there's ( ) nurse sitting near the door and I thought ..
you know it's a chance for me to run away ..and I just ran
away (P30408)
However, some patients were cautious or devious in making sure they were not
spotted by nurses and prevented from leaving.
pt: no I thought ..(..) do it in secret........ oh yeah I crept round
there.. yeah I crept round ..wasn't nothing to do with the
staff's fault ..it was my fault...cause I'd stormed out of the
ward round Wednesday when he said to me come back
when you're sober ..I stormed out and I come in here
(bedroom) and J followed me out quick so I thought I'll wait
until she goes back in the office ..then I'm going to go.
(P10811)
46
pt: yeah .. well I told one of the staff .. the one that stands in
the way of the phonecall .. I was .. but at that exact moment ..
there was another patient they had to keep an eye on .. and
there was that one man there .. and when he's gone to see
the other patient .. I absconded then .. once he went to see
the other patient ..( P30303)
pt: it was locked .. they unlocked the door and I sneaked out.
int: how did the door get unlocked?
pt: the staff opened it .. the domestic.
int: oh the domestic opened it .. and while her back was
turned ...?
pt: yeah .. I sneaked out. (P60411)
Some patients literally 'did a runner'.
pt: I rushed .. I walked but I rushed.
int: did you have to look out to see if the coast was clear?
pt: no I just rushed out. (P12912)
pt: it was just the door was open .. I just ran .. just jumped ..
jumped .. the open door.. and then just run down the stairs
and run out. (P60308)
pt: yes ..I was thinking about going home .. and so I just left
the ward ..sort of ran off you could say (P31902)
Tables 2 - 5 show that nearly all those who literally ran were young, male,
involuntarily detained sufferers of schizophrenia. This is likely to be indicative of the
fact that they are observed by nurses more closely and find it more difficult to
abscond.
Destination and activity
Roughly two thirds (63%) of absconders went home on leaving the ward, and
while there engaged in normal life activities like housework, shopping, decorating,
sleeping, eating, watching television, household repairs, looking after children, chatted
to family, socialised, played games/sports, cleaning, etc. All absconders, not just those
who went home, largely engaged in normal everyday activities while away. Table 3
shows that the behaviour of involunatrily detained patients may have been slightly
more disturbed and unusual while away from the ward, however the difference is not
massive.
pt: I just went to my house ..I just went to my place. (P11508)
int: right...was there anything in particular that you wanted to
get off the ward to do? pt: no ..I just wanted to get home.
int: you just wanted to get home ...did you go straight home?
pt: yeah. (P11909)
pt: ...I went home ...I then phoned them up and ( ) saying that
I'm at home at the moment yeah ..I did phone them and told
them that I am at home ...that they know I'm safe enough ...
(P12703)
47
The next most popular destination (32%) were the houses of friends or relatives. Male
absconders were more likely to visit friends and engage in social activity (Table 2).
pt: no I just rushed out .. I thought I go home but I don't have
a key on me .. nothing .. so I went to a friend of mine and
they brought me back here. (p12912)
pt: I just went to my mates house .. I was being a big poof
and kissing and everything (P21312)
pt: I went to my mate's house (P21706)
pt: I don't know .. I just go all over .. I usually go to my
brother's off licence .. he's like a brother to me .. and he gives
me a few cigarettes now and then .. and I just sit there .. pass
time .. (P42912)
A few went to the pub, and 11% admitted to smoking cannabis while away from the
ward. Even when absconders did not go to the pub, many drank alcohol while away,
19% in all.
pt: walked round for a while ...then went to the pub ..had a
few cokes and watched the football match. (P11502)
pt: well .. drinking in the pub ..public house .. it was all um
brandy Martell .. brandy .. I can't remember much after that ..
I went home and slept it off but I .. I never slept very good .. I
only woke up about six am the next morning .. after drinking
brandy .. which was normal .. you know .. anyone would .. if
they had problems wouldn't they .. mental problems ..
(P20509)
pt: I got drunk and stoned and I come back the next day
(P21308)
And a few went to religious services.
pt: I didn't sleep the first night .. second night I slept in a
cardboard box .. down Farringdon .. went to church .. went to
Mosque .. they didn't like me because I was shouting .. in the
Mosque .. (P61710)
pt: went to church (P60411)
One patient refused to be seen by a local priest from the mosque for healing rituals.
pt: then they said that ..they're going to get a priest at my
home you see .. for that thing yeah .. the priest can pray
something .. from the Koran yeah .. the Holy Koran .. and to
control myself I said that .. I broke this master plate you see ..
I lost my temper yeah .. I smashed a plate and I said .. which
motherfucker wants to come and control me .. I'll rip his arse
from .. I said that yeah .. at that time I lost my temper you see
.. I don't like priests .. all these things .. because I don't
believe in priests .. it's a whole load of bullshit . (P21809)
Very few patients appear to have left the ward with no specific destination in mind,
however those that did tended to wander the streets.
48
pt: I was just strolling out...taking fresh air ..looking around..
yes ...that's it ..just getting fresh air ..that's all. (P12109)
int: and where did you go in those three days?
pt: all over .. I went to the A1s, the B2s, the B3s ..
int: sorry what are the A1s and B2s .
pt: A1s are the high roads .. the highways .. the B2s are the
train tracks, the B3s are the trains ..that's the classification of
transport.
int: so did you not go to your uncle's house?
pt: I did not. I went the other direction ..
int: where did you sleep at night?
pt: anywhere.. on the concrete.
int: on the concrete? did you sleep all three nights outside?
pt: I did. (P31311)
pt: I just walked the streets (P40211)
Two patients attempted suicide following their abscond from the ward, one in
response to persistent command hallucinations.
pt: no I just wanted to go home and I bought some
paracetamol ..I only took about twenty though and they was
knocking at my door so I couldn't do any more because they
were a blister packs ... (p10811)
pt: no the voices just said like go for a walk .. so I went for the
walk and then half way .. then they told me to go home .. so I
walked home .. then as soon as I got in .. they said take the
pills .. take pills and I kept looking at the bottle trying not to
listen to the voices .. I put on my radio full blast .. I put my tv
on full blast but it didn't help so in the end I just took them.
(P40211)
Returning to the ward
The majority of absconders return to the ward by themselves (43% of the
interview sample). However this obscures that fact that many came back in response
to pressure from others(Table 7):
Expectation that the police would call
pt: I don't know .. I didn't really want to .. but I had come back
I know.. .. because if I didn't come back .. they send the
police ..don't they. (P61708)
Verbal pressure from friends and relations
pt: not only because I didn't have no medication at home .. in
fact I have got medication at home but not as much as .. not
that much but it's not ..that's not the reason why .. the reason
why is I came back here because my mother wanted me to
and my sister wanted me to ..(P31902)
Lack of any alternative place to go
int: so what made you decide to come back?
49
pt: there's no where for me to go. (P10902)
Additional reasons for returning voluntarily are laid out in Table 7, and include feeling
cold, hungry, unwell, in need of medication or of treatment for medication side
effects.
A further significant number are physically brought back to the ward by
friends and relations.
int: how did you return to the ward?
pt: by tube with my brother ..( ).(P11508)
int: and you came back by yourself?
pt: no ..my sister dropped me off here. (P12703)
pt: yeah .. yeah .. all my family were going .. oh you're going
to be in so much trouble for this .. and all this .. you know ..
and I wasn't going to come back ..it's just that my sister came
and got me last night .. I wasn't planning on coming back ..
but my sister come and got me last night .. they see that I
was bad .. my other sister .. and .. the ones that took me out
and dropped me off at my mum's and they .. they just see
that .. I ..they could see I was bad and they said come on
come back to the hospital so they rung up the hospital and
said don't have a go at him or anything .. you know .. and um
.. brought me back ..(P20308)
Rather more rarely, the ward nursing staff themselves return a patient to
hospital. This appears to happen when there is serious and urgent concern about the
patients condition, or when the patient is spotted close to the hospital.
int: so you said you returned to the ward with staff ..staff
brought you back ..
pt: I was telling them I didn't want to come back ..they said no
you've got to .. (P10811)
int: so you ran out in the road and then what?
pt: got caught.
int: who did you get caught by?
pt: the nurse.
int: and then what happened?
pt: they brought me back to the ward. (P60306)
Actions of the police in returning absconding patient seems to be very
variable. Those occasions on which large numbers of police in riot gear arrived at
patients' front doors were graphically described by interviewees.
pt: well .. the police brought me back .. I didn't recognise
them at the time because I'd had the council come round ..
because I'd put in a request for some repairs to be done ....
you know it sounded like someone from the council . [......]
..come out and I opened the door .. I said what's going on ..
they had crow bars .. there were all riot police with shields .. I
said what's going on .. and they er said to me that um .. well
HERE'S A WARRANT HERE ... not well you've run away
from hospital and we've got to take you back there .. HERE'S
A WARRANT HERE .. AND IT SAYS HERE LOOK AT THIS
MR N ..: they had a video camera .. as well .. there was about
50
.. twelve .. at least fourteen police out there .. twelve
policemen .. with riot shields [.......].. so like I unlocked the
door .. [......].. come out .. I said what's going on .. I said
there's no need for all this .. and I said I haven't done
anything to warrant this .. you know .. I thought to meself ..
but like you know .. it was like a life and death .. situation you
know .. something warranting that .. so I come out .. and er
you know .. I don't know exactly what they said .. they just
said stand in the corner like .. you know .. so .. put your arms
up .. you know ..so I did that like that and then they .. they
started holding me ..pulling me .. you know .. dragging me
down on the floor .. and all that ..put me face on the floor ..
pushing it like that .. and sort of all that treatment .. so I
thought there's no use struggling .. but .. they can really hurt
you .. like you know and I thought .. like you know ...I've got to
say something anyway because if they don't .. they just give
you more you know ... apply pressure on you cause they put
handcuffs on and they weren't the loose .. you know loose
with the chain .. they were stuck like that .. and er they put
them on really tight .. and they was bending me arms like that
.. so .. actually I had big swellings on there ..[.......] .. and they
brought me to hospital .. (P21306)
pt: the police came ... I was having sex with my girlfriend in
bed .. having sexual intercourse and .. I shouldn't be telling
you this really should I .. I was having sex .. and a police
officer came to the door and said I'm PC C from S N police
station .. can you open the door please ..
int: so you opened the door and the police were there .. how
many police were there?
pt: twenty officers.
int: twenty officers?! that's a lot of police?
pt: four police cars and two vans ..
int: you said it was int he middle of the night .. what time was
pt: three o'clock in the morning. (P60411)
By contrast, on other occasions patients seem to have used the police more like a taxi
service.
pt: they .. cause my brother came round .. and said to me that
I had to go back to the hospital .. and I said that I wasn't
going back .. so he said to me .. I had to go back .. so I said
all right then .. so I just waited and then called the police .. so
the police came round and got me .. and brought me back to
the hospital .. and stuck me in the hospital again .. (P21706)
Mostly returns by the police were relatively sedate affairs where the sight of the
officers in uniform, plus a few words of conversation, persuaded the patient to return
peacefully. However it should be borne in mind that even two police officers carry the
implicit threat of force if co-operation is not forthcoming.
int: so you left .. how did you feel when the police turned up at
your
place to bring you back?
pt: I felt threatened but felt ..but then they started talking to
me .. and they just willingly brought me back.
int: how many police were there?
pt: two... there might have been three at one stage .. no there
was two.(P52507)
51
Tables 2 and 3 show that male involuntary patients are those who are returned by the
police. It would appear that such patients are viewed as particularly dangerous and
uncooperative. Table 3 appears to show that two informal patients were returned by
the police, however close inspection of the interview responses of these patients
shows that general practitioners and social workers were in attendance. It therefore
seems likely that the patients were being compulsorily detained for the first time, after
leaving the ward whilst still informal.
Differences between Trusts
Table 1 examines any potential differences between the three NHS Trusts in
the study with respect to leaving and returning. From the data collected in this study
these appear to be minimal. There is little apparent difference in method of leaving,
destination, activity, or method of return. Each Trust appears to be equally well
supported by the police.
However when the larger numbers of the quantitative data set are examined,
some differences do emerge. As the following table shows, Trust E has higher levels
of absconders while patients are off the ward, as compared to the other two Trusts.
Trust S has the lowest number, with nearly all absconders leaving from the ward (p <
0.001 by chi square test). This may reflect more risk taking in Trust E.
Place of absconding episode * NHS Trust Crosstabulation
163
NHS Trust
O
168
76.9%
82.8%
11
1
5.2%
.5%
28
30
2
60
13.2%
14.8%
2.4%
12.0%
E
Place of
absconding
episode
Total
Ward
Count
% within
NHS Trust
Temp. off
Count
ward
% within
(escorted) NHS Trust
Temp. off
Count
ward
% within
NHS Trust
Failed to
Count
return from % within
leave
NHS Trust
Count
% within
NHS Trust
S
78
Total
409
94.0%
82.1%
12
2.4%
10
4
3
17
4.7%
2.0%
3.6%
3.4%
212
203
83
498
100.0%
100.0%
100.0%
100.0%
Trust E also has the lowest rate of absconding patient return by the police (8% of
absconders, versus 17.2% in Trust O and 16.9% in Trust S, p = 0.001 by chi square
test). Police were no less likely to be informed about an absconding patient in Trust E.
However Trust E absconders were no more likely to have risk to others noted in their
care plan. Instead dramatically higher levels of risk to others were noted in Trust O
care plans (55% of care plans, versus 10% in Trust E and 16% in Trust S, p < 0.001
by chi square). Trust O also uses a higher number of Treatment sections (as opposed
to Assessment sections) of the Mental Health Act when admitting patients who
subsequently abscond. Absconding patients in Trust O are also much more likely to be
placed on intermittent nursing observations in the 24 hours preceding the event (34%
52
of absconders, versus 1.8% in Trust E and nil in Trust S, p < 0.001 by chi square).
Risk to self is identified much less frequently among absconders from Trust S, and
Trust E absconders were more likely to have a history of suicide attempts (26% of
absconders, versus 15% in Trusts O and S, p = 0.013 by chi square test). There is no
difference between Trusts in the proportion of absconding patients with a forensic
history of any kind.
The pattern of negative outcomes of absconding incidents by Trusts is
complex and the full table is presented below. It would appear that harmful outcomes
are slightly more common in Trust O, and that drug use during an absconding episode
is less likely in Trust S. This cross tabulation is significant by chi square test (p =
0.002), however eleven of the cells have frequencies of less than five, making the
result problematic.
Risk outcome * NHS Trust Crosstabulation
192
NHS Trust
O
173
90.6%
E
Risk
outcome
None
Harm to
self
Harm to
others
Property
damage
Other
Drug use
Total
Count
% within
NHS Trust
Count
% within
NHS Trust
Count
% within
NHS Trust
Count
% within
NHS Trust
Count
% within
NHS Trust
Count
% within
NHS Trust
Count
% within
NHS Trust
S
76
Total
441
85.2%
91.6%
88.6%
3
6
3
12
1.4%
3.0%
3.6%
2.4%
2
6
8
.9%
3.0%
1.6%
1
3
4
.5%
1.5%
.8%
3
3
3.6%
.6%
14
15
1
30
6.6%
7.4%
1.2%
6.0%
212
203
83
498
100.0%
100.0%
100.0%
100.0%
The pattern of ward security status between Trusts is also complex. Ward
security status was only logged in this study at the time an abscond occurred. Thus
only the ineffective application of security measures has been recorded. Those
occasions on which such measures were successful were not identified in this study.
The following table shows that Trust O is marginally more likely to have the door
locked at the time of an abscond, however Trust S is much more likely than the others
to have a nurse stationed at the ward door (a so called 'door stop') to prevent
unauthorised departures by patients (p < 0.001 by chi square). These figures may
indicate that the use of 'door stops' is not an effective strategy to prevent absconds, as
52% of absconders in Trust S managed to avoid them.
53
Security status of ward * NHS Trust Crosstabulation
2
NHS Trust
O
10
.9%
4.9%
1
5
43
49
.5%
2.5%
51.8%
9.8%
E
Security
status of ward
Locked
Door stop
Open
Total
Count
% within
NHS Trust
Count
% within
NHS Trust
Count
% within
NHS Trust
Count
% within
NHS Trust
S
Total
12
2.4%
209
188
40
437
98.6%
92.6%
48.2%
87.8%
212
203
83
498
100.0%
100.0%
100.0%
100.0%
54
Table 1: Methods by Trust
trust
E
O
S
method of leaving
13 walked off ward
6 failed to return from agreed time out
1 ran out
1 was angry and told staff when left
13 walked off ward
4 ran out
1 was angry and told staff when left
1 failed to return from agreed time out
1 walked away from their escort
1 made an excuse to leave the ward and
then left
1 failed to return from leave
1 left via the fire exit
7 walked off ward
1 failed to return from leave
destination
12 went home
5 visited friends
1 visited family
1 went to the pub
3 wandered the streets
10 went home
2 wandered the streets
1 delivered flowers to a woman he
had been accused of stalking
1 went to the social club
2 went out with friends
1 went shopping
6 visited friends
2 visited family
1 ran out in the road
1 went for a walk
activity
17 took part in normal life
activities
2 also smoked cannabis
3 wandered the streets
2 made suicide attempts
24 took part in normal life
activities
4 also smoked cannabis
1 delivered flowers
2 wandered the streets
1 sorted out burgled house
1 ran out in road
method of return
5 with police
12 of their volition
1 with ward staff
3 with relatives and friends
1 unknown
11 of their own volition
5with police
1 with police and ambulance
5 with relatives and friends
1 with ward staff
4 went home
1 went for a walk
1 visited the pub
2 visited friends
1 visited family
9 took part in normal
activities
1 also smoked cannabis
7 of their own volition
1 with police
1 with police and social
worker and ambulance
55
life
Table 2: Method by gender
methods
place
activity
* 2 failed to return from leave
* 21 went home
* 37 were undertaking ‘normal life’
* 6 were out unescorted for
* 16 visited friends
activities
agreed short periods of time
* 3 went to the pub
* 7 of these smoked cannabis
* one was with a nursing escort
* 3 visited family
* 1 attempted to visit a woman
for a walk in the grounds
* 1 went shopping
he had been accused (and
* 1 made an excuse to leave the
* 4 wandered the streets
sectioned) for stalking
ward temporarily and then
* 3 simply wandered the streets
absconded
* 1 sorted out his flat that had
* 1 left via the fire exit
been burgled
* 5 ran out the main door
* 26 simply walked out
* 1 was out unescorted for an
* 8 went home
* 6 undertook ‘normal life’
females
agreed short period of time
(1 not before she’d done a trip
activities
* 7 simply walked out
to Manchester!)
* 2 made suicide attempts
* 2 informed staff they were
* 1 visited friends
* 1 went for a stroll
leaving while angry and were
* 1 went for a stroll
* 1 visited home to collect an
considered awol after days had
* 1 ran out in the street and was awaited letter
elapsed.
caught by staff in the street and * 1 ran out in road
* 2 ran out of the ward
brought back.
‘normal life’ activities include going home to do housework, visiting friends, going to the pub, sex, decorating, etc.
males
56
method of returning
* 11 were returned by police
* 20 returned of their own volition
* 1 returned with their social
worker
* 2 were returned by ambulance
* 8 returned with relatives or
friends
* 1 returned with police
* 7 came back of their own volition
* 1 returned with friends
* 2 returned with ward staff
Table 3: Method by Mental Health Act status
mha status
informal
involuntary
method of leaving
9 walked off the ward
7 asked to leave the ward for a
short period of time
1 made an excuse to leave the
ward and then absconded
1 left via the fire escape
1 was angry and informed staff
she was leaving
21 walked off the ward
6 ran out
2 asked to leave the ward for a
short period of time
2 failed to return from leave
1 was angry and informed staff
she was leaving
destination
6 went home
6 visited friends
3 visited family
2 went to the pub
2 wandered the streets
activity
15 took part in normal life
activities
3 also smoked cannabis
2 wandered the streets
1 spent time sorting out their
home which had been burgled
1 made a suicide attempt
method of return
11 of own volition
6 with relatives and friends
1 with police and ambulance
1 with police/sw and ambulance
1 with police
1 unknown
17 went home
5 visited friends
2 visited family
3 wandered the streets
2 went for a walk
1 went met up with friends and
went out with them
1 went to the social club
1 delivered flowers to a woman
he had been accused of stalking
1 ran out in the road.
26 took part in normal life
activities
4 also smoked cannabis
1 delivered flowers to a woman
he had been accused of stalking
1 ran out in the road
3 wandered the streets (1
thinking
about
committing
suicide)
1 made a suicide attempt
21 of own volition
9 with police
4 with relatives and friends
2 with ward staff
57
Table 4: Method by diagnosis
diagnosis
schizophrenia
method of leaving
23 walked off the ward
5 ran out
3 failed to return from agreed time
out
2 failed to return from leave
1 made excuse to leave ward
1 left via the fire exit
other
10 walked off the ward
3 ran out
5 failed to return from agreed time
out
1 walked away from escort
2 informed staff angrily that they
were leaving
destination
13 went home
2 wandered the streets
11 visited friends
2 went to the pub
1 went shopping
3 visited family
1 went for a walk
1 delivered flowers
10 went home
1 went to the pub
1 went for a walk
3 wandered the streets
5 visited friends
1 ran out in the road
58
activity
14 took part in normal life
activities
2 also smoked cannabis
2 wandered the streets
1 delivered flowers
1 sorted burgled flat
method of return
22 of own volition
6 with police
1 with police, sw, and ambulance
1 with police and ambulance
2 with relatives and friends
1 unknown
16 took part in normal life
activities
4 also smoked cannabis
3 wandered the streets
1 ran out in road
2 made suicide attempts
16 of own volition
4 with police
2 with ward staff
1 with relatives and friends
Table 5: Method by age group
age
under 35
method of leaving
23 walked off ward
6 failed to return from agreed
time out
5 ran out
1 walked away from escort
1 failed to return from leave
over 35
13 walked off ward
3 failed to return from agreed
time out
2 ran out
1 failed to return from leave
1 made an excuse to leave ward
2 angrily informed staff they
were leaving
1 left via the fire exit
destination
12 went home
1 went to the pub
12 visited friends
1 went shopping
3 wandered the streets
1 ran out in road
1 visited family
11 went home
2 went to the pub
3 visited friends
3 wandered the streets
1 visited family
1 delivered flowers
2 went for a walk
59
activity
31 took part in normal life
activities
3 also smoked cannabis
3 wandered the streets
1 sorted out burgled flat
1 ran out in road
method of return
24 of own volition
8 with police
5 with relatives
1 with ward staff
1 unknown
12 took part in normal life
2 also smoked
3 wandered the streets
2 made suicide attempts
1 delivered flowers
18 of own volition
1 with police
1 with police, sw, ambulance
1 with police and ambulance
2 with relatives and friends
Table 6: Returning to the ward
How it
happened
Police
12 interviewees had been
returned by the police
Full riot squad of 12
policemen with shields
arrived at door, another
reports 20 policemen
arriving at his flat at 3 a.m.
Others report 2-4
policemen calling round
Most are picked up from
their home address
Some feel threatened or
frightened by the police, a
few are restrained or
handcuffed, most come
quietly
1 Rang the police and they
took him back
1 Taken by the police
while on the streets
Ambulance
2 interviewees
were returned
by ambulance
On one of
these
occasions the
police also
attended
Method of return
SW/CPN
Friend/relative
These
9 interviewees
professionals mention that relatives
occasionally
and/or friends played
attend with
a role in their return
the police. In
Usually they
the patients
accompany the patient
view they do
all the way back to the
not appear to ward
play a
significant
role, but their
presence is
noted
60
Ward staff
2 interviewees were
brought back by ward
staff
One appears to have
been followed into the
street outside the
hospital and forcibly
returned
In the other case staff
interrupted and
prevented a suicide
attempt by calling at the
patients home
Of own accord
3 Walked back
7 Came back by public
transport
Sometimes patients returned
by themselves after the ward
staff ring them at home, one
returned in a cab ordered by
the ward
2 returned once they knew
the police had been officially
notified about the absence
Occasionally relatives or
friends persuade the patient
to return by themselves
Sometimes patients ring the
ward staff to let them know
they are returning
Table 7: Reasons for return - those patients who came back voluntarily
(or semi voluntarily with relatives)
Relatives and friends use a lot of verbal pressure in order to persuade the patient to return
"int: right .. your brother talked you into coming back? pt: yeah .. it took a long time to convince me"
To give the Dr another chance
2 To get medication to relieve side effects
Cold
Hunger
Not wanting to get the nurses into trouble
Not wanting to get relatives into trouble
2 To avoid being picked up by the police
2 returned for a CPA meeting
4 Nowhere else to go
2 Only wanted to be out for a little while, knew they would have to return
To get medication for symptoms
Threat of physical violence from relative
3 feeling unwell and in need of care
2 To get discharged, or discharge in view and not "wanting to ruin things"
End of activity they had left for, e.g. "int: what made you decide to suddenly come back? pt: the football match had finished."
Nothing to do at home
61
Findings 5
Life on the ward and reasons for leaving
Why did absconders leave the ward?
Tables 1 - 5 summarise the reasons patients gave for absconding from the ward
in some detail. The main reason for leaving without permission could not always be
elicited during the interview, and for some, the main reason was linked to psychotic
thinking or symptomatology. More details on this are provided below. However for
most interviewees, the main reasons for absconding were very diverse, ranging from
medication side effects to wishing to see relatives. No one main reason for leaving
predominates over others, with some patients leaving because they feel well, others to
drink alcohol, other because they are angry about a care decision, and yet others
because they feel neglected by staff.
In addition, it was quite clear from the interviews that most patients had more
than a single reason for absconding from the ward. Their main reason or trigger for
leaving was set against a background of discontent with their social situation as a
patient on an acute psychiatric ward, the treatment they were receiving, or negative
relationships with professional staff. These themes are explored in more detail below.
Angry leavers
Using the interview data, a distinction can be made between those absconders
who angrily leave (AL) from the ward, and those who are going to (GT) some other
place or activity. This division is not neat and tidy in every case. For example 'going
to' something can be done angrily, especially if a request to leave the ward to do
something in particular is refused by the staff. For example, one lady wished to visit
the grave of a close relative at the local cemetery, and when the request was refused,
she left the ward very angrily. Another example would be the equivalency between
'angrily leaving' the ward to get away from stuffiness, or 'going to' fresh air.
