Absconding: a literature review

Absconsion in forensic psychiatric services: a systematic review of literature

While serious concerns are often raised when patients abscond or leave unauthorized from psychiatric services, there is limited knowledge about absconsion in forensic psychiatric services. Following the preferred reporting items for systematic reviews and meta-analyses guideline, we searched Medline/PubMed, PsycINFO, EMBASE, CINAHL, Scopus, and Web of Science through May 2020 for eligible reports on absconsion in forensic patients with no language limits. The search string combined terms for absconsion, forensic patients, and psychiatry in various permutations. This was supplemented by snowball searching for additional studies. Of the 565 articles screened, 25 eligible studies, including two interventional, seven cross-sectional, and 16 case-controlled studies spanning five decades were included. Absconsion and re-absconsion rates ranged from 0.2% to 54.4% and 15% to 71%, respectively, albeit higher rates trended with less secure psychiatric units. Previous absconsion, aggression, substance use, high Historical Clinical Risk Management-20 score, anti-sociality, psychiatric symptoms, sexual offending, and poor treatment adherence were the factors reported with a degree of predictive value for absconsion. However, the construct of absconsion was heterogeneous in the included studies and the quality of evidence on the predictors of absconsion was limited. Serious risky behaviors including re-offending, violence, self-harm, suicide, rape, and manslaughter were perpetrated by patients during unauthorized leave. Nevertheless, the rates of re-offending were generally low in the included studies (highest recidivism rate = 0.11). There is need for standardized assessment and documentation of absconsion to improve risk analysis and management. Furthermore, it is necessary to develop a structured guideline for defining absconsion, and to create a protocol that operationalizes all absconsion-related behaviors/events to promote reliable assessment and comparative analysis in future studies.

The reasons why patients abscond from public hospitals in southeastern Iran: a qualitative study

BACKGROUND

Patient absconding from hospital is one of the permanent issues the hospitals face, which poses many risks and challenges to the patient, hospital, and society. The present study aimed to identify the reasons for patient absconding behavior for public hospitals in southeastern Iran.

METHODS

The present study is a qualitative study which was conducted at three public hospitals in southeastern Iran using purposive sampling through semi-structured interviews with 63 informants involved in patient treatment process. Data were analyzed using Colaizzi content analysis (CCA) method.

RESULTS

Three main themes of economic, social factors, and factors related to the hospital covering 15 subthemes were identified to explain the reasons for patients absconding behavior.

CONCLUSION

There are many reasons for reducing patients absconding from hospitals, and one of the main reasons is the patients' economic and social problems. The absconding behavior can lead to harm and problems for patients, and some emotional and occupational consequences for the employees and nurses. Paying attention to this issue and considering some courses of action to prevent patient absconding might lead to a considerable promotion of public trust and eliminate many problems for hospitals.

Escape and absconding among offenders with schizophrenia spectrum disorder - an explorative analysis of characteristics

BACKGROUND

Escape and absconding, especially in forensic settings, can have serious consequences for patients, staff and institutions. Several characteristics of affected patients could be identified so far, albeit based on heterogeneous patient populations, a limited number of possible factors and basal statistical analyses. The aim of this study was to determine the most important characteristics among a large number of possible variables and to describe the best statistical model using machine learning in a homogeneous group of offender patients with schizophrenia spectrum disorder.

METHODS

A database of 370 offender patients suffering from schizophrenia spectrum disorder and 507 possible predictor variables was explored by machine learning. To counteract overfitting, the database was divided into training and validation set and a nested validation procedure was used on the training set. The best model was tested on the validation set and the most important variables were extracted.

RESULTS

The final model resulted in a balanced accuracy of 71.1% (95% CI = [58.5, 83.1]) and an AUC of 0.75 (95% CI = [0.63, 0.87]). The variables identified as relevant and related to absconding/ escape listed from most important to least important were: more frequent forbidden intake of drugs during current hospitalization, more index offences, higher neuroleptic medication, more frequent rule breaking behavior during current hospitalization, higher PANSS Score at discharge, lower age at admission, more frequent dissocial behavior during current hospitalization, shorter time spent in current hospitalization and higher PANSS Score at admission.

CONCLUSIONS

For the first time a detailed statistical model could be built for this topic. The results indicate the presence of a particularly problematic subgroup within the group of offenders with schizophrenic spectrum disorder who also tend to escape or abscond. Early identification and tailored treatment of these patients could be of clinical benefit.

Absconding During Inpatient Care from a Tertiary Psychiatric Hospital: A Comparative Study

BACKGROUND

Absconding from psychiatric hospitals is of great concern for patients and caregivers. Absconding affects not only the treatment and safety of these patients but also patient's caregivers and the community. Further investigation is needed to examine the pattern of this event and the characteristics of patients who abscond. Hence, our study was aimed to examine the sociodemographic and clinical profiles of inpatients who absconded from a psychiatric hospital in five years and to compare them with matched controls.