Nevertheless, it was possible to draw a distinction for over half the cases fairly easily.
The findings from this analysis are summarised in Tables 3 and 4.
Just over one in four of absconders fell clearly into the category of being an
angry leaver. Immediate triggers for leaving angrily were refused requests for leave:
pt: they said they were going to give me some leave and they
didn't give me any leave .. and I was better so I just left and I
came back after a few days. (P21706)
pt: and the next day I found out I wasn't entitled to no leave ..
so I absconded .. I walked out and came back ..(P62301)
Refused requests for discharge:
62
pt: the night before ..I didn't sleep at all ....because of my
tribunal and er ...my tribunal wasn't successful ..that's why I
left ...left the ward without saying anything to anybody well I
got my letter from the tribunal saying you know on the face of
the envelope saying and when I looked at it ..it said cannot be
discharged yeah ....so I felt very angry ...and then I just left
the ward ...basically then I just ran away ...because I know if
somebody wants to catch me then they can yeah ..then I took
a black cab to my home... (P12703)
pt: no. I had no intention of leaving the ward ..I just felt like
yesterday ..the reason why I left yesterday is because I was
taken for a FOOL you know ..getting all prepared ..getting all
dressed up ..in the end he didn't have no intentions of letting
me go. (P11508)
And a variety of other frustrations and arguments. However, as Table 3 shows, not
every angry leaver had an immediate prompt for their absconding. many left angrily
on the basis of long term dissatisfaction with being a psychiatric patient. Restrictions
on the patients freedom, unhappiness with enforced treatment, or feeling well and yet
still being in hospital, were all sources of frustration and anger for patients.
pt: I'm not a prisoner! I come here for help yeah ..if I go out I
need help .. I will come back .. I'm the one who come first
place .. nobody brought me here .. do you understand?
int: yes .. nobody brought you here .. you came here ..
pt: on my own .. (P21704)
pt: I felt much better .. I've been better for a long time now
and they still keep me in hospital. (P21706)
pt: yeah .. I came in of my own free will darlin' .. and the way I
got treated in X ward ..was DISGUSTING! Wouldn't anybody
go apeshit if they all surrounded you saying you should take
this .. you should take that and you should do this .. HOW DO
THEY KNOW WHAT THESE DRUGS DO TO PEOPLE
UNLESS YOU TAKE 'EM YOURSELF! (P22003)
In contrast to the angry leavers, those who left the ward to 'go to' something
had more longer term reasons for doing so. In fact only 3 of the 18 patients (29% of
the total number of absconding events) who fell into this category had any immediate
trigger for leaving, and for two of these the trigger was sight of the open door and an
opportunity to abscond. The GTs left primarily for social interaction with friends and
relatives, and to look after their household and family responsibilities.
Table 4 shows the proportion of ALs to GTs by gender, Mental Health Act
status, age, ethnicity, diagnosis, and NHS Trust. No clear pattern can be seen, and no
chi square test was significant. None of these variables appear to be related to whether
an absconder leaves the ward in anger or not.
63
Planned versus impulsive leavers
Table 7 contrasts those who plan to leave with those who leave suddenly and
impulsively. Numbers in this table are incomplete because not every interview
provided enough information about the abscond in order to determine exactly what
occurred. However it is clear from this table that such sudden absconds are more
common amongst those who are involuntarily detained in hospital. For these patients
the presentation of a visible opportunity to leave, or receiving some bad news about
leave or restrictions, can result in sudden and immediate action. It is also apparent in
the table that involuntarily detained patients are much less happy to be back on the
ward. Instead they are angry about their return and vigorously express the feeling that
they would rather be at home.
int: right .. how do you feel about being back in hospital now?
pt: I feel bad .. I want to go home (P21706)
pt: no .. I want to leave as soon as possible. (P22306)
pt: angry.. I don't like it at all. (P60306)
Psychiatric symptoms as triggers for absconding
34% of those interviewed had 'mental state' reasons for absconding. This is
likely to underrepresent the numbers for whom this was a contributory cause to
absconding, because some absconders (13%) were too disturbed be readily
interviewed upon their return to the ward. Patients' mental state as a reason for
absconding is therefore likely to be more important and prevalent than the interview
data alone suggests.
Table 5 examines in more detail the 34% or 18 patients interviewed whose
mental state contributed to their absconding. A small number of these patients could
not give a clear account of their abscond or its reasons, and in one or two cases
interviews were terminated prematurely because it was clear that patients were not in a
fit state to give informed consent or to be interviewed at all. It can be seen from the
table that a wide variety of psychiatric symptoms can lead to absconding. The most
obvious of these are command hallucinations (voices telling the patient to abscond) or
paranoid delusions that compel the patient to run away in order to seek safety.
Anxiety, worry and restlessness also propel patients into leaving the ward without
permission. Thought disorder or disorganised thinking might contribute to absconding
decisions through confusion or inability to understand or comprehend one's
predicament.
However what is also apparent from table 5 is that psychiatric symptoms do
not, by themselves, fully explain absconding. Not even for this group of patients.
Instead it can be seen that all the reasons described below also contribute to the
absconding of the acutely ill. These are normal, everyday, sensible and understandable
reasons for wanting to leave a psychiatric ward without permission. The way that
these can work together with psychiatric symptoms is illustrated by one interviewee:
64
int: do you ever get frightened here?
pt: yeah .. when a new patient comes in.
int: what is it that frightens you exactly.
pt: when they grab you .. it frightens me.
int: have you been attacked before?
pt: well ( ) just grabbed hold of my arms and wouldn't let me
go .. that's the day I went missing.
int: and how did he end up letting go of you?
pt: because I struggled and got free.
int: was there anybody around to see the incident?
pt: no there wasn't .. they were all in the office.
int: what happened immediately after you got free.. what did
you do?
pt: told a member of staff .. and then I come in here [own
room] .. and got ready and just went out.
int: what exactly made you want to leave?
pt: that and the voices .. what I've got in my head. (P40211)
Life as an inpatient on acute psychiatric wards
Returning to Tables 1 and 2, and looking also at Table 6, absconding patients
feelings about being inpatients on an acute psychiatric ward are explored. Neither the
social stigma of being a psychiatric patient, nor the ward environment appear to be
areas of prime concern for absconding patients. Few remarked upon these issues at all,
although the Trust with the oldest buildings does attract most of the criticism about
the ward environments. Neither are patients concerned about the fact that they are
under surveillance by nurses at all times while on the ward. What they do express
great concern about are: being frightened of others; being cut off from family and
friends; being unable to deal with their everyday responsibilities; being bored; and
feeling trapped and claustrophobic. This is what being an inpatient meant to the
sample of interviewed absconders.
Many interviewees (42%) expressed feelings of fear. Some of this fear was
related to psychiatric symptomatology, most was not. Patients were fearful of the
whole experience of being in hospital, sometimes fearful of the staff, but mostly afraid
of other patients. What a frightening place an acute psychiatric ward can be, even
without any actual violence, is vividly conveyed by the story of one absconder:
pt: the patient .. A with the night staff argued all the way
round to my bed .. and I had the cover of my bed ..I slung the
cover off my bed because it shocked me .. this was about
three four in the morning .. and I got woken up .. middle of
the night .. three o'clock and I wondered what it was .. and I
heard two people shouting .. a girl and .. a male and a female
voice .. and I found out afterwards it was one of the patients
and one of the night staff .. they were arguing for some
reason
int: is your bedspace quite far from this lady's bedspace?
pt: yes it is ..
int: ok .. so then that morning .. what were you thinking that
morning?
pt: well I was terrified .. I couldn't go back to sleep afterwards
and I was depressed over it .. didn't get enough sleep .. and I
just wanted to go home .. after that ..
65
int: were you frightened that you were going to be harmed?
pt: yeah .. in a way I thought I was going to be harmed ..
that's the reaction it brought on in me .. I got very frightened ..
and fidgety .. started shaking .. and I had to make meself a
cup of tea to calm me down .. horlicks I mean .. (P30303)
It is easy to imagine the degree of shock involved in being woken in this way in the
setting of an acute psychiatric ward. Patients fears about each other are quite
ubiquitous.
pt: there is this patient I was bit scared of him .. I don't know ..
at first I sort of had a crush on him and then it sort of turned
into sort of like and obsession or something .. and I always
thought that he was going to come and knock on my door
and maybe try and do something and I used to tell the staff
that and they thought no it's not going to happen (P52009)
pt: the new bloke just arrived and he just sort of grabbed my
two arms and he wouldn't let go .. I was just frightened of
him.
int: was he angry?
pt: yeah .. so I just left the ward. (P40211)
Any disturbance on the ward can raise a patients level of anxiety and fear, even if they
are not involved. Events at night seem to elicit particularly strong feelings of
vulnerability.
26% of absconding patients mentioned feeling isolated from friends and
family, and 42% felt homesick. Not all absconders had these feelings. Some were
visited very frequently, and yet others did not desire any contact with their family.
However for those that wanted more contact and did not get it, being in the acute
psychiatric ward could be a lonely experience. Hence most absconders went home or
to family and friends on leaving the ward, and many gave social contact as a reason
for leaving the ward.
pt: that's right .. the thing is if I'm not at home I feel that my
younger brothers and sisters .. they feel ill .. there's
something done in the face .. or something like that you see ..
if I'm not home. (P21809)
pt: yeah .. I just left to go round and see family .. (P42804)
The patients home (when they had one) was a source of worry and
preoccupation for absconding patients. This and other everyday responsibilities
created reasons for patients to need to leave the ward without permission. Thus some
patients left the ward to obtain personal property from home, others left to deal with
unpaid bills, keep the home clean, or just to check on the house in case of burglary.
I: right so all the time that you're in here you're aware that
it's..
pt: ..empty ..yeah.
I: do you worry about that?
pt: they can't get much ..all they can get is the television.
I: so it's not something that particularly bothers you?
66
pt: well ..I wouldn't like to lose my television ..but that's all
they can get...it is pretty safe there really because we've got
intercoms and a locked door so they have to buzz but if
anybody was smashing my window or that next door would
come out ...cause they're old ladies and they keep an eye out
... (P10811)
Indeed, patients are quite right to worry about the security of their house and property
while they are in hospital.
int: so how do you feel about being back in hospital now?
pt: terrible.
int: in what way?
pt: my house is burgled .. I have nothing left when I go back ..
if I wasn't here nothing would have happened to my house
..simple as that.
int: do you feel angry about that?
pt: I feel very angry.
int: who do you feel angry with?
pt: with myself.
int: what about with the staff here .. the doctors .. nurses?
pt: everybody ..everybody. (P51510)
Other patients worry more about their responsibilities to others, with children and
elderly relatives both being mentioned as in need of care and attention from the
patient.
pt: yeah .. I worry about my kids .. and my mum and dad ..
just keep worrying. (P42912)
On top of these worries about events and people within hospital, and social
networks and other responsibilities outside hospital, absconding patients also found
being on the ward a very boring experience. 42% talked about feeling bored.
int: do you feel more tired when you're back on the ward or
do you sleep..?
pt: ..to pass the time?
int: yeah ..
pt: to pass the time. (P10902)
pt: well as far as I'm concerned there's not much to do .. you
just end up smoking ..walking up and down . (P31912)
pt: like I just keep on doing .. I don't get that really frightened
.. I just get bored .. I just keep thinking about what might
happen next cause I'm always too bored .. it's like I'm locked
up in a prison .. (P21706)
This latter interviewee links feelings of being bored with feeling locked up. 58% of
the interviewees mentioned similar feelings.
pt: n...well sometimes I get the claustrophobic feeling ..
(P10902)
int: was there any particular reason you wanted to go to your
flat?
pt: yes.
67
int: and what was that?
pt: to get away from these walls?
int: so you didn't want to be on the ward itself?
pt: they lock you in. (P60411)
pt: I had no leave and they took my leave away .. I just felt
very trapped ..confined .. just had to get out of .. off the ward.
(P60308)
Treatment
Many absconders were seasoned inpatients, having had a series of previous
admissions. Table 8 shows that their expectations of inpatient hospital care were
modest and realistic, with the most frequently anticipated form of treatment being
medication.
int: so what kind of thing were you expecting when you came
here?
pt: basically treatment.
int: what sort of treatment?
pt: medicine. (P20605)
Opinions about the medication actually received in hospital were divided and
predominantly negative, as shown in tables 13 and 14. Medication was seen as not
required at all due to feeling well, the wrong type, not as good as what had previously
been prescribed on other occasions, producing unwanted side effects, given in too
high or too low a dose, or given by injection when it should be oral, or in syrup when
it should be tablets. In fact there was a great deal of negative talk about medication in
the interviews of absconding patients. Disagreements about medication can be reasons
for patient to abscond.
pt: well .. they went apeshit! the lot of people .. the lot of them
went apeshit! they all wanted to give me an injection .. cause
I wouldn't take it orally .. they're not allowed to enforce people
..to fucking take medication like that darlin'! REGARDLESS
OF THEIR BEHAVIOUR darlin'! People going up to people
like that have got every fucking right to complain! (P22003)
However the recognised need for medication can also be a reason to return:
int: so you were at home and then what made you decide to
come back to the ward?
pt: I don't know .. I just wanted some medication so the
voices would go. (P40211)
Table 14 shows that views about medication were equally as negative, whether the
patients were compulsorily detained or not. Some absconders were positive about
their medication regimen, most were not and were full of a variety of complaints
about it.
68
Absconding patients views about doctors and nurses
In parallel with their predominantly negative views about medication, doctors
and nurses were harshly judged by the absconders (see tables 9 - 12). Doctors were
seen as distant, disbelieving of patient reports, authoritarian, inaccessible and not
having sufficient time to listen to patients' problems. Involuntary patients who
absconded had more extremely negative attitudes towards doctors. These were linked
to the doctors actions under the Mental Health Act, and to medication related issues.
Just as some absconders were positive about about medication and doctors,
some were also positive about nurses, commenting favourably on their availability and
friendliness. However again the dominant view was negative. They were seen as
powerless in comparison to doctors, bossy, and unwilling to spend time with patients.
The role in enforcing medication was particularly disliked. In the case of nurses,
Mental Health Act status did not seem to influence absconder views (table 12).
It should be emphasised that some absconders did hold positive opinions about
nurses, doctors and medication. However, these positive views were held in relatively
smaller numbers. Additionally, these views are not representative of patients as a
whole, only of the absconders.
Feeling well and feeling ill
Three themes could be identified in the interviews which described conflicts
between the interviewees and both medical and nursing staff over differing
perceptions of ‘wellness’. The first theme is a scenario that’s probably familiar to
most psychiatric nurses. The patient is saying they are well, the staff disagree.
‘I don’t feel ill anymore .. there’s no need for me to be in
hospital at the
moment .. the main problem
has
disappeared .. I've been high .. and now I’m coming back to
my stability .. the doctors can’t see that I thought to myself .. I
just felt within myself I couldn’t cope with being here any
more .. it was making me feel too down.’
Twenty three of the fifty two people interviewed fell into this category. The majority
of whom agreed that at some point during the course of their stay in hospital they had
felt mentally unwell. Even those admitted under section were not querying whether
they had been unwell, but rather whether they were ill enough to warrant an
admission to hospital. Eleven had come into hospital voluntarily and seven of these
were later detained under the mental health act. Out of the twenty three, having to
remain in hospital even though they believed themselves to be well was not
particularly an issue for about ten people. They appeared to accept that this is what
staff thought would be the best thing and were content to wait to be discharged, albeit
they were expecting to be discharged fairly soon. However, for the rest being detained
in hospital against their will when they felt well enough to go home was proving to be
a major source of conflict with the staff.
69
The quote below is typical in that most described an improvement in their
mental state during the course of their stay, but talked about a prolonged stay in
hospital as being detrimental in that it exacerbated their sense of isolation, most of the
interviewees had less contact with family and friends while in hospital, and also
increased their concern over issues in their life outside the hospital, such as
accommodation and relationships.
‘I’ve made it quite clear to the staff the situation I’m in ..
they’ve seen me communicate with people well .. they’ve
seen me take action while under pressure .. they’ve
seen violence against me and I’ve done the appropriate
thing.’
This group were, on the whole, angry at their treatment by the psychiatric system.
Those admitted informally described the process whereby they had been able to
identify when they were becoming unwell and had sought help voluntarily. At this
point, their judgment about their mental state was seen as accurate and therefore valid
and a stay in hospital was suggested, to which most readily agreed, having already
anticipated this as a probability when they made contact with the services.
However, once admitted, things alter and in particular the perception of the
patient’s ability to judge their own mental health changes. At some time it is decided
that they are no longer fit to assess themselves and their judgment is now perceived as
incorrect and therefore invalid. From the point of view of these interviewees the
consequences of initiating contact with the services and agreeing to a stay in hospital
were profound. Having acknowledged that they required some sort of help, most
later found themselves detained against their will with all the treatment necessities
and restrictions that a section incurs. What came across in the interviews was a strong
sense of not being valued, of feeling betrayed, of being up against the system, and
consequently of feeling trapped while in hospital and, as in this quote, not knowing
what to do to convince staff that they were well enough to go home.
The second theme was much less common but has potentially serious
consequences. It is simply the reverse of the first scenario. That is to say the staff
think the patient is well enough to go home but the patient disagrees, believing they
need to stay in hospital.
‘well I can’t be discharged .. because I’m not well enough .. I
realise that now .. see I was going out and testing meself
.. I wanted to test meself to see what I’d be like .. I want
to get out of this whole regime but I can’t because ’m not
well enough .. but I go out and I test meself to see if I can do
and then I fall apart.’
The patients in this group had also sought help voluntarily and agreed to be admitted
to hospital. At first sight, it seems paradoxical that they should be in my sample since
by definition if you wanted to remain in hospital then how could you hope to achieve
this by absconding? Women in particular would be much less likely to achieve their
desired outcome of an extended stay because, if you’re a woman and you go awol
chances are you’ll be discharged or placed on leave in your absence.
70
However, as can be seen from the quote, absconding from the ward and the
events during the abscond can be acts designed to demonstrate just how unwell the
patient believes they are. To be told you are well enough to go home when you see
yourself as unwell, is taken as a rejection. These interviewees described not being
believed by staff and the response to this was to abscond and partake in selfdestructive behaviour. An awareness was shown that their behaviour was seen as
‘attention seeking’ but deny this was the case. They talked about their conduct as
actions not primarily aimed at eliciting a response from the team (not least because the
team response would not necessarily be the preferred one), but rather as a response to
how they are feeling at the time.
‘Only today, being told that I don’t suffer with deep depression
.. I suffer with binge drinking .. which is a load of rubbish .. I
suffer with depression .. I said to the doctor you don’t
know me .. you don’t know how I feel .. how can you judge
me .. he don’t don’t know how I feel inside .. I said it’s like
being in a black pit and trying to climb out of it .. he was
meaning to be hard.’
This quote is from a patient who was back on the ward having absconded and taken an
overdose after being told by her doctor that she was not clinically depressed and was
therefore ready to be sent home on leave. It seems that at least in some instances, the
very fact that you can identify and talk about your problem is considered proof that
you do not require professional intervention, and that in fact staff fear such
intervention serves only a negative purpose in that it condones and encourages the
patient to see themselves as ill when this is in direct conflict with what staff believe.
Indeed, this woman was told by a member of the team that a sure sign she wasn’t
really suicidal was that she could talk about it rather than just getting on with it.
On initially making contact with the mental health services, presumably these
people were taken seriously when they communicated their problems since they were
admitted to hospital. However, in common with those quoted in the first theme, they
related the view that once in hospital, the ability to judge their own mental state was
seen as irrelevant. Both medical and to a lesser extent nursing staff, were perceived
as setting themselves up not simply as experts on mental illness, but also as experts
on the subjective experience of the illness. The result was that the patients believed
their opinions were being trivialised and hence their experiences invalidated.
A third theme was also identified in which people were saying they knew they
were ill or had been ill, they knew the staff also perceived them as being ill, but the
conflict arose over the way the way the problem was being defined.
‘I was able to tell the nursing staff .. but it would be the same
thing ..sort of question they’d ask me .. is the television
talking to you ..can you hear your name on the radio .. I’d
be telling them no .. it’s nothing like that you know .. it’s
just .. I know it’s my mind ..it’s just not intact you know .. but
they all ask the same sort of questions .. all of them.’
Most people talked about their illness in terms of it affecting their ability to function
on a day to day basis, so that being able to cope became a central means of defining
their state of mind. They talked about trying to communicate with staff about how
71
they were feeling but, like the patient quoted here, described being met with
responses which focused on symptomatology. They felt they were not being listened
to, or acknowledged, and were being asked questions which held no relevance for
them. This led to feelings of deep frustration and anger, and a belief that they had
little say in their own treatment since both medical and nursing staff had already
made up their minds about what the problem was and how it should be addresses.
Of course, many will say that the reason staff focus on the symptomatology is that
treating the symptoms will enable the patient to cope. However, for those people who
may have shown typical symptoms on previous admissions but don’t on this occasion,
or who don’t consider their symptoms to be a primary problem or even a problem at
all, the issue is more complicated. As one man said ‘I only hear voices they don’t
disturb me.’
‘my main problem is I’ve got mental disorder .. and I know
that I’ve got it .. cause I know that I’ve got mental illness .. I
can feel it in my brain .. every time it hurts .. like I get afraid of
people cause of it .. I keep getting ill .. so I come back to the
hospital to take my medication.’
The interviewee quoted here described being in a state of perpetual fear when he is
unwell. A number of people in this sample talked about ongoing anxiety/fear as core
feelings of their ‘unwellness’, which they mostly did not relate to hearing voices or
other obvious symptomatology. Their anxiety was often exacerbated by having to
keep quiet about it for fear of the consequences. Trusting staff was seen as too risky.
These patients claim that experience has taught them to limit what they reveal to staff.
Experience which includes having leave denied, being detained further in hospital, or
having medication increased or administered forcefully. The result is a situation where
patients are desperate for help but at the same time are terrified of the help they may
receive. Many in of this group, including the person quoted, complained about their
medication and were seen as non-compliant. However, most appeared to want some
form of medication, just not the particular drugs they were on at the time, which they
felt offered them no relief from their state of mind.
72
Table 1:Reasons for leaving by NHS Trust - I
Trust
E
O
S
Main reasons
Akathisia
Obtain money, finance 2
Angry at delayed access to Dr Psychotic reasoning 2
Angry at refused leave
See relatives, missing them
Attacked by fellow patient
2
Feel well
Self hamr
Feeling neglected by staff 2
Speak to wife
Homesick 2
To avoid taking medication
Housework
Told by solicitor by phone
No clear reason elicited 3
that he was free to leave
Trapped, locked in
Angry at enforced medication
Angry at refused discharge 2
Angry at refused leave 2
Angry at restricted leave
Bored
Couldn't wait for official leave
arrangements to happen
Drink
Drs don't understand my
problem
Feeling neglected by staff
Feelwell
Finance/housework
Homesick 2
No clear reason elicited
Other patients disturbing 2
Psychotic reasoning 2
See girlfriend before transfer
to locked ward
Visit relatives/friends 2
Went to check on house and
found it had been burgled
Angry at not being allowed out
to the shop
Bored and fed up
Drink
Homesick 3
Overslept whilst on leave
See relatives, missing them
Stigma
Mentioned by 3
"I don't want people to
think I'm mad anymore"
" there are things that
happen when I'm ill .. for
instance you know the way
I behave ..and neighbours
the things that they see
that I do .. and they don't
understand that it's
because I'm sick"
Mentioned by 1
" I don't want her to know
I'm here...... she might
think I'm crazy. int: so she
has no knowledge that
you've ever been in a
psychiatric hospital? pt:
no.. she thinks I'm living in
Ireland"
Mentioned by 0
73
The ward environment
Noise: snoring disturbs
sleep, ward front door bell
Not being allowed to smoke
cannabis
Other patients
Unwelcome physical
contact from other patients
Fear of new patients who
are unpredictable
Assaults, fear of assaults
The freedom of an open
ward evokes fear of what
might happen
Lack of freedom to make
snacks and beverages
when desired
" the food's lousy"
Lack of privacy: " this ain't
even private .. it's my room
..[gestures to noise from
adjoining room]"
Institutional: " it's not a warm
or comfortable
environment.. it's very much
like industrialist .. metal
beds .. metal like beds
The ward is cold
Dislike of non British food
Not allowed to drink alcohol
Don't know what to say to
them
Got involved in a fight
Noisy at night, keep you
awake
Frightening to be suddenly
awoken by another patient
in the middle of the night
Arguing between other
patients, and between
other patients and staff is
intimidating
Delusional and paranoid
fears about other patients
Table 2: Reasons for leaving by NHS Trust - II
Trust
E
O
S
Social
Isolated, no friends or relatives
Missing family, wanting more visitors
Some relatives close, and relied upon a lot, others rarely seen when patient
is ill
Visiting relative get irritated by patients behaviour while ill
More likely to be visited by relatives on a closed ward
Not all family members care enough to keep in contact during an admission
Missing children/family 2
Family bring in all meals
Worry about family when head of household
Whole family visits in shifts, keep in touch with reality
Family don't visit at all 2
Have lots a friends, daughter, girlfriend, but they don't visit - asbconds to
see them
Hiding admission from girlfriend
Suddenly turning up at home after absconding frightens the family
Visitors are not allowed onto the ward 3
Family live too far away to visit
Have visitors every day
Uses telephone to stay in touch, but no privacy
Worry about younger siblings while away in hospital
Family get upset by illness and decrease contact during admission
Patient doesn't know what to say to visiting relatives, doesn't want them to
visit
Contact from some relatives is unwelcome
Missing family while in hospital
Children don't visit, don't understand what's wrong
74
Responsibilities
Cleanliness and tidiness of home 2
Risk of burglary
Potential loss of job through absence
Bills to be paid, need to deal with important letters 2
Find somewhere to live 2
Admissions and illness cause worry to the children, and affect their
lives
Worried about losing flat while in hospital
Oldest man, household leader
Care of sick elderly relative with arthritis
Flat burgled while in hospital 2
Deal with unpaid bills
Access personal property
On last admission flat was stripped of property, including all the
furniture
Care of daughter ill with flu
Need to check on post and flat
Care of mother who has dementia
Care of elderly father
Elderly parent not on the phone
Access of personal property (clothes)
Lost job due to illness
Admission caused loss of place on college course
Table 3: Immediate versus longer term reasons for leaving
Angry
leave
from
Go to
Other
Triggers/Reasons
Immediate
48 hours before
Requested leave refused at ward round 2
None in particular 6
None in particular 7
Fed up, frustrated
Got letter from tribunal refusing discharge Restrictions, not allowed to make tea
Prompt access to Dr refused 2
Frightened by another patient during the
Lies told about him at tribunal
night
Assault by another patient and auditory
Enforced medication 2
hallucinations
Unhappy with medication
Argument with nurse about visitor being
Feels self cured
denied access
Feeling locked in
Leave decision postponed because
meeting delayed
None in particular 10
Just want to be out 2
Opportunity 2
Wanted a drink
Sudden urge
Homesick, worried about house 4
Awareness that being on a sec 41
meant that he would not get leave for a
long time
Missing company of friends
Nurse would not spend time listening to
account of bad dreams
Refusal of permission to visit grave
None in particular
Needing access to post
Known childcare need
Planned response to expiration of
section
Disagreement with staff about leave
request
None in particular 5
Asked to go on leave when patient did
Sudden urge
not think she was ready
Overslept while on leave
Unable to relax
Member of staff told him to leave
Wife said she didn't want him back
Psychotic reasoning or don't remember 5
home
Telephone conversation with solicitor
Considered himself cured
Auditory hallucinations
Planned in conversation with another
Having to wait for leave escort
patient
Psychotic reasoning or don't remember
5
Ward too boring to return from leave
Nurses neglecting me
Just want out
Anticipating official leave
75
Table 4: Angry leaving from versus going to
Angry leave from
14 Male
3 Female
4 Informal
MHA
13 Involuntary
8 35 & under
Age
9 36 & over
5 Afro-Caribbean
Ethnicity
3 Bangladeshi
1 Other African
0 Somali
1 Other Asian
7 White European
Diagnosis 10 Schizophrenia
7 Other
7E
Trust
9O
1S
No result significant by chi square
Gender
Go to
14 Male
4 Female
9 Informal
9 Involuntary
14 35 & under
4 36 & over
5 Afro-Caribbean
1 Bangladeshi
4 Other African
2 Somali
0 Other Asian
5 White European
12 Schizophrenia
4 Other
6E
7O
5S
76
Other
13 Male
4 Female
6 Informal
11 Involuntary
8 35 & under
9 36 & over
2 Afro-Caribbean
1 Bangladeshi
0 Other African
1 Somali
0 Other Asian
13 White European
8 Schizophrenia
7 Other
8E
7O
2S
Table 5: Patients whose mental state is implicated in their absconding reasons and triggers for leaving
Schizophrenia
Other
diagnoses
Mental state
Erotomania (attachment to doctor who
would not see her immediately on
demand)
Vague paranoid ideas about what
others on the ward were saying to
each other
Couldn't relax or sit still (?akathisia)
Account of abscond marred by mild
thought disorder or disorganised
thinking
Not hearing voices this admission,
reason for being on the ward is
"having a fever"
Anxious, restless, irritable
"My mind is not intact"
Poisoned by the tablets given by
nurses
Florid paranoia: food and drink on the
ward poisoned, people on the ward
are going to murder the patient, fear of
imminent death
Command hallucinations from the TV
Suicide attempt linked to anger at
misdiagnosis by doctor
Fed up
Major anxiety and panic (left to treat
self with street drugs)
Garbled account, with references to
"voices" and "superstitions"
Very garbled account
Frightened by bad dreams
Hearing voices, mind racing
Depressed, feel really sick
Garbled account of abscond, claims to
have met Mike Atherton while away
from the ward
Vague flights of ideas
Command hallucinations, voices told
patient to abscond 2
Loss of concentration, preoccupied
Feels a burden to others
Suicidal impulses
77
Other reasons/triggers
Left to sort out unpaid bills at flat
Sudden awareness of implications of
sec 41
Refused leave at ward round 2
Feeling bored, locked in, trapped
Homesick
Objects to medication side effects
Fear of other patients
Restrictions on behaviour and activity
Isolation from family, missing family 2
Lack of privacy
Homesick 2
Dissatisfaction with medication
Refusal of permission to go to the
shop
Missing family/friends
Boredom, nothing to do 2
Delayed access to doctor, not seen at
ward round, and no specific date given
for CPA meeting
Assaulted by another patient
The doctors preach at you
Refused permission to visit grave
Feeling trapped, locked in
Worry about elderly mother
Visitor refused access
Table 6: Feelings about being on the ward or absconding
Freedom,
liberation,
power
Anxiety,
fear
Trapped,
locked in
Observed,
monitored,
watched
Boredom
Homesick
Isolation
Anger
"I think it was like three good days of my life cause I was free .. and having a good time"
"I saw my mum and dad ..I saw my own place after two ..two weeks ..my own room with my own
things you know ..my own car ..you name it ..it was completely different ...it was freedom when I
went over there you know"
"as long as they give me my medication and like able to be you know to well freely go about my
business you know"
The feeling of freedom is mentioned by 6 other absconders
Nervous and fearful about coming into the psychiatric hospital 2
Anxiety as a psychiatric symptom
Unhappy about lax sharps policy and fears being cut by another patient wielding a razor in the
middle of the night
Frightened by an argument between another patient and a member of staff during the night
Frightened that other patients "might come in and kill me" during the night
Other "commotions" between patients and staff evoke fear, the ward id "disturbing" 2
Worry about practical issues: visas and residency, not able to attend appointments about this,
dependent relatives
Fear of the staff
Frightened all the time on the ward vs feel safe on the ward
Frightened by criticism from others
Frightened by the experience of C & R
Fear of sexual assault by another patient
Fear arising out of paranoid delusions of poisoning or plots 2
42% of interviewees expressed some feelings of fear, the remainder explicitly denied any such
feelings
These are mentioned by 58% of interviewees
Claustrophobic
Like a prisoner, or being in a prison 3
Unable to go out when you want
Linked to being detained under the MHA
Use of keys by the staff symbolically emphasises this feeling
Not wanting to be on the ward
"I feel like I'm in a cage"
Linked to the ward door being locked on occasion 2
No interviewee mentioned this, noticed it, or complained of it at all
Mentioned by 42% of interviewees
Sleep a lot to pass the time 2
Smoking
"you just end up smoking ..walking up and down"
"Chat, talk to people, socialize"
Activities mentioned: watching TV, read a book, play table tennis, listen to music, playing games,
OT groups
Not enough books to read
"boredom .. there's nothing to do in the hospital.. all I have to do is stand for all day .. stand in one
place for all day and don't even go out .. ain't got nothing to do in there"
Several respondents link their boredom to not being able to go out
Some report that they are bored all the time, and one gave it as a reason for not returning from
leave
42% of patients mention that they prefer to be at home, with their family if they have one
"wanted to get home" 7
"int: do you wish to go home? pt: yes.. yes .. yes"
26% of interviewees mentioned feeling isolated from their families and friends
This is clearly linked to feelings of wanting to go home
Two patients also felt ignored and neglected by the staff
This is linked to refusals of leave or discharge, negative tribunal decisions, delayed access to
doctors, and enforced medication
78
Table 7: Planned versus impulsive leavers
Planned
leaving
Impulsive
leaving
How
feeling on
return
Involuntary
2 Left with clear plan to commit
suicide
3 Watched and waited for
opportunity to leave
4 Planned to be away for a specific
and limited period of time
Left with a specific task to carry out
Secured funds for transport first
None packed their bags before
leaving
10 Sudden decision, impulsive
leaving
Rather be at home
Happy to be back
Feels punished
Feels will be punished in future
Bored
3 Regretful
4 Not too bad/all right
Warm and safe
2 Rather be at home
2 Angry to have been brought back
Pleased because people cared
enough to bring them back to the
ward
Hate it
79
Informal
2 Planned to be away for a specific and
limited period of time
1 Packed bags before leaving
2 Left with a specific task to carry out
Planned for half hour
4 Sudden decision, impulsive leaving
3 Happy to be back
Regretful
4 Not too bad/all right
Rather be at home
Feel bad regardless of location
Frightened of the voices
Feel stupid/chagrin
Terrible (due to flat being burgled)
Table 8: Expectations by Trust
trust
E
O
S
general specific expectations
medication 9
place to stay / peace of mind / group and
1:1 therapy / short stay (2 weeks) / nice
quiet long rest
‘nurses to come and talk to me about my
problems’
‘medication .. and moral and friendly
support’
‘to be looked after well and get better’.
medication 9
short stay (1 week)
‘a bit of restitution from the pressure from
the outside world’ 2
regular food
companionship
‘I came here for me throat .. I had a cough
..tonsilitis’
‘lots of nurses and lots of rules’
medication 4
to be able to go out
short stay 2
rest from family
expectation failures
‘I expected good medication but I didn’t get none .. I’ve
been getting worse and worse’
‘nothing .. not too much’
‘nothing in particular’
expectation surprises
choice in type of meds (liquid, tablets,
injection), having facilities like an art room,
not as many rules to follow as expected.
‘I thought they might discharge me because
I’d had a drink’.
‘they’ve put me on diazepam and melleril .. and I’m
getting worse’
‘when I see Dr X he was really offish with me .. that
made me feel I wasn’t getting any help’
‘I’m not quite sure really you know .. staff treat you
differently .. they’ve got things like OT and stuff’
‘to get some help .. I was hearing voices .. I wanted the
voices to go away’
‘I don’t understand why I’m here’
‘more freedom ..less drugs ..they pumped me up full of
drugs last time and they’re trying to do the same thing
now’
‘I’ve had enough of the hospital ..I’ve been in hospital
for three months ..all I came in for is so that I could stay
here for about a week or somthing and I’ve been here
three months and about a week now!’
length of stay: ‘it’s turned out to be longer than I
expected ..’ expected 2 or 3 weeks stay in hospital
‘I was expecting it to be a rough unpleasant ..
violent in a way .. which once I’d been here
and everything .. I found it was a very
pleasant ward to be in .. a lot better than I
expected’
‘I had visions of them sort of forcing it (meds)
down my throat but they didn’t’
‘people want me in strait jackets’
80
Table 9: Doctors by Trust
E
’m frightened of the consultant because
she doesn’t seem to want to let me go’
‘I mean as the doctor said to me if
somebody really wanted to kill themselves
they would just do it’ (re registrar)
‘he’s nice .. but I went in Wednesday and
I was drunk .. he said come back when
you’re sober .. that’s when I ran home’
(same pt re consultant)
‘can’t tell the doctor .. it would take too
long’
‘they’re so busy’ (having to wait to see dr)
‘Dr 14 is all right .. I like him .. he’s a good
man .. and apart from that I don’t hardly
know any other drs’ (although pt doesn’t
agree with meds treatment)
‘I’ve known him very well since I became
a pt here’ re able to talk to dr
about doctors
O
‘I think he’s a very sarcastic person .. he seems to
think he could just see you and then he knows
what’s wrong with you .. which I think is wrong’ (re
Dr 4)
‘when I see Dr 4 I didn’t have a chance to say a
word because he said what he had to say and that
was it .. as blunt as that’ (re Dr 4)
‘what gets me .. why can’t they be polite back to
me .. I’m always polite to him’ (re Dr 4)
‘he had his opinions and they were made up
before .. I was totally honest .. I told him
everything .. but it didn’t influence his thoughts in
any way I don’t think what I said’
(re Dr 4)
‘I don’t like them doctors .. they’re too bossy’
‘I find talking to them a lot harder .. because they
normally think they know it all’
‘I hate his guts’
‘I get on all right with the doctors’
‘he’s great’
‘I get on very well with the doctors .. like a house
on fire’
‘I haven’t got a very good relationship yet because
I’ve met him only about two times .. and he’s a
busy guy’
81
S
male pt prefers male doctor
‘the doctors .. they believe the nurses .. they
never listen to the patients’
‘he will say what do you know about
medication .. I am the doctor’
‘I can’t talk to them .. they don’t understand
.. I tell them what’s wrong with me and they
don’t want to know’
‘they don’t really want to know .. they just
want to get on with what they’re doing .. you
can’t tell them that .. it’s them that tell you’
Table 10: Doctors by Mental Health Act status
about doctors
positive
informal
involuntary
erotomania
‘I get on very well with the drs .. like a house on
fire’
‘she’s good’
‘I like him .. he’s a good man’ (although doesn’t
agree with meds he’s on)
gets on ‘all right’ but does not discuss anything
with dr ‘ I just like keeping things to myself’
‘I’ve only seen him once .. it’s ok .. he’s a busy
man’
‘I’ve got a very good relationship yet becasue I’ve
only met him two times .. he’s a busy guy’
‘the doctors seem quite good’
‘I get on all right with the drs’
‘I get on with the drs well’
‘he’s great’
get on ‘all right’ with dr
‘when I speak to my consultant I don’t have an
opinionated self’ (meets dr half way so gets on
well)
negative
‘he was really offish with me .. I didn’t have a chance to say a word .. he said what he had
to say and that was it .. as blunt as that’
male pt prefers male drs
‘I don’t think I’d be able to tell them .. it would take too long’ (re voices)
‘he’s always talking to me like I’m a very high quality good precious boy’
‘I can talk to them but they don’t understand’
‘I find talking to them a lot harder because they think they know it all’
‘they don’t really want to know .. they just want to get on with what they’re doing’
‘being told that I don’t suffer with deep depression .. the doctor said to me if somebody
wanted to really kill themselves they would just go off and do it’
‘he’s a very sarcastic person’
‘why can’t they be polite back to me .. I’m always polite to him’
‘the doctors .. they believe the nurses .. they never listen to the pts’
‘he will say .. I am the dr .. what do you know about medication .. I have nothing to say to
him’
‘I don’t like the doctors they’re too bossy’
‘I worry about them .. what the nurses and drs are doing to me .. giving me medicines
..without a reason’
‘they’re so busy ..I’ve been sitting here patiently for a whole week waiting for a doctor’
‘I’ve seen him once’
‘I feel frightened of the consultant because she doesn’t seem to want to let me go’
‘I hate his guts’
‘he has his opinions and they were made up before .. he listened but it didn’t influence his
thoughts what I said’
‘she’s a bitch ..she put me on a section 3’
‘I’m finished with my dr’
82
Table 11: Nurses by Trust
about nurses
O
S
‘the nurses are nice .. they looked after me’
‘the staff here .. they don’t listen ..even if
‘I get on quite all right with them’ 5
you’re ill .. very ill .. they don’t give a shit about
‘they are friendly and giving medicine properly’
you .. they’re all drinking tea in the office ..
‘I’ve got great respect for most of them’
nobody listens to you .. sometimes staff are
‘I used to feel scared talking to people in case I was a too bad’
nuisance’
‘the thing is the nurses can’t do nothing ..
‘all right ..some of them I don’t like’
without the doctor .. you have to wait .. you’re
‘I like them .. you get the odd one or two that try and be not feeling well and they can’t do nothing
pushy and bossy but as long as you do as you’re told about it’
there’s no problems’
‘the staff haven’t got time for you here .. they
‘I’ve known him for years .. he’s known me for years .. just want to do their own thing you know ..
he understands me a damn site better than anyone now I don’t really speak to them because I
else’ (re only staff member pt likes)
know they haven’t got time for me ... they’re
‘you don’t know what to expect here .. not from the all right’
nurses .. you know .. the attitude you’re going to get
from one minute to the next you know you get one
good nurse .. you get one bad nurse ..they just walk
around .. they don’t want to be here’ 2
‘I feel they force me to take the medicines ..I cannot
trust any nurses’
‘it’s the psychiatrist who you tell what’s going on in your
head .. not really nurses .. I don’t have anything to say
to the nurses’
‘I can’t trust them .. you talk to someone and it’s not
just you and that person you talk to it’s every nurse ..
it’s all the nurses you’re talking to’ (re
handover/notes/etc)
rest have very brief comments on staff ‘they’re ok’ or in 2 documents (E) - difficult to make sense of what is being said.
E
‘the nurses seemto understand a little bit more
[than drs] when I talk to them’
‘I get on fine with them’
‘anything that’s on my mind .. I can tell them’
‘very good .. I get on with them’
‘ok ..I know the staff well’
‘they were too busy’ (after an incident)
‘I don’t get on with none of them .. I don’t talk to
anyone .. I might get another injection or
something like that’
‘when they give me my tablets I just say .. didn’t
matter what happened before that .. I just say not
too bad’
‘they find it difficult to look after anyone that’s
psychiatrically ill and jumps around screaming on
the ward and things’
‘I feel the nurses have been neglecting me .. so I
wasn’t getting anything out of being in hospital’
‘the staff muck me about .. the day staff are all
right’
‘all those agency nurses who haven’t a clue’
83
Table 12: Nurses by Mental Health Act status
informal
involuntary
positive
‘you don’t know what to expect here from the
nurses .. the attitude you’re going to get from one
minute to the next .. you get one good nurse .. one
bad nurse ..they don’t want to be here’
‘I’ve known him for years .. he’s known me for
years .. he understands me a damn site better
than anybody else’ (X)
relationship with nurses is ‘all right’
‘I’ve got great respect for most of them’
able to talk more to nurses than drs
‘they’re very nice ..the nurses .. they seem to
understand a lit bit more’
‘the nurses are nice .. they looked after me’
‘I get on quite all right with them’
‘they’re all right’ (Y)
‘I get on fine with them’ 2
‘they’re friendly’
‘very good .. I get on with them’
‘I know the staff well’
‘I get on all right with the nurses’ 2
helpful talking to the nurses 1
‘the day staff are all right’ (Z)
gets on ‘very nicely’ with nurses
gets along ‘very well’ with nurses
negative
‘when they give me my tablets I just say .. didn’t matter waht happened before that I
just say not too bad’
‘they find it difficult to look after anyone that’s psychiatrically ill’
generally doesn’t get on with staff at all (X)
‘you get the odd one or two that try to be pushy and bossy but as long as you do as
you’re told there’s no problems’
‘they’re too busy’
‘I don’t get on with none of them .. I don’t talk to anyone .. I feel too shy .. too afraid ..I
might get another injection’
‘they wake me up too many times’
‘they haven’t got time for you here’
‘can’t trust them’ (confidential info passed on at handover, written in notes etc.)
didn’t feel listened to 1
‘I felt bad because he said it in front of everybody .. in the staff room’
‘it’s basically no relationship .. it’s basically a relationship with medicine’
‘staff treat you differently from other staff .. I get on with the staff all right as long as
you give them the due respect they deserve they’ll be all right with you’
‘some of them I don’t like’
‘they don’t listen ..even if you’re ill ..they don’t give a shit about you’
‘the nurses can’t do nothing without the doctor .. you’re not feeling well and they can’t
do nothing about it’
‘in here they don’t talk much’ (Y)
‘I cannot trust the nurses’
‘I feel that the nurses had been neglecting me .. so I wasn’t getting anything out of
being in hospital’
‘it’s not their job .. it’s the psychiatrist who you tell what’s going on in your head .. I don’t
have anything to say to the nurses’
‘the staff muck me about’ (Z ref to night staff)
‘all those agency nurses who haven’t got a clue’
84
Table 13: Medication by Trust
E
O
S
positive
negative
‘getting me better in terms of medication
..if I don’t want to get tablets .. I get
liquids ..if I don’t want to get tablets or
liquids I get injectionables’
‘I’ve been very happy especially with the
medication I’m on now’.
‘I just wanted some medication so the
voices would go’ (re reason for returning)
‘I’m expected to be here for medication’
(reason for return)
need medication 2
‘you’ve got to have something to keep
you going ..taking your medication to
keep you stable’
‘once I weren’t having my medication
(while absconded) I realised I needed it’
‘where I hadn’t been taking my tablets
for depression .. I lose all concentration’
medication ‘sometimes’ helps
‘the medication’s been ok’
‘I feel a lot better since taking it anyway’
‘I didn’t have no medication .. I needed it’
‘I shouldn’t be on medication.. there’s nothing wrong with me ..I only hear voices’
1 felt better for not taking meds
‘no medication helps me because all I need .. if anything I suffer with depression not schizophrenia’ (pt has diagnosis
of schizophrenia)
‘it’s too much medication .. my brain can’t communicate properly’ ‘I’m frightened of the injections and the way they
give it to me’ ‘I was getting so many terrible effects’‘I keep getting ill .. so I come back to the hospital to take my
medication’
‘I expected good medication .. I had it for two years ..they won’t give it to me again ..it was clozaril’
‘they’ve given me tablets that are causing me other side effects’ ‘I mean I’m a well man’
‘my construction of thought was impaired ..I couldn’t communicate properly’ (result of injection)
‘I don’t need this medication .. it makes me drowsy’
fear (feeling unsafe) of injections especially when enforced 2
‘I don’t want to take the medicines .. they make me dizzy’
‘they refused to stop the medicine .. I asked to stop the medicine’
‘when I take the syrup I feel so clumpy ..I only take the tablet’
‘syrup .. in liquid form .. I think they’ve given me too much’
‘I don’t like the injection itself’ (as opposed to medication)
complaints of side effects 2
‘I was expecting them to treat my anxiety with either medication or some other way .. they put me on diazepam and
melleril which isn’t helping me .. I’m getting worse’
‘I feel better without the medication because some medication causes me drowsiness ..I feel too sleepy .. if I have
something on my mind .. to do something tomorrow .. and if I take the tablets .. then it makes me forget’ ‘I think they
should have prescribed me something else’
‘the medication is not working’ ‘ the right medication would make me feel happy’ ‘ I was on injections .. that helped me
but I was getting side effects and I come off it’.
85
Table 14: Medication by Mental Health Act status
informal
involuntary
positive
‘once I weren’t having my medication (while absconded) I
realised I needed it’
‘where I hadn’t been taking my tablets for depression .. I
lose all concentration’
‘I didn’t have no medication .. I needed it’
‘I wanted some medication so the voices would go’
‘you’ve got to have something to keep you going ..taking
your medication to keep you stable’
medication ‘sometimes’ helps
‘the medication’s been ok’
‘I feel a lot better since taking it anyway’
‘I was always going to take the medication .. and the
injection even though I didn’t like the injection .. I never
missed one in 20 years’
like choice offered of meds (tablets, syrup etc)
‘I’ve been very happy especially with the medication I’m
on’
‘I’m expected to be here for medication’ (reason for
returning)
negative
‘they refused to stop the medicine .. I asked to stop the medicine’
‘I was expecting them to treat my anxiety with either medication or some other
way .. they put me on diazepam and melleril which isn’t helping me .. I’m getting
worse’
‘I shouldn’t be on medication .. I only hear voices’
felt better without medication 1
feel fear (unsafe) about injections especially enforced 1
‘my construction of thought was impaired ..I couldn’t communicate properly’
(result of injection)
‘I don’t want to take the medicines .. they make me dizzy’
‘they’ve given me tablets that are causing me other side effects’ ‘I mean I’m a
well man’
‘no medication helps me .. I suffer from depression not schizophrenia’
‘the medication ain’t working’ (wants different meds)
‘I just want to stop it’ ‘the injection is making me worse’ ‘I was getting so many
terrible [side] effects’ ‘I come back because I need my medication’
‘syrup .. in liquid form .. I think they’ve given me too much’
‘I think they should have prescribed me something else’
86
Findings 6:
Absconding and ethnicity
The reader is reminded of the cautions expressed in the chapter giving an
overview of the data. Numbers in some of the ethnic minority categories are small,
and any generalisations made about such groups in this report must be considered to
be highly tentative. Stronger conclusions can be drawn about white Europeans and
Afro Carribbeans, who were well represented in both quantitative and qualitative
samples.
It should also be emphasised that all ethnic groups of absconders had many
things in common. Few like being in hospital, they feel bored, trapped, worry about
their families and responsibilities. The text below examines only the differences
between groups in order to discover more about how motivations to abscond arise
differently, and how the dilemmas of a hospital admission are differently accented for
ethnic minority groups.
Afro-Caribbean absconders
Table 1 shows that Afro-Caribbean absconders were no more likely to abuse
cannabis while away from the ward than the white Europeans (22% and 24% of each
group respectively). On balance, this group is more negative than positive in their
attitude to medication (Table 3). It would appear from table 4 that a high number of
absconders in this group were without accommodation outside hospital, however
examination of the quantitative data set shows that only 8% of absconders from this
group were homeless, compared to 13% in the white European group. This group was,
however, the most socially isolated of all, with few outside contacts during their
hospital stay. Very few absconders in this group expressed any fear about being in
hospital, and none admitted that they were ill, although some were willing to say that
they had been ill (Table 7) . This latter point is in contrast to every other ethnic group
of absconders except the Somali's, who also believed themselves to be well.
Care plans for this group rated them as at risk of harming others or abusing
substances at the time of their first abscond no more frequently than for other groups.
Similarly, this group of absconders were no more likely to have had previous contact
with the police (at time of first abscond) or to have a forensic history. However this
group (along with the Somali group) were more likely to have the police informed
about their abscond (68% of absconding events, versus 20 - 44% for other groups,
significant by chi square, p < 0.001). This difference was not present for first
absconding events, only for subsequent ones, and is greater for male absconders than
for females. It would appear, therefore, that absconding by a member of this group
heightened and amplified the anxieties of staff in a way that did not occur for others.
87
Bangladeshi absconders
Table 2 shows this group to be proportionately more negative in their
evaluation of doctors than others. This may be linked to the fact that no Bangladeshi
absconder had a good word to say about medication (Table 3). No one in this group
lived alone, and all expressed worries about their families. However the Bangladeshi
absconders were not visited by their families while in hospital (Table 4). In contrast to
the Afro-Caribbean absconders, and in common with the white European absconders
this group talked a lot about being frightened in hospital (Table 5).
The quantitative data shows that although all absconders tend to be younger,
the absconders from this group are particularly so with 62% of them aged between 16
and 25 years old. For most other groups only 18 - 25% of absconders were this young
(significant by chi square, p = 0.027). There is a tendency for this group of absconders
to be more likely to be married or in a stable partnership, however this did not reach
significance. Further support is given to this interpretation by the fact that Bangladeshi
absconders are much less likely than other groups to live alone (significant by chi
square, p=0.004). Table 6 shows that this group are the fastest to return to hospital,
with 79% being back in under 24 hours. This is likely to be linked to the fact that
more absconders were brought back to hospital by relatives than for any other group.
The rarity of harm to others as an outcome of absconding makes statistical
calculations of significance problematic. However 6.3% of absconds by this group
resulted in some harm to others compared to much lower numbers in other groups. Of
all groups, this was the least like to be considered at risk of using drugs (5% versus a
24% average, significant by chi square, p < 0.001).