METHODS

A retrospective chart review of inpatients who absconded and matched control inpatients during the specified period of five years from January 2014 to December 2018 was done at a psychiatric hospital. Each control was matched with a corresponding absconding case on the following order: (a) admission ward, (b) admission period, (c) diagnosis, and (d) age. Results: Among 20,052 adult admissions during the specified period, 38 patients absconded, with a rate of 1.8 per 1,000 admissions. Most of them were male, from a younger age group, diagnosed with schizophrenia or mood disorder, and having comorbid substance use disorder, irritable affect, impaired judgment, and absent insight. Most of the events occurred within the first two weeks of admission. About 11% of them had a history of prior absconding from the hospital.

CONCLUSION

Knowledge about the associated sociodemographic and clinical profile would help clinicians and mental health care professionals to prevent absconding. Further risk assessment using a patient's profile would help to reduce absconding events from psychiatric hospitals in the future.

Profiling Absconders from Public and Private Inpatient Psychiatric Units: a Comparative Analysis

Research related to absconding and its associated risks is limited in relation to inpatients from private psychiatric units. This study aimed to compare patients who abscond from public and private psychiatric inpatient settings. Demographic data was collated on the subjects (n = 214) who all had a history of absconding. Public absconders (n = 159) were more likely to have a psychotic illness, increased number of psychiatric diagnoses, history of aggression, substance use and homelessness, when compared to private absconders. Predictors identified for private absconders (n = 55) were female gender and fewer drugs used. This study has implications for the different profiles of absconders between the public and private settings.

Absconding from a psychiatric hospital in Johannesburg, South Africa: Are we seeing a decrease since the implementation of the Mental Healthcare Act?

BACKGROUND

Absconding from psychiatric facilities, the aetiology and impact of which have major socio-economic implications, has a multifactorial aetiological basis. Absconding patients are at higher risk of self-harm, violence, non-adherence, relapses, substance use and negative media attention. Most health professionals associate absconding with the escape of potentially dangerous psychiatric patients. Absconding causes fear and uncertainty, and portrays psychiatric services negatively. Identification of potential absconders would assist with risk assessment and prevention.

AIM

The aim of this study was to formulate an absconding rate as well as a descriptive profile of absconders since the inception of democracy and deinstitutionalisation.

SETTING

The study was conducted at Sterkfontein Hospital, a specialised psychiatric hospital outside Johannesburg.

METHODS

A retrospective record review of absconders from Sterkfontein Hospital in Johannesburg over 1 year was conducted.

RESULTS

The absconding rate was 7.83%. The characteristics of the typical absconder included single, unemployed male, early 30s, known to psychiatric services, diagnosed with schizophrenia and co-morbid substance use. An absconder is more likely to be a forensic patient not returning from official leave of absence.

CONCLUSION

The absconding rate has decreased to less than half that of a previous study, and is within international norms. While the descriptive profile is of limited value, it does appear that psychiatric patients are being treated in a less restrictive manner resulting in fewer absconders and a change in the method of absconding. The implications for clinical practice are firstly that a clearer definition of the term absconding is needed as this will impact risk assessment and management. It is recommended that future studies separate forensic and general populations. Lastly, the formulation and use of a risk assessment tool may be of value.

Seeking freedom: A systematic review and thematic synthesis of the literature on patients' experience of absconding from hospital

WHAT IS KNOWN ON THE SUBJECT?: Absconding refers to patients leaving psychiatric hospitals in an unexpected and/or unauthorized way and is often recognized as a form of challenging behaviour. There is some research about the rates of absconding, risks associated with it and interventions to try and reduce it; however, relatively little is known about the experience from the perspective of patients and this evidence has not previously been systematically reviewed. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Patients abscond to find relief, to regain power and control over their lives and/or to address unmet needs. Absconding can therefore be viewed as a means of seeking freedom. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurses need to be aware that absconding is a positive act from the patient perspective and work collaboratively with them to reduce factors which motivate this behaviour. From the point of admission, nurses have an important role to play in reducing the sense of fear, isolation and powerlessness which motivates patients to abscond. Practical interventions such as giving patients the time and information necessary to be involved in decision-making, or asking about their responsibilities and commitments outside of hospital, may have a significant impact on the experience of admission and reduce the risk of absconding. Abstract Introduction Absconding from psychiatric hospitals is associated with significant risks, but is difficult to assess. It is often considered a form of challenging behaviour for mental health nurses, yet there is little evidence considering the behaviour from the patient perspective. Aim To identify and review evidence pertaining to the experience of patients who abscond from hospital, paying particular attention to their reasons for doing so. Method A systematic review and thematic synthesis of eight peer-reviewed studies. Results The meaning patients associated with absconding is best characterized as an act of seeking freedom. Within this, four sub-themes were identified: 1) seeking freedom to find relief, 2) to regain power and control over their lives, 3) to address unmet needs and 4) opportunistically. Discussion Perspectives on absconding are markedly different between nurses and patients. Nurses may view absconding as challenging or deviant behaviour, whilst patients understand it as a positive experience. This is because the hospital environment is not meeting their needs. Implications for practice Patients decide to abscond from hospital for valid and rational reasons. Mental health nurses are in a position to understand and address the issues underpinning them with a view to reducing absconding. Further research on absconding from hospital, taking the patient's perspective, is needed.