Somali absconders
This group of absconders seemed to be particularly cut off from their families.
All were refugees and two had no family at all in the UK, and the third received no
visitors while in hospital. None of the absconding Somali's interviewed felt that they
were ill or need to be in hospital (Table 7). As with the Bangladeshi group, the
quantitative data shows Somali absconders to be significantly younger also. This
group (along with the Afro-Caribbean group) were more likely to have the police
informed about their abscond (70% of absconding events, versus 20 - 44% for other
groups, significant by chi square, p < 0.001).
White european absconders
White European absconders were equally as likely as the Afro-Caribbean's to
abuse cannabis while away from the ward. In addition, they were the only absconding
group from which a small number went directly from the ward to the pub (Table 1).
This group had the most positive attitude towards medication, although there were
still significant numbers who were full of complaints (Table 3). In contrast to the
Afro-Caribbean absconders, and in common with the Bangladeshi absconders this
group talked a lot about being frightened in hospital (Table 5).
88
There was a non-significant tendency for this group to have proportionately
more affective disorders and proportionately fewer in the schizophrenia category than
other groups. Absconders from this group are much less likely to have been
compulsorily admitted to hospital (34% versus 50 - 65% for most other groups,
significant by chi square, p = 0.001). Care plans for this group rated them as at risk to
themselves at the time of their first abscond much more frequently than for other
groups (41% versus 10 - 18% for most other groups, significant by chi square, p =
0.001). In line with these findings, absconders from this group were very much more
likely to have a history of suicide attempts (38% versus 5 - 12% for most other
groups, significant by chi square, p < 0.001).
The rarity of harm to self as an outcome of absconding makes statistical
calculations of significance problematic. However 5.8% of absconds by this group
resulted in some harm to self compared to much lower numbers in other groups.
89
Table 1: Method by ethnicity
ethnicity
afro-caribbean
bangladeshi
other african
somali
other asian
white
european
other
method of leaving
9 walked off ward
1 ran out
2 failed to return from agreed
time out
1 informed staff and left while
angry
3 walked off ward
2 ran out
3 walked off ward
2 failed to return from agreed
time out
1 walked off ward
1 failed to return from leave
1 failed to return from agreed
time out
1 walked off ward
15 walked off ward
1 failed to return from leave
4 failed to return from agreed
time out
3 ran out
1 left via the fire exit
1 made excuse to leave ward
1 walked away from escort
1 informed staff while angry
1 walked off ward
1 ran out
destination
4 went home
2 visted family
3 visited friends
2 wandered streets
1 delivered flowers
activity
9 took part in normal
activities
2 also smoked cannabis
2 wandered streets
1 delivered flowers
4 went home
1 visited friends
1 wandered streets
2 went home
1 went for a walk
2 visited friends
3 went home
4 took part in normal
activities
1 wandered streets
5 took part in normal
activities
life
2 with police
4 of own volition
life
1 with police
4 of own volition
2 took part in normal
activities
1 sorted out burgled flat
life
3 of own volition
1 visited friends
life
method of return
2 with police
8 of own volition
2 with relatives and friends
1 own volition
14 went home
3 went to the pub
7 visited friends
2 wandered the streets
1 ran out in road
1 went for a walk
1 visited family
1 took part in normal life
activities
18 took part in normal life
activities
6 also smoked cannabis
2 made suicide attempts
2 wandered the streets
1 ran out in road
1 went for a walk
1 went home
1 went shopping
2 took part
activities
1 police
1 self
90
in
normal
life
4 with police
13 of own volition
3 with ward staff
4 with relatives or friends
1 with police, sw and ambulance
1 with police and ambulance
1 unknown
Table 2: Doctors by ethnicity
afrocaribbean
bangladeshi
other african
somali
other asian
white
european
positive
‘the doctors seem quite good’
‘I get on with the drs fairly well’
‘I get on with the drs well’
‘when I speak to my consultant I don’t
usually have an opinionated self’
‘I’ve only met him about two times so I
want to see how it goes today’
‘I get on all right with the doctors’
‘I’ve known him very well ever since I
became a pt here’
gets on ‘all right .. not bad’ with drs
‘he’s a good man’
‘I told Dr 14 I loved him’
‘I get on very well with drs like a house
on fire’
‘he’s great’
‘she’s good’
‘I’ve only seen one dr ..he’s all right’
‘I’ve only seen him once .. that’s ok ..
he’s a busy man’
negative
‘I think he’s a very sarcastic person’
‘I feel like swearing at dad dr because he’s always talking to me like I’m a very high quality good
precious boy’
‘they’re so busy’
‘I’m finished with my dr’
‘he will say what do you know about medication I am the doctor .. I have nothing to say to him’
‘I don’t like them drs they’re too bossy’
‘I’ve seen him once’
‘I worry about what the nurses and drs are doing to me .. giving me medicines without giving me
a reason what’s wrong with me’
‘they get on with what they’re doing .. they don’t really want to know’
‘they believe the nurses .. they never listen to the pts’
‘as the doctor said to me if somebody really wanted to kill themselves they would just do it’
‘he was really offish with me .. he never give me a chance to say anything .. he said what he had
to say and that was it .. as blunt as that’
male pt prefers male drs
‘I don’t think I’d be able to tell them ..it would take too long’
‘why can’t they be polite to me .. I’m always polite to him’
‘I can’t talk to them .. they don’t understand’
‘I find talking to them a lot harder .. because they think they know it all’
‘I’m frightened of the consultant .. she doesn’t seem to want to let me go’
‘I hate his guts’
‘he has his opinions and they were made up before .. it didn’t influence his thoughts in any way
what I said’
‘she’s a bitch’
91
Table 3: Medication by ethnicity
afrocaribbean
positive
negative
like choice offered of meds (tablets, syrup etc)
‘I’ve been very happy especially with the medication I’m on’
‘sometimes the meds can’t help as much as it’s expected to ..I
think it’s just based upon the illness itself .. the illness just has to
go away the same way it came’
‘I know the drug that used to help me ..clozaril .. they won’t give me that drug’
‘syrup .. in liquid form .. I think they’ve given me too much’
‘my construction of thought was impaired ..I couldn’t communicate properly’ (result of
injection)
‘I shouldn’t be on medication .. I only hear voices’
‘no medication helps me because all I need .. if anything I suffer from depression’
‘I expected good medication .. I had it for two years .. they won’t give it to me again .. it
was clozaril’
1 complain about side effects
‘they’ve given me tablets that are causing me other side effects’ ‘I mean I’m a well
man’
‘when I take the syrup I feel so clumpy ..I only take the tablet’
‘I don’t want to take the medicines and I’m scared of the injections aswell’
bangladeshi
other african
somali
white
european
‘the idea is to continue on medication .. but right now I’m feeling
fine .. I want to go home’
‘once I weren’t having my medication (while absconded) I
realised I needed it’
‘where I hadn’t been taking my tablets for depression .. I lose all
concentration’
‘medication’s been ok’
‘I feel a lot better since taking it’
‘I didn’t have no medication .. I needed it’ 2
‘I was always going to take the medication .. and the injection
even though I didn’t like the injection .. I never missed one in 20
years’
‘I wanted some medication so the voices would go’
‘I just want to stop it’ ‘the injection is making me worse’ ‘I was getting so many terrible
[side] effects’ ‘I come back because I need my medication’
other asian
other
‘they refused to stop the medicine .. I asked to stop the medicine’
‘the medication ain’t working’ (wants different meds)
‘I don’t like the injection itself’ (as opposed to medication)
‘I was expecting them to treat my anxiety with either medication or some other way ..
they put me on diazepam and melleril which isn’t helping me .. I’m getting worse’
feel fear (unsafe) about injections especially enforced 1
complaints of side effects 1
meds caused nightmares
‘I don’t need this medication .. it makes me drowsy’
‘you’ve got to have something to keep you going ..taking your
medication to keep you stable’
92
Table 4 (Part 1) Responsibilities by ethnicity
afrocaribbean
somali
other
african
accommodation
4 people in hospital due to lack of accommodation:
‘I feel like I ought to get out and get myself a flat you
understand .. a couple of times I’ve been out to get
myself a flat.’
5 lived alone; none were worried about their
unoccupied property while they were in hospital.
family/friends/isolation
most isolated both inside and outside hospital:
‘I’m a bit of a loner because of this sort of illness.’
‘I have not friends and family to go to the house to do anything at all.’ Those completely
alone more likely to be above 30yrs/age.
Only 2 people had long term partner, 1 also had child. Although both in regular contact,
neither were visited on ward by partners.
‘it would be good if there was some form of communication .. a two way thing .. whereas I
could see my girlfriend and she could come up here and visit me .. and then like with my
daughter .. then like she could also feel safe.’
all were refugees. only issue talked about re
accommodation was one person had their flat
burgled while in hospital: ‘they took the tv .. the video
.. hi fi system .. £220 .. they took everything .. I have
nothing left when I go back .. if I wasn’t here nothing
would have happened to my house ..simple as that ..
I feel very angry.’
one person was homeless: ‘I’ve been homeless in
this country for three months .. and I don’t want to be
in hospital but I don’t have my own place.’
Two lived alone but were not concerned about their
empty property: ‘my neighbours will look after my
flat.’
two people had no family at all in this country:
‘cause I’m on my own in this country .. they have a family to bring something here .. what I
need from outside .. I don’t have any of those things .. I don’t have anybody .. I have to
do it myself.’
third person lived at home with family but was never visited by family while in hospital.
One person had children; ‘I miss them a lot .. they don’t like to come to hospitals .. they
don’t know what to say to you so when I do see them it’s that .. mummy where have you
been .. like I know you’ve been in hospital but how come you haven’t come to see us ..
you can come up and see me .. like there’s nothing stopping you .. but it’s like oh this is a
psychiatric hospital.’
One person missed out on a college course due to their illness and subsequent
admission to hospital.
93
Table 4 (Part 2) Responsibilities by ethnicity
white
european
accommodation
2 people had had their home burgled during hospital
stays: ‘the last time I was in hospital it all got fucking
stripped of furniture .. the lot and everything ..telly
..fridge .. microwave ..double bed.’
family/friends/isolation
Many in this group were living with or near family and friends and missed having frequent
contact with them:
‘people have got to have contact with their family while they’re here .. it calms them down
a hell of a lot and it makes them act different.’
This group missed the conforts of their own home:
‘it’s not a warm or comfortable environment .. it’s
very much like industrialised sort of thing .. metal
beds and everything .. I went to my flat and I went to
sleep in my own bed .. I just wanted to sleep in my
own bed.’
How family were coping without the patient was also a source of worry.
‘the reason I went absent without leave is because I miss my family terribly and I wanted
to be at home with them.’
‘I do worry about me mum a lot because she’s not well .. it’s not easy for her to get about.’
2 people had children and in both cases they expressed deep concern for their offspring.
‘I was sort of craving for my wife and kids in a way .. I was worried about them .. I was
very anxious and like fidgety .. and I kept on thinking and thinking and when I got round
there .. my wife told me my youngest daughter was very ill with that new flu and I thought
to myself well it must have been that that I was feeling.’
‘my youngest is upset .. me eldest had to get a letter from the doctor’s like .. a certificate
because he’s at university .. he’s got some exams to put in .. where he hasn’t been able
to concentrate he had to get a certificate so that he could put them in a bit later.’
‘we just have a little place .. it’s really really lovely ..
it’s my pride and joy.’
A number of people described feeling cut off while in hospital:
‘[I live] with me mum and dad and brother .. I see them now and again .. I don’t talk to
them that much .. they don’t visit .. I don’t want to see them in here because I don’t know
what to say to them.’
Three people lost jobs as a result of their illness and subsequent admission to hospital.
94
Table 4 (Part 3) Responsibilities by ethnicity
accommodation
family/friends/isolation
Two people were married and had children; the rest were all living at home with family. A
lot of concern was expressed for parents and siblings: ‘In the house I’m the eldest .. there
are older brothers and sisters but they moved away .. so at the moment I’m the
household leader if you want to call it.’
‘I worry about my kids and mum and dad.’
‘I worry about my younger brothers and sisters.’
Although none in this group lived alone, only one was regularly visited in hospital. ‘I have
to phone them to come and visit me .. if I don’t phone them to tell them to come .. they will
not come.’
‘I had a lot of contact before but not this time.’
This person lived alone in council accommodation
and is aware that if his property remains empty
beyond a certain period of time it will be
repossessed by the council. Since his stay in
hospital was proving to be a considerably long time
this was a great worry to him.
‘I thought what am I going to do .. am I going to lose
me flat.’
‘when I went awol I had to sort out bills that are
unpaid with my flat for a long time and I was really
worried about it .. I couldn’t see to talk to anybody
that would help me with it.’
‘I’ve got a few family and friends .. they help quite a lot when they can.’
banglade
shi
and
indian
other
95
Table 5 (Part 1) How people felt on the ward by ethnicity
afrocaribbean
feeling bored/homesick
1 person complained of feeling bored: ‘
there’s nothing to do .. I thought golly I’m
gonna explode .. my brain will explode if I sit
here and wait any longer .. and I thought oh
there’s no way I’m sitting here waiting ..
whatever the consequences may be .. I just
went.’
feeling trapped
4 people talked about feeling
trapped:
‘I felt like I was a prisoner.’
‘I feel trapped in a place I don’t
want to be in.’
feeling frightened
Just two people in this group described feeling frightened and
in both cases their fear was related to the way they perceived
their treatment on the ward:
‘when I first came to live here I was frightened a bit .. when
they’d lock me in and grab me and all that.’
‘[I was frightened] of the nurses because they find it difficult to
look after anyone that’s psychiatrically ill .. you don’t get taken
care of properly if you don’t behave yourself .. assessed to
make sure you’re not ill .. so you can go home.’
‘it’s like a prison.’
‘I feel trapped here .. I get more
depressed in here .. I’m not a
prisoner! I come here for help ..
if I go out and I need help .. I
will come back .. I’m the one
who came here in the first place
.. nobody brought me here .’
‘I’m like in prison because they
don’t allow me out.’
‘it’s like I’m locked up in a
prison .. I’m always trapped on
the ward .. I can’t even go out ..
ain’t got any leave.’
2 people in this group talked about their fear on the ward
which also related to treatment issues:
‘I’m scared of the medicine .. it might give me side effects.’
‘frightened .. I get worried here because they want me to get
trapped here.’
‘boredom .. no that’s not the right word .. lets
just way I wanted to be at home .. I was
missing my home.’
somali
other
african
2 people complained of feeling bored in
hospital:
‘there’s nothing to do in hospital .. all I have
to do is stand for all day .. stand in one place
for all day and don’t even go out .. ain’t got
nothing to do in here.’
‘they don’t really do much here .. I just really
wanted to be at home .. I mean I prefer
everything like I do at home .. I do my
housecleaning .. I do whatever .. it’s my
home .. I can do what I like.’
96
Table 5 (Part 2) How people felt on the ward by ethnicity
white
european
feeling bored/homesick
6 people talked about feeling bored during
their admission:
‘I didn’t come back because I thought it
would be too boring.’
Some related feeling bored to feeling unwell:
‘I don’t do nothing .. but I’ve got nothing to do
.. there’s things to do but I don’t really feel
like doing them.’
feeling trapped
This group related their sense
of being trapped to their state
of mind:
‘when I first came here I had a
feeling of being trapped.’
‘there’s no way out apart from
running.’
‘I’m sick .. like depressed .. I’m
trapped in here because I like
go home and I have rows with
my brother so I can’t live at
home.
feeling frightened
Almost half of this group expressed fear/anxiety while in
hospital. A further 50% of these related their fear to their state
of mind at the time:
‘[I felt frightened] all the time .. anxious .. frightened of the
voices.’
‘I think my illness made me sort of frightened ..once I
barricaded me door without the nurses knowing so I could get
a good night’s sleep.’
Others were frightened of events on the ward:
‘there was a lot of trouble on the ward the previous night and I
got a bit frightened .. I had the cover slung off my bed .. I was
terrified.’
2 people were anxious about their treatment:
‘I do sometimes [feel frightened] because I can’t go out.’
‘it’s the tablets that are making me feel anxiety.’
97
Table 5 (Part 3) How people felt on the ward by ethnicity
banglade
shi and
indian
feeling bored/homesick
1 person in this group said they were bored
on the ward.
‘in fact I feel very bored in the hospital ..
when I’m at home time passes quickly ..
you’re bored in hospital you see.’
feeling trapped
‘it’s like I feel I’m here .. I can’t
go out .. so I’m inside here .. I
have to go out and then I can’t
got out so I can only wait .. just
do a runner.’
‘yeah I feel trapped .. it’s too
much medication .. my brain
can’t communicate.’
feeling frightened
Half of this group talked about feeling frightened on the ward.
They were the only group to express fear of other patients:
‘like he go to the dining room or dinner room and keep coming
and keep looking at me .. keep staring at me .. they’re
criticising me.’
‘I’m frightened of the people here .. people bully you and all
that .. just like to be left alone.’
2 people talked about anxiety related to their mental state:
‘I see things that’s not there.’
‘sometimes I get frightened of myself and sometimes I get
frightened of what I’ve done .. I don’t remember what I’ve
done.’
There was also fear of medication
‘I’m frightened of the injections and the way they give it to me.’
‘I’m scared of the injections as well.’
other
this person talked about having nothing to do
on the ward but lots to sort out at home:
‘I go out mainly back to my flat to sort out like
.. so it takes the monotony of being in
hospital all day .. it’s not worth me sitting
down idle doing nothing because I only think
about doing something.’
98
Table 6
Duration of abscond * ethnic origin Crosstabulation
ethnic origin
Duration
of abscond
Less
than 24
hours
Between 1
and 2
days
Between 2
and 3
days
Between 3
and 4
days
4 days or
more
Total
Count
% within
ethnic
origin
Count
% within
ethnic
origin
Count
% within
ethnic
origin
Count
% within
ethnic
origin
Count
% within
ethnic
origin
Count
% within
ethnic
origin
Afro-Carribean
50
Bangladeshi
60
Other
African
33
Somali
17
Other
Asian
15
White
European
42
58.1%
78.9%
50.0%
53.1%
42.9%
22
9
21
8
25.6%
11.8%
31.8%
3
1
3.5%
5
7
Total
229
32.8%
50.0%
63.6%
51.6%
14
58
5
2
139
25.0%
40.0%
45.3%
50.0%
18.2%
31.3%
2
4
1
8
19
1.3%
3.0%
12.5%
2.9%
6.3%
4.3%
3
3
1
2
1
10
3.5%
3.9%
1.5%
1.6%
9.1%
2.3%
8
3
9
3
5
18
1
47
9.3%
3.9%
13.6%
9.4%
14.3%
14.1%
9.1%
10.6%
86
76
66
32
35
128
10
11
444
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
p < 0.001 by chi square
99
Turkish
Other
Table 7 (Part 1) Feeling well or ill by ethnicity
AfroCaribbe
an
Somali
other
African
Bangla
deshi
and
Indian
feeling well and wanting to go home
about feeling unwell - defining the problem
10 people felt they were well enough to go
home at the time of interview:
‘I was just basically surprised by the lack of
need .. for me to be here.’
‘I shouldn’t be on medication .. there’s
nothing wrong with me .. I only hear voices
.. they don’t disturb me.’
‘now I’m better .. cause I’m really good ..
because I know that I’m doing well .. and I’m
a hundred percent.’
‘I don’t feel ill anymore .. there’s no need for
me to be in hospital at the moment .. my
main problem has disappeared .. I’ve been
high .. and now I’m coming back to my
stability .. the doctors can’t see that I
thought to myself.’
all three people in this group felt they were
well enough to go home:
‘I’m well now there’s no need to be keeping
me here.’
‘the first time when I was like actually ill .. I
came in here for about three months cause I
was actually ill .. I was hearing voices .....
they started asking me questions if I’m
hearing voices I told them no I don’t hear no
voices no more.’
‘I’ve been getting worse and worse and worse.’
‘I feel very well and I still feel strongly that I
shouldn’t be here .. I should be discharged.’
‘they feel that I’m not getting well .. to myself
I think I’m well.’
‘my main problem is I’ve got mental disorder .. and I know that I’ve got it
..cause I know that I’ve got mental illness .. I can feel it in my brain ..
every time it hurts .. like I get afraid of people .. cause of it.’ ‘I keep
getting ill so I come back to the hospital to take my medication.’
‘I was able to tell the nursing staff ..I was able to tell them and that but it
would be the same sort of question they’d ask me .. is the television
talking to you .. can you hear your name on the radio .. I ‘d be telling
them no .. it’s nothing like that you know .. it’s just I know it’s my mind ..
it’s just not very well at the moment .. my mind you know .. it’s just not
intact .. but they all ask the same sort of questions .. all of them.’
100
feeling unwell at time of interview
‘maybe I kill myself .. I just wanted to
leave everything .. just to die .. I came
back because of my medicine .. I was
feeling bad.’
(absconded day before and was being
discharged that day)
‘I wanted to die actually ..I went out for
dying .. but I couldn’t do it .. I was a
coward.’
‘I was hearing voices .. I want the voices
to go away .. I see things that’s not there.’
Table 7 (Part 2) Feeling well or ill by ethnicity
white
Europe
an
other
feeling well and wanting to go home
‘I make really a song and dance because I
don’t want people to think I’m mad
anymore.’
‘I feel I’m responsible enough to lead my
own life and I don’t want to be in hospital.’
‘I’m better off with employment not in a
hospital.’
about feeling unwell - defining the problem
‘at the beginning I wasn’t well I wanted to leave the ward at
certain times when I wasn’t allowed to. I don’t think the
nursing staff actually knew why I wanted to leave the ward. I
had problems at home.’
‘I must have been ill and I couldn’t handle it no more .. I
thought people were going to kill me on the ward so I just
packed up and run away .. I thought I was going to die
anyway .. I thought someone was going to kill me anyway.’
‘I’m entitled to be sick after losing my son .. but I’m not
mentally ill.’
‘I had no concept of time .. I have now I think .. but then I
had no concept of time at all .. I felt as though I was in a
parallel universe .. I had to walk a certain way .. irrationally ..
very irrational.’ did it frighten you? ‘very much.’
‘I would say that I was ill .. I was really ill you know ..
because I couldn’t understand what they were saying unless
it was explained to me .. you know .. I didn’t know what was
going on .. if they were sitting round looking at each other ..
like if I was telling you something .. your mind is working it
out at the same time .. trying to understand it .. and I thought
like I can’t hear none of that because like I’m ill.’
101
feeling unwell at time of interview
‘I’m in hell in the head .. another voice in my mind .. I
used to have voices all the time .. I know you couldn’t
live without a certain amount of voices but my voices
are a lot.. I feel ever since I got to hospital I got worse
in all my illnesses.’
‘I just wanted some medication so the voices would go.’
‘I became frightened because I was given a tablet by a
doctor ..and I’m still feeling the effects of that tablet
now .. since then the tablet has made me feel very
hyperactive and suicidal.’
‘it’s like everywhere I go I think a lot of the devils are
possessing me .. repossessing me .. I think too much ..
my mind is racing .. I think all weird stuff .. like I’m
hearing voices and that.’
‘I got into a state outside so I just come back.’
‘being told that I don’t suffer with deep depression ..I
suffer with binge drinking which is a load of rubbish .. I
suffer with depression ..I’ve had it since I was so high.’
Findings 7:
Nurses' Perceptions
How staff feel
A range of feelings were described, from fear to relief. The nurses interviewed
found it hard to generalise about their feelings, but stressed that it depended on the
nature of the client who had absconded.
“It depends on the patient the situation and what what was
happening on the ward at the time.” 207
“It depends on their mental state , I think the assessment is
main factor in deciding when to start worrying and not to start
worrying. I mean if somebody’s obviously suicidal or a harm
to themselves or to other er and you’re quite concerned and
there’s no point wasting time. But if its somebody who’s
informal, who has been doing quite well, we’re planning the
discharge and they’d been going out by themselves um for a
few hours even ... It’s a matter of risk assessment.” 201
“Um it depends on the patient, um and how much of a risk
they are , if ones ones at risk of er harming themselves or
someone else or is quite vulnerable then there’s anxiety, um,
if if the patient’s not so much at risk then , as, a few patients
who abscond quite regularly um so there’s not much surprise
when they do abscond.” 107
Specifically, 17 nurses spoke of worry and concern when patients abscond, with 6
using the term anxious. Feelings of guilt (N=1), responsibility (N=1) and
disappointment (N=1) were rare in this sample. The majority (N=17) spoke of feelings
of relief when a patient returned safely to the ward.
Interviewees were specifically asked if they had ever felt relief when patients
absconded. Sixteen of the twenty four agreed that there were times when a patient
leaving the ward was a relief, this was generally when the patient was difficult to
manage (especially noisy or violent) or when they felt they were in hospital
inappropriately.
“You don’t basically feel relieved if its someone that you really
think should be on the ward, sometimes you feel a little
relieved and someone’s a bit of pain in the arse and they’ve
gone and you know they’ll be back at some point and you
know they’re really not going to get up to much mischief
outside” 113
“I don’t know, you feel relieved in a way. Patients who are
really manic or really noisy or really intense and give you a
really hard time It’s nice to get a break from them when
they’ve gone, (laughs). Patients like that are normally the
ones we’re more worried about when they have gone so, just
getting a bit of piece and quiet I suppose from them” 210
102
Dangerous Acts
Although negative outcomes to absconding are relatively rare, they do happen
on occasion. Three nurses spoke of their experience of patients who were involved in
dangerous acts whilst they were away from the ward. Two spoke of suicide (attempts)
and one spoke of a client injuring themselves as they tried to escape from the ward.
there are times when you know we’ve had, we’ve had
patients abscond who have gone out and and harmed
themselves or have um killed themselves. 1061909.
I've known of someone who’s actually gone absent, but he
was informal. And then he took a massive overdose, and he
was you know ill for quite some time after that. 2122709.
There was an incident where some, a a client on the ward
was being specialed by two RMN's er and he broke free, got
through the fire escape in the male dormitory and jumped
from the landing on the fire escape on the first floor and he
hurt his ankle. 1131305
There was a patient who was informal and went off the ward,
and went to up a building, and was going to, and wanted to
jump off, 2052211
These stories underline the fact that an abscond can have serious consequences. It is
because every nurse knows of stories like these, or may have experience of these
actual events, that nurses' dominant feeling is of anxiety and worry for the patient
when they abscond.
Risk Assessment
The interviewees referred to informal risk assessment in twenty cases. All
nurses stressed that risk assessment starts from the time the patient is admitted and it
is on- going .
“Um risk should be assessed first um the minute the patient
comes in, if they’re a risk to themselves or to others, um.
They’re normally assessed daily and we do that normally
from um getting to know the people, having a quick chat, also
keeping up to date with what’s happening in the ward round,
handovers, notes, if there’s anything in the notes.” 207
A specific tool was being used in seven wards, but three nurses (from different wards)
referred to the tool being new, and one said that it was not being used.
Um well in the past, well we’ve just implemented a new, well
we’re in the process of looking at a new er a new risk
assessment tool but in the past its been based on the
assessments that are done er on admission and on the
subsequent time after admission by the the multidisciplinary
team. 1061909 .
103
Well we’ve got a new risk assessment tool at the moment
which we use but before we had one that was really bad but
you just look at their past history and I mean different people
approach it in different ways but I go through their past
notes, past history, whatever people have told me about them
and their behaviour on the ward so, is other professionals,
community professionals. 2101204.
Um I mean we’ve got a risk assessment tool but it’s not tend,
it doesn’t tend to get used to be honest, (OK) um its quite an
old one, I know the um trust is looking into sort of risk
assessment sort of generally um and they’re trying to develop
something that’s a bit more user friendly um so in terms of
assessing risk it is um, its a bit ad hoc really, to be quite
honest. 301
For many nurses although there was a statement of risk to self and others noted in the
admission assessment in the notes , the risk posed by the patient who was missing was
only discussed once they had absconded, in relation to who should be notified.
“Well everybody’s assessed from the day of admission really
risk assessment is an ongoing thing...um but um...when the
patient’s gone AWOL then it becomes more of an urgent
thing really. 2010702.
Patient observation
Risk assessment and absconding was linked by many nurses to nursing
observation levels for individual patients, and the policies that determine them. All the
interviewees felt that although they are involved in deciding the patient’s observation
levels, - these levels remain unclear and at times confusing.
The thing is close obs is a very difficult thing and at times it
could be cloudy in the sense that it could be that the patient
doesn’t need to be on close obs but , obviously if the staff
believe that a patient should be on close obs we sit down and
discuss it amongst ourselves (.) and then inform the doctor in
charge of the client....1042402.
Yes they do but that’s, that’s only like, if they actually do the
ward round, if they actually assess somebody, if they saw
someone and they felt there was a major change in their
mental state and they were at risk of like I say harming
themselves or others, they will place them on observations,
but you know the the psychiatrist, the consultant isn’t on the
ward very often so they actually take into account what the
nursing staff, how we feel and the the junior doctors or
SHO’s, whoever’s available at the time....2091104.
Although some observation levels are decided by the consultant, and the junior
doctors, fifteen nurses felt that most of the observation levels are decided in the ward
team meetings and it is a joint decision.
Yeah its decided, well its not necessarily a consultant but one
of the doctors would be involved, if the nursing staff feel that
104
an observation record could be changed um, .....it needs to
come from , to come from close obs onto unobtrusive obs
you can um discuss it er with the ward doctor um and they
can change the obs level otherwise its decided in ward
rounds, or management rounds. 1070106.
Um should be a joint decision really between nursing and
medical staff. 1051803.
But as I say, you usually try to make it a team decision and
also going on the person who’s admission who’s probably got
the best view of the assessment that they’ve just done. Erm,
it’s usually a consultation between everyone. 2042111.
Eight interviewees emphasised that, they have the power to commence close
observation if they felt the patient was at risk.
The consultant only comes maybe once a week at the best
twice a week and she doesn’t really know what’s going on inbetween. Like when we think a patient is at risk we will put
them on obs, straight away. 2030607.
“If you feel that the situation was fairly bad, we have enough
staff so we can start it.But of course I will you know if if it
happens for example in the evening fine, so then I need to
inform the the senior nurse in charge, ..But yeah if if there’s
something we need that someone needs to be on some kind
of obs so.. 2060803
However, these interviewees stressed that although they have the power to commence
close observation, they cannot stop or reduce it without consulting the medical team,
in fact it is the medical team which is responsible for stopping close observation.
...they’re either decided by the nursing staff there and then or
usually they’re decided in conjunction with medical staff of
course but that’s not always possible er otherwise nursing
staff will will sign a level A, B or C observation to to a client,
um now nursing staff can assign that level of observation or
they can increase a level of observation er making the
observation more intensive but what our policy is, nurses
don’t reduce observation level er unilaterally, we always
reduce in conjunction with medical er recommendation so we
always liase with medical staff if we’re going to reduce
someone’s observation levels but we don’t always liase
with medical staff if....1131305.
Nineteen nurses mentioned that they have disagreed with the doctors over risk
assessment. This implies that sometimes nurses perceive risk differently from the
doctors. Such conflicts affect decisions not just about observation levels, but also
about leave and discharge.
.normally the the medical staff would take our opinions quite
seriously, occasionally you know they don't or they’ve a
differing opinion about the patient. ....... sometimes, one of
the consultants in particular has been what we thought,
overcautious with patients who we thought aren’t really that
much at risk um whereas the other, there’s a , the other
consultant tends to be a little bit more carefree and maybe
105
doesn’t consider people as much at risk sometimes .
1070106.
I have been talking with doctor that I did not agree with the
point of view. Because I think that the doctor has once given
someone leave, and I thought according to my assessment
being with the patient more than the medical, I felt the need
to, that person would be a risk if he goes. So I have been,
have been in conflict with doctors. 1092808.
Some nurses questioned the efficacy of intermittent nursing observation:
there's a hundred ways and a hundred reasons someone can
abscond you know, there's there's two qualified staff, two
unqualified on the floor on on the ward, um someone say on
level B observations, its an open ward environment er one
staff member is answering the phone, another staff member
goes for a pee and the two um unqualified staff maybe
serving dinner and during that fifteen minute observations,
even if you're following the fifteen minute observations if if
you er literally, exactly know their whereabouts every fifteen
minutes to the on the second on the dot, in fifteen minutes a
client could have left the ward and be at X station and be half
way to London 1030305
And under such circumstances, nurses still feel that they may be blamed if something
goes wrong:
Sometimes yeah sometimes, if er someone was on level B
observation who's um maybe aggressive tendencies or
maybe even homicidal tendencies have been increasing um
er recently and prior to either being transferred to the um
locked ward or being placed on level one observations that
client happens to abscond during that period then um they
they do feel.........that they will be held responsible and you
know something may go wrong and they will be blamed.
1030305
Even arms length, constant, close observation can fail to prevent an abscond
sometimes:
if they're on close observation, they can still sort of abscond
they can hit you and then just disappear. 2020501
It is for these reasons that nurses report that carrying out close observation is stressful:
if the patient is some kind of close observation or special obs
so then it feels like oh God I have failed, you know I haven't
managed to keep the patient here. Although this can happen
to anyone you know, if there is only one person doing the
close observation which means that you have a patient you
know, that you can see, see her all the time so it could be just
the second when you watch somewhere else that that she is
going but I think that you feel sort of like a failure there ... it
could happen to anyone you know and especially if you're
got two hours of close observation, so its quite a long time if
someone is really high abscondance risk, it is like quite
stressing. 2060803
106
Not only can close observation be a negative experience for nurses, but patients don't
like it much either:
well at the moment we've got a patient who's been on obs for
a long time because she's um at risk from er absconding and
there's basically no support at all for this, from the
management, It's just they basically want her kept on the
ward and that's OK for them to say but they don't take into
account the feeling of the patient, like what if they want to go
for a walk and sometimes if somebody's been on observation
for over a month its hard to keep somebody on a ward when
you know that when when the weather's nice outside, when
you want to get a bit of exercise its just like that, You feel
very unsupported because when somebody is on
observations because they're an absconsion risk it takes up a
lot of the nursing hours and if you're doing an observation for
maybe three to four hours that means you've only got three to
four hours working on the ward of you're doing a seven and a
half hour shift. 2070907
Blame for absconding and the nursing team
A few members of staff saw absconding as inevitable from wards that are not
locked.
It could happen to anyone you know and especially if you’re
got two hours of close observation, so its quite a long time if
someone is really high abscondance risk , it is like quite
stressing . 206
But I don’t think people blame each other, it may be my
interpretation but I don’t think so. I think it’s quite easy to
happen on this ward, because the observation levels are not
very good. 205
The most common place to lay blame was with the nurse observing the patient or
observing the door. Specifically, eighteen nurses spoke of blaming one another.
if you know you asked a member of staff to keep an eye on a
patient and the patient absconds of course you’re going to
come back to that particular staff and ask them what happen,
where were you when the patient absconded you know. 108
"Why did you let this patient go, why were you not watching
her?" These things do happen but they shouldn’t happen if
you know what I mean. If you’re doing the job properly, it
wouldn’t happen, "Where were you at, why was you not
watching her?” 20330607.
there may be occasions you know when staff go oh you know
bloody idiot, he let so and so out but not that often I don’t
think. 301
There was some discussion as to the unsuitability of agency staff and nursing
assistants to do observations.
107
People can still wander off unbeknown to the agency staff
because obviously you know, they’re shown round, they’re
introduced to the patients but they’re not er built up a
relationship etc. 205
the job is that they know who they’re looking out for .You
know whether they’re an NA or and RMN common sense tells
you you’re sitting by the door for a reason and that’s not just
to sit by the door and look at the wall it’s to monitor patients.
2081004.
Nine nurses spoke of managers blaming the nurses when a patient absconds
from the ward and five mentioned punitive measures given to nurses following an
absconding incident. This led to ten nurses feel insecure about their jobs.
they again er, um fearful that the the management will
scapegoat them and point their finger at them ... its fearful
that you’re you’re going to be blamed in some way for this
happening. 1030305
I mean you’re only safe to play it by the book basically, er
otherwise er, any short cuts you find your way, yourself on
your way out.201
Nurses who talked of punitive measures also mentioned that they were not being
supported by the management.
Well generally, I’m not talking about X Ward but generally, er
there have been instances whereby patients have absconded
and er they’ve scrutinised the policy and er examined
everything to ensure that everything that could have been
done was done and where they found that er not everything
which could have been done was done or this or that person
was not consulted or whatever, er there have been punitive
measures , yes, people have been disciplined, people have
been suspended, etc etc. and um.......they may not
necessarily have done it on this particular ward but this is a
very small community and obviously one of the things, well if
it can happen to so-and-so, well it can happen me.
201110702
Um, yeah I think like when people absconding and you know
..... At the end of the day if anything does happen when
people abscond, it does actually you know a lot of the onus is
on the nurses who are on duty at that time and that has
actually happened in the past .When one person did
abscond, and what happened the nurse didn’t document this
apparently, there was something, and the nurse was actually
suspended from duty for a time. 2091104.
Two nurses felt that the medical team have blamed them when patients have
absconded.
We received plenty of um advice and criticisms informally
generally about instances and in fact about the general rate,
we’ve had criticisms certainly from one consultant, quite
regular criticisms and little graphs in fact to show that
108
instances of absconding have increased over the previous
three months or what have you know so we get that kind of
feedback certainly 1131305.
Specifically, ten nurses felt that their jobs were on the line as a result of patient’s
abscond.
I think with certain high risk patients, um if I were to be on
duty and um a high risk patient absconded and er the
decision was probably postponed to, there there there, there
is er a certain culture in the unit for certain patients to be er
circulated um to, around about ten o’clock or midnight in case
they come back, stuff like that ..If then I was to hear that the
patient was found somewhere floating in the river or
something, yeah, I would definitely resign or something I
mean you’re only safe to play it by the book basically, er
otherwise er, any short cuts you find your way, yourself on
your way out . 2010702.
Yeah like I said earlier on if the person is at risk and he goes
out of the ward I feel like if anything happens it means if I will
be free I’ll be asked to talk and that sort of thing so its like
you think there’s something here for you to I mean ... to give
evidence something like that so you feel insecure. 3021512
Agency nurses
The reliance on agency staff to cover the wards was seen almost universally by
the interviewed nurses as having a negative impact on absconding and on patient care
as a whole. They may be blamed for letting the patient leave the ward as in the
following examples:
when you're using a lot of agency staff you know and there's
somebody on the door and you know the patient is brought
back and they will say to you well I've just walked out the door
past so and so and it does happen. 1061909
agency staff don't always listen to the handovers as closely
as they should and you know you go round and you bring
them around and you describe, you know I've had had
incidents where I've like brought an agency nurse around,
showed them the people that I didn't want leaving the ward,
they've let that person go and they've stopped a relative you
know because they obviously weren't actually paying
attention. 1061909
The following quotes illustrates the fact that agency nurses cannot make a full
contribution to the ward nursing workload, nor do they carry the same responsibility
as the permanent staff::
I think that the main things is er, is happening because you
see sometimes there is only me qualified and then there's
two or three agency nurse, so everything come on top of the
one nurse. 1092808
109
Because you feel its your registration if anything does happen
(sure) you know you were the one, you were the permanent
nurse, "oh I'm an agency nurse I was only there for one shift"
you know and there's that feeling yeah. 2091104
if you've say got two permanent members of staff and two
agency nurses who don't know the ward then you know two
permanent members of staff will be wandering around doing
things, I think it would be more likely that people would
abscond 3014112
The heavy use of agency nurses also decreases the overall quality of staff-patient
relationships:
you're using sort of predominantly bank and agency staff who
don't know the patient, who don't know the ward er,. ... levels
of frustration among the clients increases often because
maybe they can't talk to their key nurse or whatever (sure) so
therefore they they get frustrated and go off. 1061909
Sometimes it helps if you've got the key nurse of a patient
around when they're upset because they
would've
established a longer term relationship then, with the patient.
And be able to quickly sit down and chat with them or relate
to them. And on this particular ward, there are quite a number
of agency nurses and it is very difficult when there are so
many new faces coming into the environment, that there are
likely to be more absconcions. 1123010
Suggestions on how to reduce absconding
The most common suggestion from the interviewed nurses was that staffing
levels should be increased. 80% of the nurses advanced this as an effective way to
reduce absconding incidents.
another thing that would help, ... it would certainly in increase
or decrease the chances of people absconding is a higher
staff to patient ratio ... so that you know somebody can go to
the loo and somebody can be on the phone and there will still
be er nurses on the ward who are you know, keeping an eye
out on these patients 1030305
Yes it does, I would say that's true, without any hesitation , if
you don't have good staffing levels there is a possibility of
patients abscond easily. 1042402
This was the only method of controlling absconding that had high levels of support
from the nurses interviewed. The objective of higher staffing levels was not just to
increase patient observation and security, but also to promote better nurse-patient
relationships:
If staff levels were increased you would have a greater input
in, not necessarily staff levels increase on it's own, you would
need to make a greater input into the patients. 1113006
110
The remaining ideas were mentioned by small numbers of nurses:
• increased facility to transfer patients to a locked intensive care environment
• better teamwork with hospital security staff
• improvements to ward design to promote general observation or observation of the
ward door
• less reliance on agency staff
• targeting nursing resources on the high risk patients
• use of adequate levels of sedation
• use of one to one close observation and adherence to observation policies
• more time for the nurses to discuss patients problems with them, so the nurses can
know their needs and deal with them
• increased availability of short term, escorted leave
• reduce ward bed numbers
• allocating a member of staff to stay by the door and prevent patients from leaving
• community meetings and open discussion about absconding
• locking the ward door
Opinions were divided about some of these absconding prevention methods.
Some nurses felt that they would work, others declared that they did not. There seems
to be a natural repugnance among nurses to the idea of locking the door. The
following two nurses treat the idea as ludicrous and only worthy of laughter:
I can't think of anything unless you're going to go to severe
measures in locking the door and things like that (laughter)
which I don't think is fair on an open ward. 2070907
(laughter), Well I could say lock the ward 1042402
And the next interviewee rejects the idea because it is considered to be counter
therapeutic:
since er, since I have been in nursing people have always
absconded and we haven't found the right solution unless
they're locked up you know somewhere, but its not very
therapeutic just locking everybody up. 2020501
Yet one felt that this strategy would at least have the benefit that it would work,
although this respondent was careful to not to imply support for the idea:
if you want someone to be one hundred percent safe then the
only way to do that to to to, the only way to stop someone
absconding one hundred percent is to have a locked
environment 1030305
These varying responses, and the one that follows reflect the fact that nurses find
themselves on the horns of a dilemma. The only way to prevent absconding that they
perceive to be totally effective is to lock the ward door. Yet this runs contrary to their
commitment to a liberal, non-coercive care environment:
Um I mean the obvious thing is you have a locked door but I
don't think (laughter) we should have a locked door, I think
we're an open ward and we should stay like that um, but I
111
think at the same time there is, there is an inevitability that
you know some people are gonna go. 3011412
Variation between Trusts
In every Trust the dominant feeling when a patient absconded was that of
worry and concern, and of relief when the patient returned. Nevertheless, also in all of
the Trusts, the majority of nurses interviewed admitted sometimes feeling relieved
when a difficult or frightening patient absconded from the ward. Mostly, nurses
blamed each other for the absconding incidents. Against this background, Table 1
shows some variations between the three Trusts in the study.
Trust E: small numbers of nurses in this Trust admitted feelings of frustration and
anger towards patients on their return from an absconding incident. No nurses from
other Trusts gave this type of response.
Trust O: nurses in this Trust had higher levels of anxiety and panic following an
abscond, and higher levels of relief upon the patient's return. This Trust also had the
highest level of blame between all parties, and the highest number of nurses who felt
that their jobs were insecure because of absconding by patients.
Trust S: a lesser number of nurse were interviewed in this Trust, and no variations
from the average in terms of nurse responses and blame can be seen.
112
Table 1: Feelings and blame about absconding incidents by Trust
Trust
E
O
S
Pt. going
1/10 anxiety or panic
1/10 disappointed.
8/10 worried /
concerned
1/10 felt responsible.
0/10 felt surprise or
guilt
4/9 anxiety or panic
4/9 worried /
concerned.
1/9 responsible.
1/9 surprised
1/9 mentioned guilt.
No
one
felt
disappointed
1/5 anxiety / panic.
5/5 worried /
concerned.
0/5 felt surprise, guilt,
disappointment
or
responsibility
NURSE FEELINGS
Pt returning
5/10 relieved.
1/10 happy.
0/10 sad.
2/10 frustrated.
1/10 angry
BLAME
Punishment
2/10 yes
Job insecurity
2/10 felt insecure
7/9 nurse to nurse
6/9 management to
nurse
2/9 medical staff to
nurse
1/9 yes
6/9 felt insecure
3/5 nurse to nurse
1/5 management to
nurse
0/5 medical staff to
nurse
3/5 yes
2/5 felt insecure
Relief (at pt going)
6/10 said yes.
4/10 said no
Blame
8/10 nurse to nurse
1/10 management
to nurse
0/10 medical staff
to nurse
7/9 relief.
1/9 happy.
0/9
felt
sad,
frustrated, or angry.
6/9 said yes.
3/9 said no
3/5 felt relieved.
1/5 felt happy.
0/5
felt
sad,
frustrated, or angry
4/5 said yes.
1/5 said no.
113
Findings 8
Relatives and Carer Perceptions
Awareness of absconding episode
All of those interviewed were aware of the specific abscond incident asked
about. However only one of the six found out about that particular incident through
being informed by the hospital. Of the remaining five:
Two became aware when the client turned up at the relative/carers home.
Two became aware when the client phoned the relative/carer and indicated they had
left the hospital.
One became aware by going to visit the client in hospital, only to discover that the
client was no longer there.
Lack of awareness by ward staff that a patient had actually left the ward was
one area of concern.
"X rang me from a station ... she said she'd had enough, that
everyone was having a go at her, that they think she is mad
... I said ‘X , you've got to get back, just walk round the block,
relax, get some fresh air.’ We were 20 minutes on the phone
but then she says she's going to go back, back to the
hospital. I was concerned, so then I phoned the hospital they weren't aware she'd left. I wasn't happy about that ."
Whilst it sometimes appeared difficult for relatives to understand how it was possible
for patients to go AWOL, nevertheless some tried hard to give ward staff the
benefit of the doubt and to understand what the problems might be for them.
However 5 out of the 6 had experienced more than one AWOL, and at times this
seemed to leave them struggling with conflicting emotions.
"...they've got a job to do and he's not the only patient, but
sometimes I get upset - he's supposed to be there, and then
they phone me and say he ain't. We don't need the police
round here - I get annoyed like of course - you tell me he's
gonna be locked up - but then he's out again."
"He was sectioned on the Tuesday, on the Wednesday
morning somebody said to me, ‘that's your brother walking up
there.’ I said 'no! it can't be' - but it was! So he'd got out even
with the section happening!"
Another issue raised by a number of relatives, again both in terms of the
specific incident and past experiences, was the lack of communication by staff when
they were aware that an absconding incident had taken place.
"We went up to see him, he wanted cigarettes, that's how we
found out, because he wasn't there. The ward doesn't contact
us at all, they never contact me. As far as I know, he can go
out when he likes."
114
Further, there were also occasions when wards did not reciprocate information
sharing, thus leaving relatives with negative feelings about the hospital. For example,
a relative informs staff that a patient is AWOL, but staff do not get back in touch to
let the relative know that a patient has returned, and how she or he is.
"... there wasn't any phone call to let me know she went back,
or that she was committed."
Asked about feelings towards the hospital, one person said
"Irresponsible. It's not the first time it's happened. I phoned
once before and they just said he's off the ward, we don't
know where he is - that was it. I felt scared that time, I had
fears about safety. They don't communicate with me, they are
secretive."
Asked if the incident had affected their relationship with, or faith in the hospital, one
respondent said:
"No. You can't just blame them all the time. They are
understaffed - but I don't know - I haven't really got a lot of
faith in the hospital anyway."
In response to the same question, one other person admitted to not having much faith
in the hospital, whilst a further two felt it had not affected their relationship, one
because ‘staff do a difficult job’. One relative would have liked an investigation into
both why staff were unaware of the AWOL, and why they did not keep him updated
after he had informed them about it. The sixth respondent was more concerned about
what he felt were unanswered questions about a client’s psychiatric history.
Feelings about absconding episodes
In terms of the specific incident referred to, none of the relatives /carers had
any fears about their own safety, though one expressed concern about the safety of
their mother, whom the client had harmed on a previous occasion. More in evidence
was a concern for the well-being of the client, with 3 of the 6 saying they had felt
worried. Of the other three, one was ‘not really over-worried’. Other feelings
experienced were: annoyance - because the abscond had resulted in a hospital move to
one less preferred by both client and relative, and into a locked ward which the
relative felt made it worse for the client; anger at the hospital, fear, frustration, stress
and a feeling of having been let down by the hospital.
Reasons for leaving
Despite the emotions aroused, no relative or carer felt that the incident had
affected their relationship with the client. Lack of any bad feeling from respondents
towards clients who absconded, appeared connected to either having some insight into
or empathy with, the reason the client went AWOL, or because of a belief that the
illness was to blame, and that the client did not intend to cause worry.
115
"Being AWOL - I was in two minds about it, because I've
been in there. I was beaten up by a patient in there, so I
understand why he wanted to leave - sometimes I did too. As
a patient the way you are treated by staff can also make you
want to leave. I felt unsafe in that environment - I can say
things now, but when you are in there you don't have a
voice."
"My brother is mentally sick. He wouldn't have done it in his
right mind, so it's a waste of time being angry or whatever
with him, he doesn't mean to cause any worry."
Other reasons given by relatives/ carers were:
•
•
•
•
•
•
a desire to sort out affairs, particularly housing
a desire to visit people
boredom
the result of people on the ward ‘having a go’ at the client
prompted by possession of his bus pass and house keys
a desire to get out
How hospitals should deal with awol incidents
Unlike their views on some issues, relatives seemed less clear about how
hospitals should deal with absconding incidents, and tended to reiterate the need for
ward staff to consider the information and other needs of relatives.
"The nurses apologised but doctors don't give you nothing.
Nobody tells you anything - they say 'don't worry' but that's all
very well for them. I would like more information from the
hospital when something like this happens - they could let
you know straight away and keep you informed - what's
happening, when he's back, how he is, what happened and
so on."
5 out of the 6 were involved in some capacity in the specific absconding incident, in
that they either informed the hospital and encouraged the patient to make their own
way back, were involved in searching or organising a search for the patient, or took
the patient back themselves. Three of the six were satisfied with the way in which the
client returned to the hospital on this specific occasion, but on the basis of past
experiences also, issues were raised about the process. In particular there seemed to
be conflicting feelings about the use of the police.
"..sometimes we do have a job getting him back - it’s like
everyone is passing the buck. I’m thick skinned, I just get on
with it, but I do get cut up, believe me ... I ring the hospital,
they say ring the police, the police say they don't have no
authorisation, they need it from the hospital. Last time when
the police was here they had to talk him out of the house then they can take him so long as he's out, - unless he's
smashing up the place ..."
"... the police kept coming round. I wasn't very happy about it.
X was on ITU at the time, they let him out for a little while by
116
himself. He decided to come home and they phoned the
police. I didn't like it - we've got nosy neighbours; the police,
they were in the back garden, the front garden, that's what
the neighbours said - I wasn't there at the time ... I suppose
the police ought to come though really, if X is a danger to
himself or others."
How hospitals could prevent absconding
Thinking about a client who left to sort out his affairs, one relative felt that
escorted leave would be the answer.
"He should be given the opportunity to go out and follow
things up that he wants - like a job and a flat - with an
escort."
Another felt that staff would be hard pressed to do any better than they were already
doing. Suggestions by the remainder included:
• implementing a system where a client could negotiate time off the ward by
informing staff of his or her intended whereabouts
• the ward should have only one door and that should be locked
• patients should be kept under close observation
• when a patient is ‘not great’, a nurse should be with him or her at all times.
Relative perceptions of client care
Half of the respondents were clearly unhappy about the care their family
member was receiving.
"It needs improving. I think his medication needs to be
adjusted for him, tailored to his needs. I don't think it is at the
moment. They need to listen to what he wants, not what they
think is best. He needs emotional support and therapeutic
support, as well as medication. They should also give him
advice and information about his diagnosis and condition encourage him to have contact with organisations and groups
which will help him move on. He needs positive images."
Other issues included lack of help to maintain the client’s life outside - for example
help with housing, help to be independent, and help to ensure bills were paid; again,
the absence of information giving to relatives and carers; a perceived lack of qualified
staff and a need for advocacy.