Development of a checklist to aid in the assessment of 'failure to return' from approved leave by acute inpatients

Better assessment of consumer behaviour and intentions prior to the granting of approved leave may reduce failure to return from such episodes of leave. The aims of this study were (i) to gain consensus on the factors associated with failure to return, and (ii) use these factors to construct a checklist to aid in assessment of consumers prior to being granted leave. Following a review of the literature a pool of 36 factors was identified. These were then assessed for relevance to absconding from approved leave using a modified Delphi approach. After two Delphi rounds, 10 factors were retained and these were collapsed under 6 domains; history of absconding, current substance use, behaviour cues, verbal cues, lack of engagement, and changes in mental state. While staff reactions to the checklist were positive, further testing of its effectiveness in the clinical setting is required.

Open doors by fair means: Study protocol for a 3-year prospective controlled study with a quasi-experimental design towards (or to implement) an open Ward policy in acute care units

BACKGROUND

Acute psychiatric wards in Germany are often locked due to the assumption that opening could endanger patients and society. On the contrary, some findings suggest that aversive events such as absconding and attempted suicides do not occur more often on wards with an open-door policy. However, these data are probably biased with regard to differing patient populations on open and locked wards. To our best knowledge, the present study is the first prospective controlled study with a quasi-experimental design dealing with this issue.

METHODS

This study investigates whether indicators of an open-door policy, as measured by a priori determined outcomes, can be improved by a defined complex intervention on two intervention wards in two psychiatric hospitals, compared to two control wards with otherwise very similar conditions. Both hospitals contain two wards identical in structure and patient admittance policies, so that a similar study protocol can be followed with similar patient populations. Both hospitals have a defined catchment area and receive voluntary and involuntary admissions. In a baseline phase, wards will be opened facultatively (i.e., if it seems possible to staff). In the following intervention period, one ward per hospital will establish an enhanced open-door policy by applying additional strategic and personnel support. As a control group, the control ward will continue to be opened facultatively. After one year, control wards will be opened according to the open-door policy as well. Interventions will include the continuous identification of patients at risk as well as the development of individual care concepts and additional staffing. For this purpose, nursing and medical staff will be methodically supported on an ongoing basis by study staff. Outcomes variables will be the percentage of door opening on each ward between 8 a.m. and 8 p.m., the percentage of all treatment days with the door opened and the number of involuntary treatment days with open doors. Data on frequencies of aggressive incidents, absconding, police searches, and seclusion or restraint will be used as control variables. Additional costs will be calculated.

DISCUSSION

Treating mentally ill patients on locked wards is a highly relevant and critically discussed topic. In particular, it is controversially discussed whether changes in door policy can be established without increasing risks to patients and others. This study aims to gain robust data on this issue, going beyond beliefs and questionable retrospective observational studies.

TRIAL REGISTRATION

Our trial "Open Doors By Fair Means" is retrospectively registered with DRKS (DRKS00015154) on Sept. 10th 2018 and displayed on the public web site. It is searchable via its Meta-registry ( http://apps.who.int/trialsearch/ ).

Long-term reduction of seclusion and forced medication on a hospital-wide level: Implementation of an open-door policy over 6 years

BACKGROUND

Psychiatric inpatient treatment is increasingly performed in settings with locked doors. However, locked wards have well-known disadvantages and are ethically problematic. In addition, recent data challenges the hypothesis that locked wards provide improved safety over open-door settings regarding suicide, absconding and aggression. Furthermore, there is evidence that the introduction of an open-door policy may lead to short-term reductions in involuntary measures. The aim of this study was to assess if the introduction of an open-door policy is associated with a long-term reduction of the frequency of seclusion and forced medication.

METHOD

In this 6-year, hospital-wide, longitudinal, observational study, we examined the frequency of seclusion and forced medication in 17,359 inpatient cases admitted to the Department of Adult Psychiatry, Universitäre Psychiatrische Kliniken (UPK) Basel, University of Basel, Switzerland. In an approach to enable a less restrictive policy, six previously closed psychiatric wards were permanently opened beginning from August 2011. During this process, a systematic change towards a more patient-centered and recovery-oriented care was applied. Statistical analysis consisted of generalized estimating equations (GEE) models.

RESULTS

In multivariate analyses controlling for potential confounders, the implementation of an open-door policy was associated with a continuous reduction of seclusion (from 8.2 to 3.5%; η_p²=0.82; odds ratio: 0.88) and forced medication (from 2.4 to 1.2%; η_p²=0.70; odds ratio: 0.90).

CONCLUSION

This underlines the potential of the introduction of an open-door policy to attain a long-term reduction in involuntary measures.

Daytime night attire as a therapeutic intervention in an acute adult psychiatric in-patient unit

Aims and Method

Dressing in-patients in night attire during daytime is currently practised in many in-patient psychiatric units, despite the lack of evidence to support its benefit in reducing absconding or self-harm. Using a triangulation design, we investigated the prevalence of, attitudes towards and associations of this practice in an acute psychiatric in-patient setting in the Republic of Ireland.