The other three were positive on the whole, although some reservations were
expressed by two of the three about the medication the client was receiving.
Whether happy or unhappy with care, three out of six questioned the efficacy
of hospital generally, wondering if it was in fact the most appropriate environment for
clients.
117
Relative involvement in client care
Only one person felt involved by staff.
"Yes - they do involve me. I was up there last week - the staff
do allow that now, they send me a letter when there’s a group
meeting"
3 people did not feel involved in client care and of those, 2 felt they would like to be.
The third was unsure. The remaining 2 felt involved through their own or the client’s
volition, not because the staff included them. Both would have liked to be more
informed by staff.
"Yes, I do in the sense that [client] phones me. I mean I
would like to be - the hospital could keep me informed but I
can't be available 24 hours a day. "
Whilst relatives who did not feel very involved in client care but would like to be,
there was also an issue about getting the balance right - between what it’s fair to
expect of themselves as ‘carer/relatives’ and what can legitimately be expected of the
hospital. There was also some sense that they need to get on with their own lives, and
that the hospital needed to respect their time.
"I have tried like, going to meetings and that, but the last
one, I went up for it, then they kept me waiting for 1.5 hours,
so in the end I left. The hospital could help by getting that
right, and by letting me know things. "
One reason given for sharing information was based on practicalities:
" If I knew about his medication for example I could help him.
Like when he turned up at the weekend, there was stuff
[medication] left here from before, but I don't know any more
what he's on so I felt I couldn't give him any of it."
Interest in research findings
When asked, all the respondents said they would like a summary of the
research findings, and one said
"It's nice to know you're doing this - it might help change
things - improve care and stop the AWOLS. "
118
Summary
Regardless of the extent to which relatives and carers were involved in either
the absconding incident or the care of the patient generally, there can be no doubt that
they are affected in some way when a patient goes AWOL. Some experienced a great
deal of worry, some anger, and some a whole range of feelings. Whatever the
emotion, findings also suggest that improved communication by ward staff could
reduce at least some of the negative impact of an absconding incident on relatives and
carers, who found it hard to understand how such incidents could occur. Despite
negative feelings about absconding, relatives were disinclined to blame clients and
more likely to feel angry with the hospital. nevertheless efforts were made to
understand the difficulties ward staff might face in this respect.
Lack of communication did seem to be a wider issue in that relatives generally
felt uninformed about the care of clients, and to some extent excluded by staff from
being involved. There were also indications that some relatives were unhappy with the
care received, and half the sample had asked themselves how appropriate a hospital
environment actually was.
119
Discussion of Findings
This study is the largest and most comprehensive examination of absconding
from acute psychiatric wards to date. It is the first to study three comparable hospitals
and twelve comparable wards over a significant period of time, and the first to
interview in depth a large number of absconding patients. In addition, this is the first
study to systematically assess the views of nurses, and of patients' relatives about
absconding. The ability to triangulate findings between these different sources of
information strengthens the conclusions that may be drawn from findings.
Equally as important was the fact that this study was the first to use an
objective definition of what constitutes an abscond, that is, absent from the ward
without permission for more than one hour. Thus the findings discussed here do not
rely on official statistics. In this study it has been discovered that official statistics are
biased by perceptions of risk and by the operations of mental health legislation.
Absconds of informal patients are less likely to enter the official record, despite the
fact that many informal patients feel equally coerced to be in hospital as those who are
compulsorily detained (Monahan et al 1995). The effects of this bias in previous
studies may have been many. For example, absconding rates are liable to have been
underestimated, and the degree of risk associated with absconding over estimated.
Also, work done previously on delineating the characteristics of absconders will apply
mainly to legally detained absconders only.
Who absconds
In this study, event based analysis of the data shows that absconders are:
young; male; a firstborn child; from an ethnic minority group; of the Muslim faith;
living with partner or parents; with a diagnosis of schizophrenia; having had a number
of transfers between wards, refusals of medication and involvement in officially
reported ward incidents in the previous week; considered by nursing staff to be a risk
to self or others; someone who has absconded during previous admissions; and has
had previous contact with the police.
This picture does confirm some of the findings from the literature, namely that
absconders tend to be young, male, suffering from schizophrenia and come from
disadvantaged groups. Previous studies have found that single patients are more likely
to abscond than those who are married, however this was not confirmed in this study.
The discovery in this study that absconding during previous admissions predicts future
absconding has not been described before. It is hardly surprising, however.
The other main feature of the event based analysis is the link that it draws
between many different forms of difficult and noncompliant patient behaviour.
Patients who abscond are also those who refuse medication, are involved in violent
incidents, have been involved with the police, and have needed to be transferred
between wards. They are also those who are considered by nurses to be high risk,
presumably based upon their past history. These findings indicate that all these patient
behaviours are likely to be related in some way, either driven by some common
120
characteristics of the patients themselves (perhaps a difficult and disruptive
personality or behaviour pattern) or a recurrent and typical failure of relationships
between psychiatric services and patients.
The latter explanation is supported by a further analysis of the data. Event
based comparisons between absconders and controls are best for the identification of
factors predictive of absconding. For in this type of analysis, the more frequently an
individual patient absconds, the more heavily their characteristics are weighted. This
is fine for drawing up a predictive profile of the absconder for use on the ward. For the
interest of ward staff is who, among the current set of patients on the ward, is most
likely to abscond today. However, if we wish to know the characteristics of patients
that contribute to their individual propensity to abscond, a patient based analysis is to
be preferred. In other words, absconders need to be entered only once into the
analysis, regardless of the frequency of their absconding, and compared to the
controls. This is the first study of absconding to have carried out a patient based
analysis of absconding, and the findings are that differences between absconds and
controls mostly disappear. If the propensity not to comply was a characteristic of the
individual, it should be linked to other individual characteristics such as gender and
age. However at this level of analysis it is not, and this indicates that the origin of
absconding and other noncompliant behaviours is more likely to be in the social
relationship between patients and the psychiatric services.
It is possible that this study was not large enough (175 absconders and 159
controls) to show significant differences at a patient based level of analysis.
Nevertheless it is clear that if differences do exist at the patient based level of analysis
must be small. They are certainly smaller than those large differences which are
readily identifiable at an event based level of analysis.
Of course it is possible that there is more than one type of absconder, and these
different types of absconders may have significantly different characteristics and
reasons for absconding. There are two ways of approaching this in the data analysis.
Subgroups of the absconders can be compared to equivalent subgroups of the, e.g.
married absconders to married controls. Or subgroups of absconders can be compared
to each other, e.g. married absconders compared to all other absconders. This latter
method heightens the contrast, provides the most detailed picture and has been used to
compare single/multiple absconders, and male/female absconders.
Most absconders do so only once. Contrasting them with those who abscond
on multiple occasions shows that they are more likely to be older, female, and not
single. Many of these one time absconders have what must be, from the patient's point
of view, a successful outcome: 38% are placed on leave or discharged. Developing
this analysis further by contrasting male and female absconders. The findings show a
multitude of differences between the two groups. These contrasts provide indicative
evidence that there may be at least two groups of absconders, with different
characteristics, social situations, patterns of noncompliance, and relationships with
psychiatric services. Some of the strongest differentiating variables between these
groups are age, gender, and marital status.
121
The evidence from this study has two important implications for further
research. The first is that study in the diverse fields of noncompliance (medication
refusal, treatment refusal, compulsory care, inpatient violent incidents and
absconding) should be brought together as these phenomena are likely to be inter
related. Secondly, there are liable to be subgroups of difficult and noncompliant
patients, and future research should be constructed with a view to explicating these
differences.
How and when
In contrast to the previous literature which reports that about half of
absconders leave whilst temporarily off the ward with permission, in this study 82%
of absconders left directly from the ward, 14% whilst temporarily off the ward, and
3% failed to return from leave. This indicates that any effort directed towards the
reduction of absconding does not need to focus primarily upon the granting of leave or
permission to leave the ward.
This study did not try to establish the efficacy of commonly used nursing
interventions to prevent absconding. These are, typically, instituting special
observation of the patient, stationing a nurse at the ward door to prevent unauthorised
departure, or temporarily locking the ward door. However, although these were not
evaluated during this study, it was established that 15% of absconders were being
specially observed at the time of their abscond, and that 11% of absconds occurred
despite the fact a nurse was stationed at the door. 1% of absconds occurred even
though the door to the ward was locked. Nurse interviewees showed in their replies
that they were well aware that acute psychiatric wards were relatively insecure and
that all these methods of preventing absconds could be overcome by patients. The
patient interviews contain accounts of exactly how they got out of the ward despite
these measures. No firm evidence could be found for a relationship between staffing
levels and absconding rates. Additionally, the failure to find any relationship between
ward observability and absconding rates suggests that physical security does not have
a very large impact.
There is, therefore, some support for the assertion that if patients are
determined to abscond, they will succeed in doing so despite the security precautions
of nurses. Also, that preventing absconding may be less a matter of providing physical
security and supervision, and more to do with professional-patient relationships.
Nevertheless, the patient interviews show that some absconds were prompted by the
sight of open ward doors and the ease of getting away. The fact that high numbers of
absconds take place at handover time when nurses are in their office also implies that
absconding patients exploit lack of supervision to make their way off the ward.
Common sense also says that locking the ward door must be at least partly effective in
reducing absconding. Therefore both factors, security/supervision and professionalpatient relationships are likely have an influence upon the rate of absconding. Faith
should not be placed in physical security measures alone.
As the majority of absconds occur during the first few weeks of admission to
hospital, interventions to prevent absconding should target patients who are relatively
122
new to the ward. This pattern may be due to patients being more acutely ill and
absconding because of psychiatric symptoms during this period of time. Or it may be
because it takes some time for staff to establish good relationships,. or for patients to
settle in to ward life. However as the mean length of stay was 28 days during the study
period, the tailing off of absconding may simply reflect the fact that there are fewer
patients with longer lengths of stay to abscond.
No relationship could be found between absconding and day of the week,
number of days since last ward round, or the weather. This latter finding was a
surprise, since previous research had found seasonal variation in absconding rates (e.g.
Bland and Parker, 1974; Molnar et al, 1985; Falkowski et al, 1990).
No association was found between individual inpatient keyworkers and
absconding, nor any association with the professional discipline of the patients'
community keyworkers. There is therefore no evidence that the interactional style of
individual nurses in any way precipitates absconding. However numbers of inpatient
keyworkers were very large, and their caseloads small. Any relationship would have to
be extreme to be statistically visible within the data.
The results do, however, show that individual Consultant Psychiatrists can
have an influence upon absconding rates, separate from the effect of the ward and its
nursing team. It is not known what aspect of the Consultant Psychiatrist's approach,
style, treatment emphasis, method of relating to their patients, or other factor,
influences absconding rates. This topic merits further investigation.
Where they go and what they do
Interviews with the absconders emphasised the ordinariness and normality of
absconding from the ward. Few of those who left the ward engaged in any kind of
bizarre activities. The majority went home, did some cleaning, cooking, watched
television, saw relatives or friends, went out for a drink or a walk in the park, etc. As
other studies have reported, the vast majority of absconding incidents resulted in no
harm, 2.4% of incidents resulted in a patient harming themselves, and 1.6% in them
harming someone else. The very normality is underlined by the fact that 96% of
absconds were successfully resolved without any harm coming to the patient or
anyone else. This can be compared with Milner (1966) who reported that 3.6% of
absconding incidents resulted in aggression towards relatives, and Walsh et al (1988)
who report figures of 6% for self harm and 1.4% for harm to others.
Nevertheless, some of the instances of self harm or attempted self harm
occurring during the study were potentially serious. Because the numbers were so low,
no particular features of these high risk absconders could be identified. Given that
acute psychiatric ward inpatients are nearly always admitted for reasons of safety, and
given that so many absconds have such trivial outcomes, professional staff are placed
in a very difficult position when trying to assess which absconds should be considered
emergencies and result in calls to the police or other services for urgent action. On
chance grounds alone, prediction that an abscond is likely to result in high risk
behaviour is most unlikely to be correct. Because false positive predictions are much
123
more frequent than true positives, other agencies are likely to lose confidence in the
psychiatric services as a result. If they arrive in a hurry at the patient's home only to
find them relaxing in front of the television, they will feel their time has been wasted.
The is most likely to happen with the police who will be most relied upon when
psychiatric staff consider that there is an emergency situation.
The opposite scenario is just as worrying, if not more so. The abscond may be
judged low risk when in reality it is not. That this is sometimes the case is shown by
the fact that some patients in this study who harmed themselves or others returned to
the ward by themselves or were taken back by relatives.
A further illustration of the difficulty facing staff when an abscond occurs is
given by data on risk assessment. Many absconders had histories of harm to self or
others, and many (70%) had these risks mentioned on their care plans. Yet very few
came to any harm during their abscond.
How and why absconders return
Most patients stayed away from the ward no more than a day or two, and most
returned to the ward by themselves, again underlining the normalcy of their behaviour.
However the simple fact that most came back by themselves conceals the fact that
many still felt coerced, either by their friends and relatives who persuaded them to
return, or because they knew that the police would be informed, or because they had
nowhere else to go. Of those who refused to return, many were physically returned to
the ward by friends or relatives.
Occasionally ward nurses would leave the ward to return absconders, but this
was very rare. Mostly they searched the ward, waited, or informed others about the
abscond and requested them to take action. Those most likely to be informed were the
police, but the decision to do this could take some time. The low frequency of calling
the patients home (by telephone) or relatives is of note. Given that most patients return
by themselves, and that significant additional numbers are returned by relatives, using
these contacts might be an effective and efficient way of getting patients back to the
ward.
Little use is made of community teams, who appear to see themselves having
little or no role in the return of absconding patients. Milner (1966) reports that a
community worker with specific responsibility for returning absconding patients can
be effective in many cases. However, in busy inner city mental health teams where
workers have full caseloads and diaries booked full of appointments with patients,
there are unlikely to be spare workers or spare time to carry out this task. This form of
absconder return may have advantages over the use of the police, as it would less
threatening and coercive. If backed up by ambulance staff, it may be found very
acceptable by patients. On the other hand, it may be less effective at returning those
who most need to be back on the ward, and in cases of recalcitrant patients, help from
the police would still be needed. Some assessment of the personal safety of the
workers concerned would also have to be made, as they may be exposed to undue risk
by seeking to persuade disturbed patients to return to the hospital.
124
This uncertainty about the actual risk posed by absconding psychiatric patients
is also expressed in the variable response of the police to requests to return patients.
This variability is not obviously linked to the risk history of the absconders concerned,
but seems to be determined more by the some factors (unknown) within the police
organisation or characteristics of individual officers. For example, although most
absconders are returned to the ward fairly amicably when a couple of police officers
call around at their house, sometimes a large number of riot police will call at the
patient's house, sometimes in the small hours of the morning.
The use of this level of force can be justifiable. The potential for serious injury
is present in any confrontation, and when in their own home patients may have access
to weapons. A London police officer was recently killed during an operation to
capture and take to hospital a disturbed psychiatric patient. The use of large numbers
of police in riot gear should be seen in the light of such incidents.
The potential exists for improved liaison between the police and psychiatric
services. This could be beneficial in many ways to both services. Following the Reed
Committee Report (Dept. of Health 1992) many advances have been made in this area
in relation to mentally disordered offenders, particularly in the development of court
diversion schemes (Cohen and Midgley 1994). Due to absconders not being offenders,
they appear to have been forgotten in discussions about liaison between the police and
psychiatry. Joint action over absconding patients is long overdue for review.
Absconding takes up many hours of valuable nursing and police time. Any potential
opportunity to save these scarce resources should be seized, while still maintaining
patient and public safety.
Why do patients abscond
The primary or main reasons given by absconders for their behaviour are
diverse. Moreover, these reasons or triggers for absconding need to be set against a
background of the absconders discontent with their position as a patient on an acute
psychiatric ward. Even those who gave psychotic or plainly incomprehensible reasons
for their departure from the ward, backed these up by additional and quite sensible
reasons for why they did not like staying. If nothing else, the interviews of absconders
reveal how unpleasant an experience it can be to be admitted to a psychiatric ward.
For some, admission to hospital is a profoundly socially isolating experience.
Many of the absconders complained that they did not see enough of their family and
friends, and worried about how they were getting along or managing whilst the patient
was in hospital. The social and family networks of psychiatric patients tend to be
restricted and frail (Brown and Harris 1978). Admission to hospital places a further
stress upon these networks, which although they can appear frail and superficial to the
outside observer, may be highly prized by the patient. It is particularly striking how
one in three male patients went directly to visit friends or seek friendly companionship
on absconding from the ward. It is all to easy for the psychiatric professional to have a
rosy view of the nature of the acute psychiatric ward as a friendly community of
people. Just because people are severely mentally ill does not mean that they have so
125
much in common that they must be friendly, understanding and supportive to each
other. In fact, they are more likely to be like any other random group of people
temporarily gathered together: superficially polite towards each other with the
blossoming of friendship comparatively rare. For the patient who has defective social
skills, making and securing friendships on the ward may be difficult or impossible.
Thus, even in the midst of people with similar difficulties, being a patient can be a
lonely experience.
Not only may other patients not be sufficient to replace the gap left by absent
friends and relatives, they may also be positively frightening. The commonplace
media picture of madness as uncontrolled violence (Philo et al 1994) also permeates
the patients' views of each other. They may be sure that they themselves pose no threat
to others, but they are by no means sure about the other patients on the ward not
posing a threat to them. Occasionally these fears are overlaid with paranoid ideation or
delusions, producing a powerful motivation to abscond or leave. More frequently, just
plain unembellished fear of assault is motivation enough. Any confrontation between
patients, or between patients and staff, can raise the anxiety of patients to unbearable
levels, even if only verbal. Events that happen suddenly, or at night when people feel
most vulnerable, are particularly likely to arouse fear and lead to absconding. Of
course patients' fear of assault is not groundless. Violent events do happen on
psychiatric wards (22.5 incidents per 100 beds per year, Noble and Rodger 1989), and
they are sometimes, albeit rarely, very serious.
Being on the ward can also make patients feel bored, trapped, and
claustrophobic. Although some hospitals in this study had occupational therapy
support to the inpatient acute wards, the nature and extent of this varied. There are
many unanswered questions about ward based activities for acutely ill psychiatric
patients. It is not really known what sort of activities are feasible or appropriate in this
context. Neither have any been assessed for their palatability to patients and
effectiveness in relieving boredom. Lastly, there is a grey area in that some such
activities can be seen as work, or therapy, or entertainment. The appropriate emphasis
for in patient contexts is not known.
Patients worry a great deal about their homes and flats while they are in
hospital. Not only are they homesick from friends, neighbours and relatives, they are
homesick quite literally for their homes. Many have not travelled a great deal or
widely, and may not be used to being away from home. Many are relatively poor and
may have taken a good deal of time to accumulate property of get their house arranged
in the way they wish. It is sobering to think of the elaborate preparations made by an
ordinary healthy person before they leave their home to go on holiday: checking
appliances to make sure they are switched off, emptying the refrigerator, making
arrangements with neighbours to collect mail, giving a friend a key and asking them to
check every so often, setting a burglar alarm, etc. All this just for two weeks holiday.
For the psychiatric patient admitted to hospital their is little time, ability or resources
for this preparation. Everything happens in a hurry, if not as a surprise to the patient.
Little wonder that they worry about their home, worry about their bills being paid of
their electricity cut off, worry about the home become stale and dirty, and most of all
worry about being burgled.
126
This latter is a serious and rational worry, as many patients live in areas where
burglary is very prevalent and likely to befall any unoccupied property. Two
absconders had their flats burgled while they were in hospital. Crudely extrapolated,
this appears to suggest that 1 out of 26 patients admitted will have their homes broken
into while they are in hospital. This high risk is confirmed by other absconders, who
related how this had happened to them on previous admissions, and how they worried
about it happening again. The emotional upheaval caused by burglary is well known,
and in addition, psychiatric patients are psychologically vulnerable people with few
financial resources. Little surprise, then, that worry about their homes and the practical
affairs related to their upkeep, maintenance, and financial management, leads some
patients to abscond.
A significant number of absconders (one in four) leave "in a huff" with the
staff, particularly when requests for leave and discharge are turned down. Some
described how they had made great efforts to appear at their best at ward rounds, or to
present their case in the best possible light, only to be refused in a way that made them
feel they were unimportant. Perhaps psychiatric professionals don't always realise how
emotive and how important it is to the patient to get a positive response to their
requests. To the staff, refusal is no more than a trivial delay in the patient's orderly
progression towards discharge. To the patient, emotionally and practically, it might be
considered a disaster - a crisis that may be further complicated and exacerbated by
their mental state.
Other angry leavers appear to be locked in to a relationship characterised by
long term conflict with psychiatry. This conflict is magnified and renewed by the
restrictions placed upon them as a psychiatric patient. Restrictions might be small,
solely a result of the needs of community living (e.g. smoking rules), or large and
related to compulsory care under the mental health act (e.g. enforced medication).
Regardless of their source or purpose, to the unwilling psychiatric patient, all of them
chafe and grate, feeding anger, annoyance, and irritation. It is not therefore surprising
that the sight of the open ward door is a temptation that cannot always be resisted.
The attitude of absconders to their illness and its treatment divides them
roughly into two groups: "refusers" and "disputers". The Refusers deny that they are
ill, assert that they feel well, and consequently believe that there is no need for them to
be in hospital. Most admitted that they had been unwell and in need to treatment, but
in their eyes the illness had come to an end and the need for treatment and
hospitalisation had evaporated. The Disputers, on the other hand, did not deny that
they were ill and in need of treatment. Instead they disagreed with the nature of what
was being offered and the way their problems were perceived by psychiatric
professionals.
With the Refusers, if persuasion and reasoned argument fail, and if the risks
posed are viewed to be great enough, staff have recourse to the provisions of Mental
Health legislation. Compulsory care is instituted and both parties have to tolerate the
consequences. For the staff this means facing the ongoing hostility, and anger of the
patients, and rejection by them. For the Refusers this means putting up with legally
authorised restrictions. It is for these patients that absconding is most likely to result in
forceful return to hospital by the police. In this situation, nurses deliberately distance
127
themselves from the legal situation, and portray themselves to the patient as equally
imprisoned by the legislative framework, i.e. we don't like making you stay or
enforcing your medication, but the situation forces us to do so. In this way they make
a small amount of potential room for the building some tenuous form of alliance or
relationship with the patient. It must be suspected that for the hard core of Refusers
eventual discharge results in the sundering of links with psychiatry and the rejection of
follow up treatment - until the next crisis and compulsory admission. Other reach
some form of accommodation with psychiatry as, over time, the view of the staff on
their mental state starts to match their own.
The Disputers tended to conceive of their problems in a wholly different way
from the staff. Either they would lay claim to what was, in their own eyes, a more
appropriate diagnosis of their problems, or they would conceive of their predicament
in terms of their ability to cope with daily life, or their cognitive ability. These
different views led to a variety of conflicts, usually either over medication, or whether
the patient was fit for discharge. One absconder left in anger to prove how really ill
she was, other left because they felt they were well enough (in terms of coping) to go
home. These conflicts also led to eventual alienation between the patients and staff.
The perennial questions of staff about textbook psychiatric symptoms clued in these
patients to the fact that these were the staff's criteria for wellness. Thus they started to
hide from the staff their real thoughts and feelings. Alternatively, if the patient felt in
desperate need, but staff refused to agree with the patient definition of that need or to
rate it with the same urgency, patients would behave in ever more extreme ways trying
to seek the response they needed to soothe their distress. Perhaps patients do not even
always know what that response is, only that the staff response that they do get is
unsatisfactory.
This latter pattern is very similar to that termed malignant alienation (Morgan
& Priest 1984), or to patient behaviour otherwise described in relation to the care of
patients with borderline personality disorder (Gallop et al 1989). This absconding
research demonstrates that these negative patterns of interaction between staff and
patients are not restricted to personality disordered patients, and are common among
those who abscond.
The experience of Refusers and Disputers in relationship to absconding
highlights several issues. Firstly that one way to reduce absconding would be to
improve staff-patient relationships. A second might be to be more open with patients
about the reasons for admission to psychiatric hospital. Admission is seldom primarily
about treatment, although treatment in the form of medication usually plays a role.
There is no psychiatric treatment that cannot be delivered to a patient at home (Marks
et al 1994). The reason for admission is primarily about safety, the safety of the
patient or the safety of the public. However it is often uncomfortable to say this to
patients, so instead the word 'treatment' is used as a euphemism, typically "we'd like
you to come in for some treatment". What a shock therefore, when the new patient
arrives on the ward, to find that they are detained there, seldom see their doctor, and
are largely left to their own devices. Given they have been told what may be referred
to as 'the big lie', it is not surprising that they become confused about what is going on
the ward, and what exactly they have to do in order to get discharged. More openness
about the reasons and criteria for admission and discharge may not lead to more
128
agreement, but it may lead to more understanding and compromise between staff and
patients.
The attribution of absconding to psychotic causes and reasoning only
accentuates alienation between staff and patients. To do so constitutes the
medicalisation of absconding, and the treatment of absconding patients with higher
levels of sedation. This is a suggested strategy by some nurses, as their interviews
show. However this implies a dehumanising picture of the acute psychiatric patient as
totally incompetent person whose behaviour is the meaningless product of a
disordered brain. This does not match the reality of daily life on the ward. Patients can
still talk reason, read the newspaper, play games, etc. Whole areas of their life and
competencies are untouched or only slightly undermined by their psychiatric
symptoms. The use of the illness as an explanation for difficult behaviour is too easy,
too lazy, and contrary to daily experience of the nursing care of patients. Mental
disorder clearly plays some role in absconding, but not by itself. To write everything
off as irrational behaviour means that listening to the patients will cease and
understanding disappear. Moreover, it distances staff relationships with patients and
adds to the very problems that this research has shown contribute to their absconding.
Given all the above, it must be expected that what absconding patients have to
say about staff is unlikely to be positive. In fact it comes as a surprise that they have
anything good to say about psychiatric professionals at all, but some do, commenting
favourably on the friendliness of nurses and expressing respect for doctors. However
the majority of comment is unfavourable, with doctors seen as distant, disbelieving of
patient reports, authoritarian, inaccessible and not having sufficient time to listen to
patients' problems, and nurses seen as powerless in comparison to doctors, bossy, and
unwilling to spend time with patients.