Results

Case-note review revealed a high prevalence of this practice (57%) and its significant association with involuntary admission. Nursing staff believed that using night attire was effective at reducing absconding and self-harm, and that only voluntary patients should retain the right to choose their clothes. Most patients interviewed were uncomfortable in night clothes and indicated that they should be entitled to choose what to wear.

Clinical Implications

Night attire is regularly used for risk-management, despite lack of evidence supporting its efficacy and negative attitudes towards it in many patients. This practice and the reasons for its implementation deserve medical documentation.

Reduced Frequency of Cases with Seclusion Is Associated with "Opening the Doors" of a Psychiatric Intensive Care Unit

BACKGROUND

Implementing an open door policy is a complex intervention comprising changes in therapeutic stance, team processes, and a change from locked to open doors. Recent studies show that it can lead to a reduction of seclusion and forced medication, but the role of the physical change of door status is still unclear.

AIMS

The aims of this study is to examine the transition from closed to predominantly open doors on a psychiatric intensive care unit (PICU) and its associations with the frequency of seclusion and forced medication.

METHOD

A PICU at the Department of Adult Psychiatry, University of Basel, Switzerland, implemented evidence-based strategies for operating an open door policy within the context of acute psychiatry and participated in a hospital-wide implementation of an open door policy before changing door status. 131 inpatient cases hospitalized on this PICU were examined regarding the frequency of seclusion and forced medication using explorative analyses over a time span of 32 weeks (16 weeks after implementation of the new treatment concept but before door opening, 16 weeks after door opening).

RESULTS

Following door status change, the PICU was completely open on 51% of the days and partly open on 23% of the days. The mean number of open hours per day was 12.8 ± 3.9 h. The frequency of forced medication did not change, and the frequency of seclusion decreased significantly [χ² (1, N = 131) = 4.73, p = 0.036].

CONCLUSION

This pilot study underlines the potential of a change of door status to attain a reduction in safety measures in the first 4 months.

Unlocking an acute psychiatric ward: the impact on unauthorised absences, assaults and seclusions

Aims and method The acute psychiatric in-patient service in Christchurch, New Zealand, recently changed from two locked and two unlocked wards to four open wards. This provided the opportunity to evaluate whether shifting to an unlocked environment was associated with higher rates of adverse events, including unauthorised absences, violent incidents and seclusion. We compared long-term adverse event data before and after ward configuration change. Results Rates of unauthorised absences increased by 58% after the change in ward configuration (P = 0.005), but seclusion hours dropped by 53% (P = 0.001). A small increase in violent incidents was recorded but this was not statistically significant. Clinical implications Although unauthorised absences increased, the absence of statistically significant changes for violent incidents and a reduction in seclusion hours suggest that the change to a less restrictive environment may have some positive effects.

Absconding: reducing failure to return in adult mental health wards

Failing to return from leave from acute psychiatric wards can have a range of negative consequences for patients, relatives and staff. This study used quality improvement methodology to improve the processes around patient leave and time away from the ward. The aim of this study was to improve rates of on-time return from leave by detained and informal patients by 50%. Following a baseline period, four interventions were implemented and refined using PDSA cycles. The main outcome measure was the proportion of periods of leave where the patient returned on time. Late return was defined as failure to return to the ward within 10 minutes of the agreed time. At baseline, the rate for on-time return was 56.0%; this increased to 87.1% post-intervention, a statistically significant increase of 55.5%. SPC charts show that the interventions were associated with improvements. The improvements have been sustained and the interventions are fully embedded into daily practice. The project was refined to local context and trialled on six additional wards: four of the six wards have successfully implemented the interventions and have on-time return rates of over 90%. This project produced a marked and sustained improvement in patients returning on-time from leave, facilitating a more open discussion between staff and patients about the purpose and value of periods away from the ward. Quality improvement approaches can be effectively applied in mental health settings.

Suicide risk and absconding in psychiatric hospitals with and without open door policies: a 15 year, observational study

BACKGROUND

Inpatient suicide and absconding of inpatients at risk of self-endangering behaviour are important challenges for all medical disciplines, particularly psychiatry. Patients at risk are often admitted to locked wards in psychiatric hospitals to prevent absconding, suicide attempts, and death by suicide. However, there is insufficient evidence that treatment on locked wards can effectively prevent these outcomes. We did this study to compare hospitals without locked wards and hospitals with locked wards and to establish whether hospital type has an effect on these outcomes.

METHODS

In this 15 year, naturalistic observational study, we examined 349 574 admissions to 21 German psychiatric inpatient hospitals from Jan 1, 1998, to Dec 31, 2012. We used propensity score matching to select 145 738 cases for an analysis, which allowed for causal inference on the effect of ward type (ie, locked, partly locked, open, and day clinic wards) and hospital type (ie, hospitals with and without locked wards) on suicide, suicide attempts, and absconding (with and without return), despite the absence of an experimental design. We used generalised linear mixed-effects models to analyse the data.

FINDINGS

In the 145 738 propensity score-matched cases, suicide (OR 1·326, 95% CI 0·803-2·113; p=0·24), suicide attempts (1·057, 0·787-1·412; p=0·71), and absconding with return (1·288, 0·874-1·929; p=0·21) and without return (1·090, 0·722-1·659; p=0·69) were not increased in hospitals with an open door policy. Compared with treatment on locked wards, treatment on open wards was associated with a decreased probability of suicide attempts (OR 0·658, 95% CI 0·504-0·864; p=0·003), absconding with return (0·629, 0·524-0·764; p<0·0001), and absconding without return (0·707, 0·546-0·925; p=0·01), but not completed suicide (0·823, 0·376-1·766; p=0·63).

INTERPRETATION

Locked doors might not be able to prevent suicide and absconding.

FUNDING

None.

Suicide after absconding from inpatient care in England: an exploration of mental health professionals' experiences

BACKGROUND

Absconding from inpatient care is associated with suicide risk in psychiatric populations. However, little is known about the real world context of suicide after absconding from a psychiatric ward or the experiences of clinical staff caring for these patients.

AIMS

To identify the characteristics of inpatients who died by suicide after absconding and to explore these and further key issues related to suicide risk from the perspective of clinical staff.

METHODS

A mixed-methods study using quantitative data of all patient suicides in England between 1997 and 2011 and a thematic analysis of semi-structured interviews with 21 clinical staff.

RESULTS

Four themes were identified as areas of concern for clinicians: problems with ward design, staffing problems, difficulties in assessing risk, and patient specific factors.

CONCLUSIONS

Results suggest that inpatients who died by suicide after absconding may have more complex and severe illness along with difficult life events, such as homelessness. Closer monitoring of inpatients and access points, and improved risk assessments are important to reduce suicide in this patient group.

The impact of structured decision making on absconding by forensic psychiatric patients: results from an A-B design study

BACKGROUND

Few studies have investigated absconding from forensic hospitals and there are no published studies of interventions aimed at reducing these incidents in forensic settings. We present a study of the impact of a new policy using structured professional judgment and an interdisciplinary team-based approach to granting privileges to forensic patients. We assess the impact of this policy on the rate and type of absconding from a metropolitan forensic facility.

METHODS

Following concern about the rate of absconding at our hospital, a new policy was implemented to guide the process of granting hospital grounds and community access privileges. Employing an A-B design, we investigated the rate, characteristics, and motivations of absconding events in the 18 months prior to, and 18 months following, implementation of this policy to assess its effectiveness.

RESULTS

Eighty-six patients were responsible for 188 incidents of absconding during the 42-month study window. The rate of absconding decreased progressively from 17.8% of all patients at risk prior to implementation of the new policy, to 13.8% during implementation, and further to 12.0% following implementation. There was a differential impact of the policy on absconding events, in that the greatest reduction was witnessed in absconsions occurring from unaccompanied passes; this was offset, to some extent, by an increase in absconding occurring from within hospital units or from staff accompanied outings. Seven of the absconding events included incidents of minor violence, and two included the commission of other illegal behaviors. The most common reported motive for absconding across the time periods studied was a sense of boredom or frustration. Discharge rate from hospital was 22.9% prior to the implementation of the policy to 22.7% after its introduction, indicating no change in the rate of patients' eventual community reintegration.

CONCLUSIONS

A structured and team-based approach to decision making regarding hospital grounds and community access privileges appeared to reduce the overall rate of absconding without slowing community reintegration of forensic patients.

Predictive validity of the START for unauthorised leave and substance abuse in a secure mental health setting: a pseudo-prospective cohort study

BACKGROUND

Risk assessment and management is central to the nursing role in forensic mental health settings. The Short Term Assessment of Risk and Treatability (START) aims to support assessment through identification of risk and protective factors. It has demonstrated predictive validity for aggression; it also aims to aid risk assessment for unauthorised leave and substance abuse where its performance is relatively untested.

OBJECTIVES

To test the predictive validity of the START for unauthorised leave and substance abuse.

DESIGN

A naturalistic, pseudo-prospective cohort study.

SETTINGS

Four centres of a large UK provider of secure inpatient mental health services.

PARTICIPANTS

Inpatients resident between May 2011 and October 2013 who remained in the service for 3-months following assessment with the START by their clinical team. Exclusion criteria were missing assessment data in excess of prorating guidelines. Of 900 eligible patients 73 were excluded leaving a final sample size of n=827 (response rate 91.9%). Mean age was 38.5 years (SD=16.7); most participants (72.2%) were male; common diagnoses were schizophrenia-type disorders, personality disorders, organic disorders, developmental disorders and intellectual disability.

METHODS

Routinely conducted START assessments were gathered. Subsequent incidents of substance abuse and unauthorised leave were coded independently. Positive and negative predictive values of low and elevated risk were calculated. Receiver Operating Characteristic analysis was conducted to ascertain the predictive accuracy of the assessments based on their sensitivity and specificity.

RESULTS

Patient-based rates of unauthorised leave (2.4%) and substance abuse (1.6%) were low. The positive and negative predictive values for unauthorised leave were 5.9% and 98.4%; and for substance abuse 8.1% and 99.0%. The START specific risk estimate for unauthorised leave predicted its associated outcome (Area under the curve=.659, p<.05, 95% CI .531, .786); the substance abuse risk estimate predicted its outcome with a large effect size (Area under the curve=.723, p<.01, 95% CI .568, .879).