Relative and carer views of absconding
Perhaps the most striking thing to come out of the telephone interviews with
relatives was how poor the communication between them and the hospital was'
although the sample was very small, so conclusions must be tentative. However most
felt as if they were left completely in the dark. And this was in relation not just to
absconding but to many other issues as well. The interviewees did not know or
understand how the ward operated, nor the difficulties of keeping patients in hospital
even when they were detained under the Mental Health Act. The fact that most
interviewees discovered the absconding incident for themselves, or even in the worst
cases were the ones who informed the ward staff that the patient had gone, was not
conducive to confidence in the care provided on the wards. The quantitative data
confirms that relatives/carers are seldom informed about an abscond (23% of
occasions), even though a substantial number (8%) were brought back to the ward by
them. Even if they are informed about the abscond, ward staff may fail to let them
know when the patient has returned. No wonder one respondent felt that the nurses
were deliberately secretive.
The interviews reveal that the carers are seldom worried about the safety of
others during the patients abscond, but that more frequently they worry about the
129
safety of the patient. They do blame the hospital not the patient, and can feel angry
and let down by those whom they trusted to care for the patient. In combination with
the fact that they feel left in the dark much of the time, this does not facilitate
teamwork between the staff and significant others in the patients life - a lack of
teamwork that must surely overflow into relationships around community care when
the patients are discharged. In addition, lack of communication may make the
relatives/carers feel less welcome to visit on the ward, contribute to the patients’
feelings of isolation, and thus to their desire to abscond in the first place.
The six interviewees did register acutely uncomfortable feelings about the use
of the police to return absconding patients. They agree that it is necessary, but felt
deeply upset about that necessity. In addition, one interviewee related how difficult
they had found it to persuade the police to take the absconder back to hospital. None
criticised in any way the methods used by the police in carrying out this task.
It is not easy to see how ward staff should respond to these mixed feelings.
Perhaps an opportunity for the relatives to attend for a post abscond debrief with the
nursing staff would help. In that meeting the staff could explain their difficulty in
managing the patient, and ease the relatives feelings about the necessity for police
intervention. Plans for managing the patient in future could then be agreed, and a
channel of communication opened with the nursing staff. Meetings like these would
not have to be formal and could take place during visiting hours. At present it would
appear from these interviews that staff hardly talk to relatives/carers at all.
Of course not every absconding patient has a significant other to be this
involved in their care. The difficulties in recruiting interviewees for this part of the
study illustrate that. However, if this is the case it only underlines how socially
isolated some patients are, and how fragile and tenuous are their social networks.
Nurses views on absconding
Nurses are well aware of the potentially serious outcomes of absconding (e.g.
Sheppard 1996, Crammer 1984), hence their feelings on discovering an abscond are
primarily those of anxiety and worry for the patient. This they have in common with
the absconding patients' relatives and carers. Exactly what action the nurses then take,
they explain, depends upon the assessment of risk posed by the patient. Should the
patient be considered low risk, then the staff may be willing to wait a little while to
see if they come back, however if considered a high risk the police may be informed
immediately. In one case related by a patient absconder interviewee, the nurses from
the ward went immediately to her house and intervened after she had taken an
overdose.
Risk assessment was viewed by nurses almost in two ways. The first was that a
risk assessment took place on admission. In some Trusts, apparently, the nature of that
assessment was laid down by policy and special forms were used. The second view of
risk assessment that emerged was that it was a continuous process throughout
admission, and that the judgement of risk had to be made anew and again once a
patient absconded. Presumably this would be to take into account the behaviour and
130
speech content of the patient during the preceding week and preceding 24 hours, as
well as a longer term perspective based on the history of the patient, maybe
accumulated over many years psychiatric treatment.
Few of the nurses mentioned any uncertainty about the risk assessments which
were made. Perhaps this indicates a degree of confidence which is not warranted by
studies which have assessed the ability of psychiatric professionals in this field.
Monahan (1981) has pulled together evidence that positive predictions by psychiatric
professionals are correct no more than one out of three times. This estimate is based
upon predictions for patients being discharged from hospital, and may well not apply
to absconders. Some have suggested that short term predictions of risk may be more
accurate. Nevertheless, the nurses in this study appeared to express a degree of
confidence about their ability to accurately predict risk that is simply not warranted by
any empirical study. For these nurses, risk seems to be a defined quantity possessed by
a patient at a particular point in time, moreover it is one that is transparent and known
to the staff. Even when this assessment is called into question by doctors and conflicts
emerge, nurses still seem fairly certain of their assessment of risk. Only two of the
interviewed nurses expressed any uncertainty about the accuracy of risk assessments.
The nurses views on constant observation and absconding do match those of
the literature. The initiation and termination of constant observation is usually
determined by doctors and nurses together (Duffy 1995), it does not always work
(Pauker and Cooper 1990), it is stressful for nurses to undertake (Phillips et al 1977),
and not particularly well tolerated by patients (Pitula and Cardell 1996). The divided
opinions of nurses on other methods of preventing absconding reflect the fact that they
do not know of any evidence to say which would be effective or not. Their emotive
reaction to the issue of locking the ward door, and their clear commitment to a liberal
psychiatric ethos where it remains open, is of interest. There are at least two
psychiatric units in nearby inner London where all ward doors are kept locked all the
time. In those places the staff find these measures unexceptionable, and in their view
effective. Such strongly contrasting differences in emotive commitment to different
methods of psychiatric nursing care are common internationally (e.g. on mechanical
restraint, Bowers et al 1995). It would seem they may also exist between different
locales in the UK.
The vast majority of nurses were convinced that increased staffing levels and
stability, plus less reliance on agency staff, would decrease absconding. This was not
solely because they felt that patients would be better observed by staff who would be
able to recognise them. In addition it was because they felt that nurses would then
have time to get to know the patients properly as people, thus being better able to meet
their psychiatric nursing care needs. The authors of this report are not aware of any
empirical study that addresses the issue of psychiatric nurse staffing numbers per se.
Changes in staffing and staffing instability have been anecdotally reported to have
negative outcomes in patient behaviour (James et al 1990). Actual staff-patient ratios
are the outcome of bargaining, negotiation, budgetary issues and historical factors.
The absence of any thread of empirical evidence is startling. These nurses may well,
therefore, be correct. More nursing staff may mean fewer absconds. Even if they are
correct, locking the door whilst keeping staffing levels at current levels may be
131
equally as effective. The type of environment produced, however, may be more
impersonal and less desirable.
There exist two incompatible views of staffing levels on acute admission
psychiatric wards. One is represented by the nurses interviewed in this study: staffing
levels are too low for safe practice and doing the task of psychiatric nursing. The
second, arising from research, shows that psychiatric nurses spend large amounts of
time on administrative tasks in the ward office, and that they may avoid patient
contact by this means. Such criticism of psychiatric nursing practice cannot easily be
shrugged off, as it has been a repeated finding of research (Higgins et al 1997, MHAC
& SCMH 1997, Cormack 1976, Altschul 1972) and is even reported by a patient in
this study:
pt: the staff here .. they don't listen .. even if you're ill yeah ..
very ill .. they don't give a shit about you .. they're all drinking
tea in the office ..( P21704)
These issues (staffing levels and deployment, observation policies, locked doors) are
so important that they cry out for research investigation.
Certainly the nurses interviewed in this study felt vulnerable to being blamed
for absconds. It was not that they felt absconds were never due to errors in nursing
care. In fact several examples were provided by them of nurses stationed by the door
who let patients out, or of constant observation not being carried out according to
procedures. However what bothered them was the lack of acknowledgement that even
when the right procedures were invoked at the right time, and carried out to the letter,
given sufficient determination and commitment by the patient they could still manage
to abscond. Should that occur and the patient or someone else come to harm, the
nurses reflected a gnawing insecurity that they could still be blamed. Or, that in
retrospect, a nurse to blame can always be found. This is no light matter. A large
number of nurses came to work thinking that if a patient absconded and something
went wrong, even if it was not their fault, they were at risk of being blamed,
suspended, or even possibly losing their jobs. These fears may or may not have been
correct, however they were present for 42% of the nurses interviewed. This may partly
illuminate the difficulty in recruiting and retaining psychiatric nurses to work in
inpatient areas.
Ethnicity and absconding
Taken as a whole, all ethnic minority patients are more likely to abscond than
their White European counterparts. This is perhaps indicative of a more dysfunctional
relationship with psychiatry and psychiatric professionals. That dysfunctional
relationship may arise from a variety of factors, from simple cultural
misunderstanding on either side, to lack of trust in psychiatry by the patients or
ethnocentric views of professionals. This study of absconding cannot answer many of
the highly important questions that surround the psychiatric care of ethnic minority
patients. What this study does illustrate is the deep differences between different
ethnic minority communities.
132
Previous research purports to demonstrate that Afro-Caribbean's are more
likely to be diagnosed with schizophrenia (Harrison 1988), more likely to be detained
under the Mental Health Act (Moodley & Perkins 1991), and more likely to be treated
with physical rather than psychological means (Chen et al 1991). This research has
been taken by some to show that psychiatric professionals use a prejudicial stereotype
when it comes to ethnic minority patients, one that characterises them as "Big, Black
and Dangerous" (Prins et al 1993). The research on absconding fails to support this
latter assertion. For if psychiatric professionals were employing such a negative
stereotype across the board, based in some way upon skin colour, then it would apply
to all ethnic minority groups. Instead this research shows stark differences between
absconders from different communities.
For example, it is not the Afro-Caribbean's who are more likely to abscond in
this study, it is instead the Bangladeshi's and Somali's, with the White Europeans
being less likely than anyone else to abscond. When male and female absconders are
contrasted, female absconders are more likely to be Afro-Caribbean's or White
Europeans who are older and separated/divorced, whereas male absconders tend to be
Bangladeshi's or Somali's who are younger and single. When assessed risk to others is
considered, it is the Bangladeshi's (56%) who are most likely to be considered a risk,
and the other African's least (5%). The pattern changes, as in a kaleidoscope, when
risk to self is considered. Now it is the White European's (30%) who are most likely to
be considered a risk and the Somali's (12%) the least.
These results illustrate that there is no monolithic black community that is
universally discriminated against and the target of psychiatric racism. Instead there are
a multitude of very different minority communities. Each has their own social
relationship with psychiatry dependent on their culture, origin, and process by which
they arrived in the UK. The problems of each, in relation to psychiatry, need to be
understood on their own terms.
Making sense of these differences with the data from the absconding study is
difficult. The differences are easier to describe than explain. For example, although
many of the findings about Bangladeshi absconders fit together (do not live alone,
brought back by relatives, etc.), other questions such as why they are so young and
why they are particularly frightened in hospital go unanswered.
One item indicative of some form of ethnic bias with regard to perceived risk
was found in the data collected in this study. The findings show that Afro-Caribbean
absconders are more likely to have the police informed about their abscond than other
ethnic groups. This is despite the fact that they were no more likely to have had
previous contact with the police and no more likely to have had any kind of forensic
history. This tendency for the police to be informed is greater for second and
subsequent absconds by male Afro-Caribbean's. It may be some subtle cue, a small
cultural variation of facial reaction, body language, timing of speech, vocabulary used
or tone of voice, that unknowingly to the patient communicates threat to the
psychiatric professional. Or, there really is a bias operating in staff's judgement of the
risk to others posed by absconding patients from this background. Or, psychiatry
really does, in some as yet undescribed way, assemble differently risky people from
different ethnic backgrounds. It certainly seems to work that way for White European
133
absconders, who have more history of suicide, are considered more of a risk to self,
and account for most of the self harm attempts during absconds. However the AfroCaribbean absconders do not have more of a forensic history behind them, nor do they
account for most of the instances of harm to others logged by this study, so the
tendency for the police to be informed more often is not so readily explicable.
The abscond data raises interesting questions about the complexity of the
interaction between ethnicity and psychiatry. It does not provide any complete
answers.
Absconding rates in the East End of London
Absconding rates in the East End of London by the Molnar and Pichoff (1993)
formula is 38.7. It is difficult to set this figure within the context of previous studies,
as widely varying rates have been reported. This figure is comparable to that reported
by Neilson et al (1996) of 34.5 for acute admission wards in Sheffield. It is very
different from that reported by Tomison (1989) of 8.7 for Barrow Hospital. However
Tomison's figure was for the whole of a 316 bed psychiatric hospital, not just acute
admission wards. Acute admission wards are likely to generate the higher rates of
absconding, therefore those studies using whole hospital statistics seem likely to
provide a misleadingly low rate of absconds when extrapolated to acute admission
wards only. In addition, most previous studies have used official reports as an
operational definition of an abscond. If the same criteria is applied to the data
collected in this study, official abscond forms were only completed for 236 of the 498
absconding events. The rate for the East End of London then dips to 18.3.
All that can really be said with great confidence about the rates of absconding
in East London is that although they are at the top end of the range reported in
previous studies, they are not exceptional.
Trust level factors
Some differences between the three Trusts studied were elicited in the course
of analysing the data.
Trust S seems less likely to allow patients to leave the ward for short periods
of time (or the staff there are better at judging who is likely to abscond when given
this privilege), as only 2.4% of their absconds take place under these circumstances,
compared to 13% and 15% in the other two Trusts. Trust S also appears to try to
prevent absconding by stationing a member of nursing staff at the door, as 52% of
their absconders leave while this policy is in operation. These modes of enhancing
ward security (low use of temporary leave and high use of 'door stops') do not seem to
have an unambiguous relationship to absconding rates, and it is far from clear whether
they are effective or not.
Trust E has the highest rate of absconding by some measures, but the data are
not consistent enough to assert confidently that this represents a real difference in
134
absconding rates. Only half the number of absconding patients in this Trust are
returned by the police, although there is no difference in the proportion of absconders
who are officially reported to the police. This may indicate a more difficult
relationship between the police and psychiatric services in this locality, or that police
there have fewer resources to expend on returning absconders, or give this task a
lower priority. More absconders leave whilst away from the ward with permission in
this Trust. This may indicate the psychiatric professionals there are confident and
willing to take more calculated risks in allowing patients to leave the ward
temporarily.
Of all the three Trusts studied, Trust O appear to have the most differences
from the other two. These findings may reflect more anxiety about patients and the
harm they may come to during an absconding event. For example, more absconders
are placed on intermittent nursing observations prior to their abscond, more were
admitted on treatment sections of the Mental Health Act, and overall, many more
absconders were considered to be a risk to others. More absconders escaped from
wards which were locked in this Trust, possibly indicating that ward doors are locked
more frequently. This was the only Trust from which some absconders reported that
their visitors had not been allowed onto the ward, motivating them to abscond in order
to see them. The interviews of staff showed the highest levels of blame for absconding
in every direction, nurse to nurse, doctors to nurses, and managers to nurses, and more
nurses were insecure about their jobs in this Trust than in others.
Each of these findings in isolation could be explained as chance anomalies.
However together they form a stronger picture, much less easy to explain away, of an
organisation in which anxiety and blame are high. These findings may indicate overall
low staff calibre in Trust O, with the high levels of anxiety justifiable because
procedures are not being properly followed. Or they may indicate that this Trust does
selectively admit patients who are more dangerous than the other neighbouring Trusts.
On the other hand the findings may indicate a punitive and unsupportive culture in
which staff feel highly vulnerable both from the actions of patients and from the
actions of colleagues and managers, and as a result struggle harder to contain patients
who are considered to pose risks to themselves and others.
As can be seen from the data in the study, different NHS Trusts can have very
different operational policies in relation to absconding, risk assessment and risk
containment. It is sobering to realise that these differences can still exist and be quite
large in Trusts which are geographically neighbouring, serve similar populations
demographically, and were even in recent memory part of one organisation. These
variations between Trusts indicate that psychiatric organisational culture is
considerably diverse, and does impact upon patient care.
Ward level factors
The use made in this study of a variety of ways to express absconding rates
enables a much fuller comparative picture to be drawn of the differences between
wards. It can be confidently asserted that some wards have significantly higher rates of
absconding across the board than others, and some lower. These variations are not
135
explicable by the complexity of design or other security features of the ward that
enhance or obstruct the observation of patients, or the ease with which they may leave.
Moreover, some wards appear to be better at preventing further absconds after one has
occurred, indicating that they may respond effectively in some way once the risk of
absconding is firmly identified.
These findings provide grounds for the assertion that the way nursing staff
deliver psychiatric nursing care on the wards can have a significant influence upon the
rate of absconding. What the important factors are have not been directly assessed by
this study. The methodology was not designed for this and does not show an
association between individual wards and the reasons patients gave for absconding.
Nevertheless this study has described the reasons patients have for absconding, and it
may be hypothesised that on wards with low absconding rates patients have fewer of
these reasons due to a different style of nursing care.
136
Conclusions and Recommendations
Limitations
This study took place in the East End of London. It must therefore be
cautioned that results may not be fully generalisable or applicable elsewhere in the
UK. The East End of London is unique in several ways. Firstly it comprises part of
inner city London, an environment which is known to have an exceptionally high
psychiatric morbidity (Johnson et al 1997). Secondly, it contains some of the most
deprived and poor areas in the UK by Jarman index (Jarman et al 1992). Thirdly, the
local population is made up of high numbers of several culturally diverse ethnic
minority communities. Each of these three factors must be taken into account when
assessing the applicability of this research to other areas.
Reliance upon nursing and medical notes for information about absconding
and control patients was inevitable. Where gaps existed, the ward nurses on duty at
the time the data was collected were asked to provide the information. Some data
items could not be collected for some patients. These methods are not fully reliable,
and the diagnostic information used in this study is liable to be particularly weak.
The interview sample was biased towards male absconders. All interviews
took place on the wards. Female absconders were more often placed on leave or
discharged without returning to the ward, and were therefore less likely to be asked for
an interview. Resources were not available for interpretation, and non English
speakers were not interviewed. In addition, some returning absconders were too ill to
consent to or take part in an interview, thus the sample is somewhat biased towards
the more cognitively competent absconders.
It may be suggested that the accounts of absconding patients should not be
uncritically accepted. They may be biased, self serving exaggerated accounts by a
particularly disgruntled group of patients, containing excuses and special pleading by
those who know they should not have absconded. In addition, these retrospective
accounts may have been influenced by patients mental disorder, e.g. delusions,
hallucinations, anxiety, paranoia, poor memory and confusion. Nevertheless the
reasoning given by patients for their abscond was, in most cases, detailed, reasonable,
and very believable. As few felt guilty about their abscond, it may be deduced that
they had no motivation to provide self justifying accounts of their behaviour. Finally,
absconders may indeed be a disgruntled and unhappy group of clients. However this
research set out to discover some of the reasons why they might be so discontent.
Asking them to elaborate on their discontents and complaints about ward life was
therefore an intrinsic part of the study design. These content of these complaints
cannot be generalised to all acute inpatients - those that stay on the ward and do not
abscond may have a different perspective. However what is described in this report
does accurately represent the views of absconders.
The strengths of this study lie in its size, independence from official reporting
procedures, prospective design, and triangulation from many data sources. The
combination of qualitative and quantitative methods has allowed comparisons
137
between different types and sources of information at the stage of analysis. The use of
computer aided qualitative data analysis has allowed statistical testing to be applied to
some qualitative interview findings, and aided in the production and application of
rigorous codes and analytic procedures.
Conclusions
Although absconding from acute psychiatric wards in the UK is a common
problem, it is not an intractable one. Findings of variations between NHS Trusts and
individual wards indicate that there are different forms of psychiatric care delivery that
can have a significant impact on absconding rates. Although for most patients the
dangers involved in absconding are small, negative outcomes do occur, and
absconding causes much anxiety for nurses and relatives/carers. It thus remains a
serious problem which requires action to prevent harm coming to patients or others.
It is possible to draw up a predictive profile of the potential absconding
patient, and this study provides the tools with which to do that. Once done,
interventions to reduce the risk of absconding may be targeted at this group,
enhancing the efficient use of nursing time.
Although the symptoms of mental illness do play a role in absconding, the
larger picture shows that life on the ward is difficult for patients. They can feel
trapped, bored, frightened, cut off from their families and friends, and have justifiable
worries about their home responsibilities. These factors contribute to the decision to
abscond from the ward, whether that takes place impulsively and in anger following
bad news, or whether patients make a more planned exit to undertake some activity
outside the ward.
Methods of physical security and supervision may not be as effective as is
often hoped. This study show that attention directed to the patients psychosocial
problems, and to the building of a good relationship with them, may be more
productive in reducing absconding. In addition, it should perhaps receive wider
recognition that even when physical security procedures are followed in detail,
patients who are determined may still manage to abscond from the ward.
Most patients go home and undertake normal everyday activities when they get
there. And most come back by themselves, under their own steam, usually the same
day. Some are brought back by relatives, and those relatives can feel uninvolved and
left in the dark about the psychiatric care of the patient. Those brought back by the
police appear to have a variety of very different experiences of their return to hospital.
Better liaison and communication between hospital, police and relatives/carers might
therefore be very productive in decreasing the workload associated with returning the
absconder, and in promoting patient safety.
As always, more research is required. This study has shown tantalising
glimpses that absconders are not all the same, and that there may be two very different
groups who have different reasons to reject inpatient care. The unique characteristics
of different ethnic minority groups in relation to absconding and psychiatric inpatient
138
care is worthy of much more extensive exploration than could be undertaken in the
course of this study. Lastly, it is now possible to construct a nursing intervention to
reduce absconding based on the findings in this report. Such an intervention requires a
controlled trial at the earliest possible time.
Recommendations
1. Some form of home care and home security service for psychiatric inpatients might
be highly valued by those who worry about their property.
2. Nurses may wish to involve relatives and carers (subject to patient agreement) to a
greater degree in the patient's care on the ward, and when seeking their return to
hospital following an abscond.
3. Psychiatric service providers may wish to discuss with the police some form of
prioritisation system for absconders who pose different risks, plus some
communication over which absconders may pose a risk to the police involved in
their return to hospital.
4. There may be a role for Community Mental Health Team staff (perhaps in
conjunction with duty systems) in the return of lower risk absconding patients. This
does not necessarily mean physically returning the patient to hospital, but may
mean a call at the patient's home and persuading them to take a hospital financed
taxi back to the ward.
5. Psychiatric staff (of all disciplines) may wish to renew their efforts to understand
and deal with the patient's worries about home life and responsibilities.
6. Multidisciplinary care teams may wish to consider transfer to a locked intensive
psychiatric care environment, or discharge, for every patient who absconds more
than two or three times during a single admission
7. A controlled trial of an nursing intervention to reduce absconding rates, based upon
the findings of this study, should be undertaken as soon as possible.
139
Appendices
Appendix
1
2
3
4
5
6
7
Page
Ward staff abscond notification form
Researcher abscond data collection form
Interview schedule for absconders
Interview schedule for nursing staff
Telephone interview schedule for relatives/carers
Index of ward observability
Notes on transcription conventions
140
141
142
146
149
151
158
160
Form A
Contact: Manuela Jarrett
Phone: 0171 505 5840
Mobile: 0966 510489
Section 1
Ward: ___________________
Date: ____________
Patient initials: _____________
Time patient noted as missing: _____________
Please tick which of the actions were taken in response to the patients absconding and at what time they were taken.
Wait_________am/pm
Patient placed on leave_________am/pm
Community worker informed ________am/pm
Police informed_________am/pm
Consultant informed________am/pm
Relatives contacted__________am/pm
Duty doctor informed_________am/pm
Researcher contacted__________am/pm
Duty nurse informed _________am/pm
Social Worker_________am/pm
GP_________am/pm
Ward Manager_________am/pm
Hospital grounds searched_________am/pm
Ward searched_________am/pm
Missing person form circulated________am/pm
Patient’s home contacted__________am/pm
_________________________________________________________________________________________
Number of staff on duty: Qualified:
Unqualified:
Students:
Agency:
_________________________________________________________________________________________
Number of patients on high obs:
Continuous:
Close:
(highest level
(level 2/B/15 mins
of observation)
observation)
_________________________________________________________________________________________
Section 2
OUTCOME
Date: ___________________
Time:
_____________________
Patient returned to ward
Method of return: ______________________________________________
Patient seen by agency and discharged
Agency (e.g. CPN, GP, ):_______________________________________
Patient not seen by any agency and discharged
Patient placed on leave
141
Form B
ward:
consultant:
patient:
diagnosis:
current/previous
psychiatric state previous admissions:
d.o.b.:
in-pt. k/w:
known to police/courts:
gender:
date of admission:
marital status:
source of referral:
previous forensic
admissions:
self mutilation history:
sibling order:
com. k/w (name/discipline):
ethnic origin:
number of ward transfers in last seven days:
religion:
risk as noted in care plan:
previous awol on this
admission:
awol on previous
admissions:
current risk to others?
highest education to date:
mha status on admission:
current risk of neglect?
living grp:
occupation:
n of medication refusals in last 2 days:
n of incident forms for last 7 days:
current risk to self?
pt confined to ward?
level of observation 24hrs prior to being
noted as awol:
did patient express wish
to leave ward within
previous 24hrs of going
awol?
accommodation:
time of last employment:
0-6mths 7-12mths 13-18mths
19-24mths <24mths
Medication at time of abscondence:
history of suicide
attempts?
approx date of
most recent att:
142
Y
N
place/situation of absconding episode:
mha status at time if different from admission:
security status of ward at time of ab.:
date of change:
circumstances that led up to awol (continue overleaf if necessary):
Risk outcome:
changes of management of care on return on return to ward
*(specify below):
research outcome:
interviewed on (date): _______________
no change
medication altered*
mha status altered*
ward transfer*
other*
___________________________________
___________________________________
at (time): ________________
not interviewed due to:
mental state/language difficulties/placed on leave/
discharged/failed to return/refused/
other
________________
143
Codes for Form B
Sibling Order
Religion
Ethnic Origin
Gender
Wards
0=only child
1=Christian
1=Afro-Carribean
1=female
1=
1=first child
2=Hindu
2=Bangladeshi
2=male
2=
2=last child
3=Jewish
3=Other African
3=
3=any
child
4=Muslim
4=Somali
Marital Status
4=
1=Single
between
5=Sikh
5=Other Asian
5=
2=Married/Stable partner 6=White European
1&2
6=None
6=
3=Separated/Divorced
4=not recorded
7=Not known
7=Turkish
7=
4=Widowed
8=Other
8=Not known
8=
5=Other
9=Other
9=
mha status
n of section
10=
0=informal
11=
12=
Occupation
Living Group
Accomodation
1=Lives Alone
1=Owner
1=Full
time
2=With partner
2=Private rented house/flat
employment
3=With partner & children
3=Private rented room
2=Part
time
4=With children only
4=Council Accomodation
employment
5=With friend
5=Housing Association
3=Student
6=In shared accomodation
6=No fixed abode
4=Retired
7=Does not live with children
7=Social services accomodation
5=Unemployed
8=With parents only
8=Voluntary organisation
6=Voluntary Work
9=With parents & siblings
accomodation
7=Long term sick
10=Other
9=Temporary accomodation
11=unknown
8=Other
10=Sheltered housing
11=Other
12=unknown
Consultants
Source of Referral
Education
Place/Situation of
1=
1=General Practitioner
1=none
episode
12=
1=ward
2=
2=Self
2=GCSEs (or=)
13=
2=OT
3=Family
3=
3=A levels (or=)
14=
3=temporarily off
4=
4=bachelors degree 4=Police
15=
ward escorted
5=Court
5=
5=CSEs
16=
4=temporarily off
6=CPN
6=
6=masters degree
17=
ward unescorted
7=Social Services
7=diploma
7=
18=
5=failure to return
8=Intensive care unit
8=other
8=
19=
from leave
9=A & E
9=unknown
9=
6=Other
10=General Hospital
10=
11=Other ward
11=
12=Other
13=emergency clinic
14=prison
15=outpatients
Risk
Security status of K/W Disciplines
Levels
of Risk as noted date of last
employment
Outcome
ward at time of
Observation
in care plan
1=self
abscondence
1=CPN
1=0-6mths
1=no harm
2=others
1=Continuous
2=Social Worker
1=locked
2=7-12mths
2=harm to
3=neglect
3=Support Worker 2=15 mins
2=door stop
3=13-18mths
self
4=no risk
3=General
4=Other
3=neither
4=19-14mths
3=harm to
5=none noted
5=<24mths
others
6=awol
4=neglect
7=drug use
5=harm to
property
6=other
7=drug use
Medication = Name of medication and total daily dose
Diagnosis = See over for ICD 10
144
Research Outcome
1=interviewed
rest not interviewed due to;
2=mental state
3=language difficulties
4=placed on leave
5=discharged
6=failed to return
7=refused
8=other (usually absent each time reseacher visits ward)
145
PATIENT POST ABSCOND INTERVIEW
Introductions
Explanations
Consent
Ice-breaking
Check tape recorder
functioning before starting. Do
a test sentence and playback.