CONCLUSIONS

The study provides limited support for the START by demonstrating the predictive validity of its specific risk estimates for substance abuse and unauthorised leave. High negative predictive values suggest the tool may be of most utility in screening out low risk individuals from unnecessary restrictive interventions; very low positive predictive values suggest caution before implementing restrictive interventions in those rated at elevated risk. Researchers should investigate how multidisciplinary teams formulate risk assessments for these outcomes since they outperform the quantitative element of this tool.

Five-year review of absconding in three acute psychiatric inpatient wards in Australia

Absconding, where patients under an involuntary mental health order leave hospital without permission, can result in patient harm and emotional and professional implications for nursing staff. However, Australian data to drive nursing interventions remain sparse. The purpose of this retrospective study was to investigate absconding in three acute care wards from January 2006 to June 2010, in order to determine absconding rates, compare patients who did and did not abscond, and to examine incidents. The absconding rate was 17.22 incidents per 100 involuntary admissions (12.09% of patients), with no significant change over time. Being male, young, diagnosed with a schizophrenia or substance-use disorder, and having a longer hospital stay were predictive of absconding. Aboriginal and Torres Strait Islander patients had higher odds of absconding than Caucasian Australians. Over 25% of absconding patients did so multiple times. Patients absconded early in admission. More incidents occurred earlier in the year, during summer and autumn, and later in the week, and few incidents occurred early in the morning. Almost 60% of incidents lasted ≤24 hours. Formulation of prospective interventions considering population demographic factors and person-specific concerns are required for evidence-based nursing management of the risks of absconding and effective incident handling when they do occur.

[Psychiatry with open doors. Part 1: Rational for an open door for acute psychiatry]

Despite the reform efforts of the last decades modern acute psychiatry still stands between conflicting priorities in everyday practice. The protection of patient autonomy might conflict with a regulatory mandate of psychiatry in societal contexts and the necessity of coercive measures and involuntary treatment might become problematic with respect to presumed but contentious interests of the patient. The conflicts particularly concern questions of involuntary commitment, door closing, coercive and isolation measures. Research on the topic of therapeutic effectiveness of these practices is rare. Accordingly, the practice depends on the federal state, hospital and ward and is very heterogeneous. Epidemiological prognosis predicts an increase of psychiatric disorders; however, simultaneously in terms of medical ethics the warranty of patient autonomy, shared decision-making and informed consent in psychiatry become increasingly more important. This challenges structural and practical changes in psychiatry, particularly in situations of self and third party endangerment which are outlined and a rationale for an opening of the doors in acute psychiatric wards is provided.

Predictors of length of stay in forensic psychiatry: the influence of perceived risk of violence

This study describes the prevalence of adverse events and length of stay in forensic psychiatric patients with and without a restriction order. Detailed clinical and administrative information from medical records and written court decisions was gathered retrospectively from admission until discharge for a Swedish population-based, consecutive cohort of forensic psychiatric patients (n=125). The median length of stay for the whole cohort was 951 days, but patients with a restriction order stayed in hospital almost five times as long as patients without. Restriction orders were related to convictions for violent crime, but not for any other differences in demographic or clinical variables. The majority of the patients (60%) were involved in adverse events (violence, threats, substance abuse, or absconding) at some time during their treatment. Patients with restriction orders were overrepresented in violent and threat events. Previous contact with child and adolescence psychiatric services, current violent index crime, psychotic disorders, a history of substance, and absconding during treatment predicted longer length of stay. Being a parent, high current Global Assessment of Functioning scores, and mood disorders were all significantly related to earlier discharge. In a stepwise Cox regression analysis current violent index crime and absconding remained risk factors for a longer hospital stay, while a diagnosis of mood disorder was significantly related to a shorter length of stay.

Study of patients absconding behavior in a general hospital at southern region of Iran

BACKGROUND

Patients' escape from hospital imposes a significant cost to patients as well as the health system. Besides, for these patients, exposure to adverse events (such as suicide, self-harm, violence and harm to hospital reputation) are more likely to occur compared to others. The present study aimed to determine the characteristics of the absconding patients in a general hospital through a case-control design in Shiraz, Iran.

METHODS

This case-control study was conducted on 413 absconded patients as case and 413 patients as control in a large general hospital in Shiraz, southern Iran. In this study, data on the case and control patients was collected from the medical records using a standard checklist in the period of 2011-3. Then, the data were analyzed using descriptive and analytical statistics, through SPSS 16.

RESULTS

The finding showed that 413 patients absconded (0.50%) and mean of age in case group was 40.98 ± 16.31 years. In univariate analysis, variables of gender [Odds Ratio (OR)= 2], ward (OR= 1.22), insurance status (OR= 0.41), job status (OR= 0.34) and residence expenditure were significant. However, in multivariate analysis significant variables were age (ORadj= 0.13), gender (ORadj= 2.15), self-employment/unemployed (ORadj= 0.47), emergency/admission (ORadj= 2.14), internal/admission (ORadj= 3.16), insurance status (ORadj= 4.49) and residence expenditure (ORadj= 1.15).

CONCLUSION

Characteristics such as middle age, male gender, no insurance coverage, inability to afford hospital expenditures and admission in emergency department make patients more likely abscond from the hospital. Therefore, it may be necessary to focus efforts on high-risk groups and increase insurance coverage in the country to prevent absconding from hospital.

Risk assessment and absconding: perceptions, understandings and responses of mental health nurses

AIMS AND OBJECTIVES

This paper reports mental health nurses' perspectives of absconding. The aims of the study were to explore nurses' perceptions of risk assessment and management practices regarding absconding from acute inpatient psychiatric settings, and their affective responses when patients absconded.

BACKGROUND

Nurses are directly involved in managing the risk of patients leaving hospital while acutely unwell, as well as dealing with the implications of an absconding event. However, despite their key role, few studies have explored nurses' perceptions of absconding.

DESIGN

An interpretive inquiry was undertaken using a systematic thematic approach.

METHODS

Mental health nurses (n = 11) from three acute inpatient mental health units in Australia took part in semi-structured interviews, with a focus on the nurses' experiences of working with patients who had absconded. Data were analysed using systematic thematic coding procedures.

RESULTS

Nurses' assessment of a patient's risk of absconding involved the use of clinical judgement, focusing on markers of absconding including the patient's history and clinical presentation. The acuity of the perceived risk determined the type of risk management strategy implemented, which could include support, observation and/or the use of containment procedures. Nurses responded with a myriad of affective reactions when patients absconded depending on their assessment of the patient's risk.

CONCLUSIONS

Support and debriefing is required for mental health nurses following an absconding event. Additional research is vital to identify alternative absconding assessment and management strategies to ensure the best possible outcome for patients and nurses.

RELEVANCE TO CLINICAL PRACTICE

Mental health nurses play a central role in risk assessment and management for absconding, with fear of repercussions a significant consequence for them. This research highlights the importance of both clinical judgment and standardised instruments in assessing absconding risk. Further research is needed to identify alternative evidence-based absconding management strategies to support nursing practice.

Reduction of seclusion on a hospital-wide level: successful implementation of a less restrictive policy

PURPOSE

Change of treatment policy from closed to open ward settings has been shown to reduce coercive measures. The aim of the current study was to examine the effects of the change from closed to open wards on the frequency of seclusion and forced medication in a hospital-wide setting.

SUBJECTS AND METHODS

2-year, longitudinal observational study with 2838 inpatient cases.

RESULTS

On a hospital-wide level, the percentage of patients with at least one seclusion was decreased significantly (χ(2)(1) = 5.8; p = .016), while there was no significant change in forced medication (χ(2)(1) = .08; p = .775). The frequency of seclusions and forced medication decreased significantly on newly opened wards, and there were no significant changes regarding seclusion on permanently closed or open wards, while the number of forced medications increased significantly on closed wards. The decrease in seclusions on newly opened wards remained statistically significant after controlling for diagnoses and severity of illness.

DISCUSSION

Our results indicate that a reduction of overall seclusion can be successfully attained, and that, in particular, the frequency of seclusion and forced medication on newly opened wards was decreased significantly. These changes were not accompanied by a significant increase in seclusion on other wards.

CONCLUSION

Open ward treatment was successfully implemented and was associated with a significant decrease of coercive measures in our study. It might therefore provide a good care model, strengthening the patient's right to autonomy and leading to a reduction of coercive measures.

Characteristics and motivations of absconders from forensic mental health services: a case-control study

BACKGROUND

Absconding from hospital is a significant health and security issue within psychiatric facilities that can have considerable adverse effects on patients, their family members and care providers, as well as the wider community. Several studies have documented correlates associated with absconding events among general psychiatric samples; however, few studies have examined this phenomenon within samples of forensic patients where the perception of threat to public safety in the event of an unauthorized absence from hospital is often higher.

METHODS

We investigate the frequency, timing, and determinants of absconding events among a sample of forensic psychiatric patients over a 24-month period, and compare patients who abscond to a control group matched along several sociodemographic and clinical dimensions. We explore, in a qualitative manner, patients' motives for absconding.

RESULTS

Fifty-seven patients were responsible for 102 incidents of absconding during the two year study window. Forensic patients who absconded from hospital were more likely to have a history of absconding attempts, a diagnosed substance use disorder, as well as score higher on a structured professional violence risk assessment measure. Only one of the absconding events identified included an incident of minor violence, and very few included the commission of other illegal behaviors (with the exception of substance use). The most common reported motive for absconding was a sense of boredom or frustration.

CONCLUSIONS

Using an inclusive definition of absconding, we found that absconding events were generally of brief duration, and that no member of the public was harmed by patients who absconded. Findings surrounding the motivations of absconders suggest that improvements in therapeutic communication between patients and clinical teams could help to reduce the occurrence of absconding events.

Closing an open psychiatric ward: organizational change and its effect on staff uncertainty, self-efficacy, and professional functioning

PURPOSE

Converting an open psychiatric ward to a closed one can be threatening and stressful for the medical and nursing staff involved. This study describes the effects of this change, in particular the before-after correlation among self-efficacy, professional functioning, and uncertainty.