The Hospital
Have you been in this hospital before?
Have you been on this ward before?
What do you think of it?
Do you like it here?
What did you expect when you were admitted?
Did it turn out like that?
What do you think of the treatment you've been given?
Only use prompts for those items not raised by patient
groups
OT
medication
talking
length of stay
ECT
How do you keep occupied on the ward?
Do you feel homesick, or wish you were at home?
Do you ever get frightened here? Or trapped?
What do you think of the nurses?
What do you think of the psychiatrists?
Check tape hubs turning.
Life at home
What sort of place do you live in outside of hospital?
Flat, house, hostel, rented, council, owned?
Does anyone look after the place for you?
Do you worry about it? If so Why?
Do you have family or friends there or nearby?
Have they stayed in touch with you while you've been in hospital?
Visits?
Is there anyone at home or nearby who you help to look after?
Children, elderly relatives, friends
What about pets?
If so How are they managing while you are in hospital?
Do you have a job? If so How will being in hospital affect that?
Do you get important mail at home (e.g. housing, giros, etc.)?
If so If you're not allowed off the ward, how do you get it?
Leaving the ward without permission
(If failed to return from leave, skip to next section)
When you left the ward on xday
What time did you go?
Did you plan to go in advance?
Did you make any preparations before you went?
Phone calls, pack bag
Did you intend to leave permanently?
Did you talk to anyone about leaving before going?
Other patients, friends/relatives, staff
What did you say to them?
Were the staff expecting you to try and leave?
How did you leave?
Did you leave from the ward itself?
If not, where?
146
Provide lots of verbal and nonverbal feedback.
Use neutral follow up
questions:
Can you tell me a bit more
about that?
Can you explain a bit further?
I'm not sure I understand what
you mean by x?
I think you're saying that x?
Have I understood that right?
Did you pretend to be going somewhere else?
Did you have to watch and wait for an opportunity
to get out?
What opportunity?
What exit did you use?
Main door, back door, fire escape,
window?
Did anyone see you go? Who?
Where did you go first? Why there?
Did you go anywhere else? To do what?
Failing to return from leave
When you didn't come back to the ward on xday
Did you plan to not to return when you first left?
Did you make any preparations before you going on leave?
Phone calls, pack bag
Did you talk to anyone about not coming back?
Other patients, friends/relatives, staff
What did you say to them?
Where did you go first while on leave? Why there?
Did you go anywhere else? To do what?
Reasons for absconding
Why did you leave the ward?
OR
Why didn't you return from leave as arranged?
(Get full answers, using plenty of follow up, exploratory questions,
before proceeding to use prompts)
Bored on the ward?
Frightened on the ward?
Wanted to be free to do what you wanted?
To be alone, not watched?
Official leave refused?
Something happened on the ward?
The staff?
The other patients?
Something that needed to be done at home?
Someone who needed looking after at home?
Someone you wanted to see who you missed?
While absconded
How did you feel while you were away?
Frightened? If so What of?
Enjoyed? If so What?
Did you miss any medication?
Was that good or bad?
What do you think about your medication?
Did you use any street drugs while away?
Or alcoholic drink?
Did you try contacting the ward to let them know where you were or
when you would return?
The return
How did you return to the ward?
Police? Was there a struggle or fight? Tell me how it all
happened?
Ambulance? How?
CPN or Social Worker? How?
Relative/friend? How?
147
Check tape hubs turning.
Provide lots of verbal and nonverbal feedback.
Use neutral follow up
questions:
Can you tell me a bit more
about that?
Can you explain a bit further?
I'm not sure I understand what
you mean by x?
I think you're saying that x?
Have I understood that right?
Other? How?
Voluntarily? If so Why did you return? And how? Bus?
Taxi? Walked? Brought back by relative/friend?
Now
How do you feel about being back in hospital?
In retrospect, how do you feel about having absconded?
Glad? Sorry?
If you weren't here in hospital, what would you be doing?
Have you left the ward before this time, without staff knowing?
If so Were your reasons the same?
If different What were they?
Do you think you are likely to leave without permission/fail to come
back, again?
Now review schedule to check that you have asked all the
questions. If not, go back to the ones you haven't asked.
Then check forms A & B with the patient to fill out any missing
detail (if possible).
Is there anything else you could tell me or would like to add?
Thanks
148
Replay last part of tape to
check it has recorded
STAFF INTERVIEW
Introductions
Explanations
Consent
Ice-breaking
Check tape recorder
functioning before starting. Do
a test sentence and playback.
Risk assessment
In your experience, how is risk assessed on your ward?
How are levels of observation for individual patients decided?
Who makes this decision?
Do medical and nursing staff agree over risk assessment?
If there is disagreement, how is this resolved?
How would you describe the relationship between medical and
nursing staff?
Do you feel that your professional judgment is valued?
Check tape hubs turning.
Absconding
What do you do when a patient absconds?
How is the decision about what to do made?
When full reply obtained, probe:
discussion between nursing staff
standard procedure (always?)
discussion with ward doctor
discussion with Consultant
How do you know what to do?
When full reply obtained, probe:
knowledge of the particular patient
read policy
informed by other staff
degree of risk involved
Can you tell me a bit more
about that?
Provide lots of verbal and nonverbal feedback.
Use neutral follow up
questions:
Can you explain a bit further?
I'm not sure I understand what
you mean by x?
I think you're saying that x?
Have I understood that right?
Consequences of absconding
Are you aware of any incidents of absconding which have resulted in
incidents of self harm or harm to others?
Are you aware of any incidents of absconding which have had
consequences for staff?
Nurses feelings about absconding
How do you feel when a patient absconds?
When full reply obtained, probe:
Irritated
Anxious
Relieved
How do you feel when they return?
When full reply obtained, probe:
Irritated
Anxious
Relieved
What does a patient absconding mean to you and the other staff?
When full reply obtained, probe:
reflection of staff practice?
Ward atmosphere?
Policy
149
What do you think might be useful in reducing the numbers of
absconding patients?
No specific prompts with this question
Now review schedule to check that you have asked all the
questions. If not, go back to the ones you haven't asked.
Is there anything else you could tell me or would like to add?
Thanks
Replay last part of tape to
check it has recorded
150
telrel3.doc
SIGNIFICANT OTHER TELEPHONE INTERVIEW
Interview with ..........................................
Client code
Relationship
parent
sibling
partner
other .............
1
2
3
7
Relative code
Could I speak to ............................................................ please?
My name is.......................................and I work for City University.
Your........................(relationship) ................... (name of client) has given me
permission to contact you in connection with research I’m doing in ....................
hospital. It’s about patients who leave the ward without permission, and if you are
willing to answer a few questions, your replies will help us understand why people
leave and what effect this has on others like yourself.
Is now a convenient time for me to speak to you - it will take about 15 minutes?
(If not, arrange another time) ...............................................
In a moment I'm going to ask my questions. I will be taking notes of your replies, but
in my final report neither your name nor that of ............................ will appear.
1(i) Are you happy to take part?
Yes
No
1
2
(If ‘no’)
1(ii) Is there a particular reason for that?
Ask everyone
2. Are you aware that ...................
.......day?
left the ward/failed to return from leave on
Yes
No
(If no go to Q7)
151
1
2
3. How did you find out that this had happened ?
phoned at home
phoned at work
other ........................
1
2
7
4. Who told you ?
nurse
nursing assistant
doctor
other
unsure (ward staff)
1
2
3
7
8
5. What exactly did they say?
6. What was your first reaction to the call?
7. What do / did you feel about .................’s leaving the ward without permission?
or
.................’s not returning when (s)he should have?
(After full reply obtained, use prompts to ascertain responses e.g. afraid, concerned,
angry, pleased, annoyed, loss of confidence, disgust in relation to:)
152
(I) feelings about client’s well-being.........
did you have any feelings about : any trouble s(he) might get into? /any harm s(he)
might come to? / where s(he) might be?
(ii) fears about own safety.......
did you have any worries / concerns / fears about what ............... might do to you?
(iii) feelings about the hospital?
8. Why do you think that ............... was away from the ward without permission?
153
9(i). Has the incident affected your relationship with ...........................?
yes 1
no 2
(If ‘yes’)
9(ii). In what way(s) ?
10(i). Has the incident affected your relationship with, or faith in,
the hospital?
yes 1
no
2
(If yes)
10(ii). In what way(s) ?
11(i). Has it happened before?
yes 1
no 2
unsure 8
(If yes)
11(ii). Can you give me the details?
154
12. How do you think incidents like this should be dealt with by the hospital?
13. And how do you think the hospital could prevent things like this from happening?
Questions 14 and 15 to be asked only of those who already knew about the
incident prior to this phone call
14(i) Were you involved in looking for or returning ................to
the hospital?
(If yes)
14(ii) Can you tell me the details?
155
yes
no
1
2
15. How do you feel about the way in which ....................... was returned?
Ask all
16. What do you think of the care ................................... is receiving ?
156
17(i). Do you feel involved in .................’s care?
(If no/unsure)
17(ii).Would you like to be?
yes 1
no
2
unsure 8
yes 1
no
2
unsure 8
18. Is there anything else you would like to tell me?
19. Would you like us to send you a summary of the report when it comes out ?
yes
(If yes) Address details
no
Thank you very much for talking to me.
157
1
2
INDEX OF WARD OBSERVABILITY
HOSPITAL
WARD
DATE
Office
use
only
1. Number of rooms open to patients during daytime shifts
2. Number of independently observable zones, as
demarcated by corners/doorways of the main corridor or
hall
3. Number of zones visible from the main nursing office or
nurses station (count from one only, not both, choosing the
one with the best visibility)
4. Number of unlocked exits from the ward during daytime
shifts, including windows which can be opened at ground
floor level
5. Number of patient releasable exits, e.g. break glass fire
doors
6. Number of exits of any sort visible from the main nursing
office or nurses station (count from one only, not both,
choosing the one with the best visibility)
7. Number of floors comprising ward
8. Number of beds
158
INDEX OF WARD OBSERVABILITY
(SCORING KEY)
HOSPITAL
WARD
DATE
Office
use only
1. Number of rooms open to patients during
daytime shifts
Score 0.5 point for
each room
2. Number of independently observable
zones, as demarcated by corners of the main
corridor or hall
Score 1 point
each zone
3. Number of zones visible from the main
nursing office or nurses station (count from
one only, not both, choosing the one with the
best visibility)
Score 1 point for
each zone not visible
4. Number of unlocked exits from the ward
during daytime shifts, including windows
which can be opened
Score 1
each exit
5. Number of patient releasable exits, e.g.
break glass fire doors
Score 0.5 points for
each exit
6. Number of exits of any sort visible from the
main nursing office or nurses station (count
from one only, not both, choosing the one
with the best visibility)
Score 0.5 point for
each exit not visible
7. Number of floors comprising ward
Score 3 points for
each floor
8. Number of beds
Divide by 10
point
for
for
Sum
all
points.
Higher scores = less
observability
159
TRANSCRIPTION CONVENTIONS
The following adapted version of Potter and Wetherell’s (1987) transcription notation
was used to facilitate understanding of the transcripts: material within square brackets
e.g. [talking to N] indicates clarificatory information; square brackets on their own
indicate that some of the script was deliberately omitted; a full stop inside round
brackets i.e. (.) indicates a noticeable pause; underlining is indicative of words spoken
with added emphasis; words in capitals were said louder than surrounding words; and
round brackets on their own indicate material that was inaudible.
160
References
Altman, H., Brown, M. L. & Sletten, I. W. (1972a) And silently steal away Diseases
of the Nervous System 33:52-58
Altman, H., Angle, H. V., Brown, M. J. & Sletten, I.V. (1972b) Prediction of
unauthorized absence American Journal of Psychiatry 128: 1460-1462
Altschul, A. (1972) Patient-Nurse Interaction. Edinburgh: Churchill Livingstone
Antebi, R. (1967) Some characteristics of mental hospital absconders British Journal
of Psychiatry 113, 1087-1090
Aspinall, P (1993) When a vulnerable patient absconds Journal of Clinical Nursing 3,
115-118
Atinkson, R. M. (1971) AMA and AWOL discharges: a six year comparative study
Hospital and Community Psychiatry 22(10)293-296
Battle, E. & Zwier, M. (1973) Efficacy of small group process with intractable
neuropsychiatric patients. Newsletter for research in mental health and behavioural
sciences 15(3)15-17
Bland, R. C. & Parker, J. H. (1974) Some features of mental hospital elopements
Canadian Psychiatric Association Journal 19:463-466
Bowers, L. & Clark, N. (1998) Incident Data from Mental Health Wards, Tower
Hamlets Trust. London: City University Department of Mental Health Nursing.
Bowers, L. Hakamies, A. & Heikinnen-Peltonen, R. (1995) Psychiatric Nursing in
Finland and the UK Compared. Nursing Times 91(20)40-41
Brown, G. W. & Harris, T. (1978) Social Origins of Depression: a study of
psychiatric disorder in women. London: Tavistock
Cancro, R. (1968) Elopements from the C. F. Meninger Memorial Hospital Bulletin of
Meninger Clinic 32:228-238
Chandrasena, R. & Miller, B. A. (1988) Discharges AMA and AWOL: A new
"revolving door syndrome" Psychiatric Journal of University of Ottawa 13(3) 154157"
Chandrasena, R. (1987) Premature discharges: A comparative study Canadian
Journal of Psychiatry 32:259-263
Chen, E. Harrison, G. & Standen, P. (1991) Management of first episode psychotic
illness in Afro-Caribbean patients. British Journal of Psychiatry 158:517-522
Cohen, S. S. (1988) Practical Statistics. London: Edward Arnold.
Cohen, C. And Midgley, G. (1994) The North Humberside Diversion from Custody
project for Mentally Disordered Offenders. Hull: University of Hull, Centre for
Systems Studies.
Coleman, W. B. (1966) Unauthorized departures from mental hospitals Mental
Hygiene 50:47-53
Cormack, D. (1976) Psychiatric Nursing Observed. London: RCN
Crammer, J. L. (1984) The special characteristics of suicide in hospital in-patients
British Journal of Psychiatry 145:460-463
Department of Health (1992) Review of health and social services for mentally
disordered offenders and others requiring similar services. Chairman: Dr John Reed.
Presented to Parliament by the Secretary of State for Health and the Home
Department by Command of Her Majesty. London: HMSO
161
Falkowski, J., Watts, V., Falkowski, W. & Dean, T. (1990) Patients leaving hospital
without the knowledge of permission of staff - absconding British Journal of
Psychiatry 156:488-490
Duffy D (1995) Out of the shadows: a study of special observation of suicidal
psychiatric in-patients Journal of Advanced Nursing 21:944-950
Gallop R, Lancee W, Garfinkel P. (1989) How nursing staff respond to the label
"borderline personality disorder". Hospital and Community Psychiatry 40:815-9.
Goodrich, W. & Fullerton, C. (1984) Which borderline pateint in residential
treatment will run away? Residential Group Care and Treatment 2(3) 3-14
Gournay, K. Ward, M. Thornicroft, G. & Wright, S. (1998) Crisis in the capital:
inpatient care in inner London. Mental Health Practice 1(5)10-18
Gudeman, J. E., Dickey, B., Evans, A. & Shore, M. F. (1985) Four Year assessment of
a day hospital-inn program as an alternative to inpatient hospitalization American
Journal of Psychiatry 142(11)1330-1333
Harrison, G. et al (1988) A prospective study of severe mental disorder in AfroCaribbean patients. Psychological Medicine 18:643-657
Higgins, R. Hurst, K. Wistow, G. & Henderson, M. (1997) The mental health nursing
care provided for acute psychiatric patients: final report for the Department of
Health. Nuffield Institute for Health, Community Care Division.
James, D; Fineberg, N; Shah, A; Priest, R. (1990) An Increase in Violence on an
Acute Psychiatric Ward: A Study of Associated Factors British Journal of Psychiatry
156:846-852
Jarman, B. Hirsch, S. White, P. & Driscoll, R. (1992) Predicting Psychiatric
Admission Rates. British Medical Journal 304(6835)1146-1151
John, C. J., Gangadhar, B. N. & Channabasavanna, S. N. (1980) Phenomenology of
'escape' from a mental hospital in India Indian Journal of Psychiatry 22:247-250
Johnson, S. et al (eds) (1997) London's Mental Health: The Report to the Kings Fund
London Commission. London: Kings Fund.
Joseph, P., L., A. & Potter, M. (1993) Diversion from Custody. II: Effect on hospital
and prison resources British Journal of Psychiatry 162:330-334
Kashubeck, S., Pottebaum, S. M. & Read, N. O. (1994) Predicting elopement from
residential treatment centres American Journal of Orthopsychiatry 64(1) 126-135
Kelle, U. (ed) (1995) Computer-aided Qualitative Data Analysis: Theory, Methods
and Practice. London: Sage Publications.
Kernodle, R. W. (1966) Non medical leaves from a mental hospital Psychiatry 29:2541
Kleis, L. S. & Stout, C. E. (1991) The high risk patient: A profile of acute care
psychiatric patients who leave without discharge Psychiatric Hospital 22(4) 153-159
Levy, E. Z. (1972) Some thoughts about patients who run away from residential
treatment and the staff they leave behind Psychiatric Quarterly 46:1-21
Lewis, A. B. & Kohl, R. N. (1962) The risk and prevention of abscondence from an
open psychiatric unit Comprehensive Psychiatry 3:302-308
Marks, I. Connolly, J. Muijen, M. Audini, B. McNamee, G. and Lawrence, R. (1994)
Home-based versus hospital-based care for people with serious mental illness. British
Journal of Psychiatry 165:179-194
Maratos, J. & Kennedy, M. J. (1974) Evaluation of ward group meetings in a
psychiatric unit of a general hospital British Journal of Psychiatry 125:479-82
McIndoe, K., I. (1986) Elope: Why psychiatric patients go AWOL Journal of
Psychosocial Nursing 26(1)16-20
162
MHAC & SCMH (1997) The National Visit: a one-day visit to 309 acute psychiatric
wards by the Mental Health Act Commission in collaboration with the Sainsbury
Centre for Mental Health. London: Sainsbury Centre for Mental Health.
Meyer, G.G., Martin, M.B. & Lange, P. (1967) Elopement from the oen psychiatric
unit: a two year study Journal of Nervous and Mental Disease 144:297-304
Miles, M.B. & Huberman, A.M. (1994) Qualitative Data Analysis. London: sage
Publications.
Miller, D., J., Stone, M., Beck, N., S., Fraps, C. & Shekim, W. (1983) Predicting
AWOL discharge at a community mental health centre American Journal of
Psychiatry 140(4)479-481
Milner, G. (1966) The Absconder Comprehensive Psychiatry 7:147-151
Molnar, G. & Pinchoff, D. M. (1993) Factors in patient elopements from an urban
state hospital and strategies for prevention Hospital and Community Psychiatry
44(8)791-792
Molnar, G., Keitner, L. & Swindall, L. (1985) Medicolegal Problems of Elopement
from Psychiatric Units Journal of Forensic Sciences 30:44-49
Monahan, J. (1981) The Clinical Prediction of Violent Behaviour. Maryland: National
Institute of Mental Health.
Monahan, J., Hoge S. K., Lidz, C., Roth, L.H. et al (1995) Coercion and commitment:
Understanding involuntary mental hospital admission. International Journal of Law
and Psychiatry 18 (3) 249-263
Moodley P. & Perkins, R. (1991) Routes to psychiatric inpatient care in an inner
London borough. Social Psychiatry and Psychiatric Epidemiology 26:47-51
Moos R. (1974) Ward Atmosphere Scale Manual. Palo Alto, California: Consulting
Psychologists Press.
Morgan, H. G. & Priest, P. (1984) Assessment of Suicide Risk in Psychiatric InPatients. British Journal of Psychiatry 145:467-469
Morrow, W. R. (1969) Escapes of psychiatric offenders Journal of Criminal Law,
Criminology & Police Science 60:464-471
Mubarak, A. R., Sekar, K., Kazi, A.. & Kavitha, M. A. et al. (1989) Escape from a
mental hospital: Comparison of escaped patients during 1977 and 1987 NIMHANS
Journal 7(2):123-126
Muller, D. S. (1962) The 'missing' patient British Medical Journal 1:177-179
Narrottan, L.., Sethi, B. B., Manchanda, R., et al. (1977) A study of personality and
related factors in absconders in a psychiatric hospital Indian Journal of Psychiatry
19:51-56
Neilson, T., Peet, M. Ledsham, R. & Poole, J. (1996) Does the nursing care plan help
in the management of psychiatric risk? Journal of Advanced Nursing 24:1201-1206
Nicholson, R., A., Norwood, S., & Enyart, C. (1991) Characteristics and outcomes of
insanity acquittes in Oklahoma Behavioural Sciences and the Law 9:487-500
Niskanen, P. Lonnqvist, J. Achte, K. and Rinta-Manty, R. (1974) Suicides in Helsinki
Psychiatric Hospitals in 1964 - 1972 Psychiatria Fennica 275-280
Noble P, Rodger S (1989) Violence by Psychiatric In-patients British Journal of
Psychiatry 155: 384-390
Nussbaum, D., Lang M., Chan B. & Riviere, R. (1994) Characterization of elopers
during remand: Can they be predicted? The METFORS experience American Journal
of Forensic Psychology 12(3)17-37
163
Pauker, S. L. & Cooper, A. M. (1990) Paradoxical Patient Reactions to Psychiatric
Life Support: Clinical and Ethical Considerations. American Journal of Psychiatry
147:488-491
Phillips M, Peacocke J, Hermanstyne L, Rosales A, Rowe M, Smith P, Steele C,
Weaver R (1977) Continuous Observation - Who needs it? Canadian Psychiatric
Association Journal 22(1)25-30
Philo, G. Secker, J. Platt, S. Henderson, L. McLaughlin, G. & Burnside, J. (1994) The
Impact of Mass Media on Public Images of Mental Illness, Media Content and
Audience Belief. Health Education Journal 53:271-281
Pitula, C; Cardell, R (1996) Suicidal Inpatients Experience of Constant Observation
Psychiatric Services Aug 47(6): 649-651
Potter J. & Wetherell, M. (1987) Discourse and Social Psychology: Beyond Attitudes
and Behaviour London: Sage Publications
Powell, G., Caan, W. & Crowe, M. (1994) What events precede violent incidents in
psychiatric hospitals? British Journal of Psychiatry 165:107-112
Prins, H. Blacker-Holst, T. Francis, E. & Keitch, I. (1993) Report of the committee of
inquiry into the death in Broadmoor hospital of Orville Blackwood and a review of
the deaths of two other Afro-Caribbean patients: big, black and dangerous? London:
Special Hospitals Service Authority
Richmond, I., Dandridge, L. & Jones, K. (1991) Changing nursing practice to prevent
elopement Journal of Nursing Care Quality 6(1)73-81
Seidel, J. & Kelle, U. (1995) Different Functions of Coding in the Analysis of Textual
Data. In Kelle, U. (ed) Computer-aided Qualitative Data Analysis: Theory, Methods
and Practice. London: Sage Publications.
Sheppard, D. (1996) Learning The Lessons. (2nd Edition) London: The Zito Trust
Siegal, R. L., Chester, T. K. & Price, D. B. (1982) Irregular discharges from
psychiatric wards in a VA medical center Hospital and Community Psychiatry 33:5456
Sommer, G. (1974) A short term study of elopement from a state mental hospital
Journal of Community Psychology 2:60-62
Sundqvist-Stensman, U., B. (1987) Suicides in close connection with psychiatric care:
An analysis of 57 cases in a Swedish county Acta Psychiatrica Scandanavia 76:15-20
Swindall, L. E. & Molnar, G. (1985) Open doors and runaway patients: A
management dilemma Perspectives in Psychiatric Nursing 23(4)146-149
Tomison, A.,R. (1989) Characteristics of Psychiatric Hospital Absconders British
Journal of Psychiatry 154:368-371
Walsh et al ?????????????
Weaver, S. M. Broome, A. K. & Kat, B. J. (1978) Some patterns of disturbed
behaviour in a closed ward environment. Journal of Advanced Nursing 3:251-263
164