DESIGN AND METHODS

Forty-four staff participated, completing pre-/poststructured questionnaires.

FINDINGS

Uncertainty was higher before the conversion than after the conversion. Professional functioning declined after the conversion. Self-efficacy was positively correlated with pre- and postconversion functioning, but negatively correlated with postconversion uncertainty.

PRACTICE IMPLICATIONS

It is important to prepare staff for this significant organizational change. Suggestions for prechange interventions are offered.

Nursing staff numbers and their relationship to conflict and containment rates on psychiatric wards-a cross sectional time series poisson regression study

BACKGROUND

The link between positive outcomes and qualified nurse staffing levels is well established for general hospitals. Evidence on staffing levels and outcomes for mental health nursing is more sparse, contradictory and complicated by the day to day allocation of staff resources to wards with more seriously ill patients.

OBJECTIVE

To assess whether rises in staffing numbers precede or follow levels of adverse incidents on the wards of psychiatric hospitals.

DESIGN

Time series analysis of the relationship between shift to shift changes over a six month period in total conflict incidents (aggression, self-harm, absconding, drug/alcohol use, medication refusal), total containment incidents (pro re nata medication, special observation, manual restraint, show of force, time out, seclusion, coerced intramuscular medication) and nurse staffing levels.

SETTINGS

32 acute psychiatric wards in England.

METHODS

At the end of every shift, nurses on the participating wards completed a checklist reporting the numbers of conflict and containment incidents, and the numbers of nursing staff on duty.

RESULTS

Regular qualified nurse staffing levels in the preceding shifts were positively associated with raised conflict and containment levels. Conflict and containment levels in preceding shifts were not associated with nurse staffing levels.

CONCLUSIONS

Results support the interpretation that raised qualified nurse staffing levels lead to small increases in risks of adverse incidents, whereas adverse incidents do not lead to consequent increases in staff. These results may be explicable in terms of the power held and exerted by psychiatric nurses in relation to patients.

The profile of absconding psychiatric inpatients in Australia

AIMS AND OBJECTIVES

The purpose of this study was to examine absconding behaviour (a patient leaving the hospital without permission) in acute and rehabilitation wards of one Australian psychiatric institution to describe the characteristics of the absconding patient and these events.

BACKGROUND

Absconding is a significant issue in psychiatric inpatient settings, with risks that include patient harm, aggression and violence. In spite of this, limited research has been conducted in Australia on patients who abscond while receiving psychiatric care.

DESIGN

The study was a retrospective descriptive analysis.

METHOD

Absconding events from three acute and seven rehabilitation wards over a 12-month period were studied.

RESULTS

The rate of absconding events by detained patients was 20.82%. Gender was not significantly associated with absconding, although 61.19% of those who absconded were men diagnosed with schizophrenic disorders. Over half of acute care patients who absconded left during their first 21-day detention order. More than half of absconding events were by patients that absconded more than once. There was limited support for the efficacy of locking ward doors. Age and diagnosis emerged as particularly important factors to consider.

DISCUSSION

The study revealed that men are not more likely to abscond than women, that locking ward doors does not deter the determined absconders and that once a person has absconded, they are more likely to do so again. Younger patients and those with a schizophrenic disorder may be particularly likely to abscond. There also appears to be a link between continuing detention orders and an absconding event.

CONCLUSIONS

Findings provide new data about the profile of absconding patients in Australia. Exploration of the reasons why patients abscond and why many do so repeatedly warrants further investigation.

RELEVANCE TO CLINICAL PRACTICE

Risk management approaches taking into account factors associated with absconding could be trialled to reduce the incidence of absconding in psychiatric inpatient settings.

Retrospective analysis of absconding behaviour by acute care consumers in one psychiatric hospital campus in Australia

Absconding is increasingly being recognized as a problem within mental health settings with significant risks for consumers. This study examines absconding behaviours across three acute care wards within an Australian psychiatric hospital campus over a 12-month period. A descriptive statistical analysis determined the rate of absconding from 49 consumers who absconded 64 times. The absconding rate was 13.33% (absconding events), with most absconding events arising from males diagnosed with schizophrenia (57.14%) aged between 20 and 29 years, and with 62.50% of absconding events occurring whilst consumers were on their first 21-day detention order. Nearly half of all absconding events were by consumers who had absconded previously, with the highest proportion of events occurring during nursing handover. A profile of people who abscond, time of day of absconding, legal status and repeated absconding behaviours are described. The emergent profile of consumers who absconded within this study bears some similarities to that described in overseas research, although in this study consumers were slightly older and 25% of absconders were female. Of particular interest are findings that identify the timings of absconding events in relation to a consumer's legal status. Implications for practice, including assessment of risk of absconding and management, are considered.

Suicide amongst psychiatric in-patients who abscond from the ward: a national clinical survey

BACKGROUND

Suicide prevention by mental health services requires an awareness of the antecedents of suicide amongst high risk groups such as psychiatric in-patients. The goal of this study was to describe the social and clinical characteristics of people who had absconded from an in-patient psychiatric ward prior to suicide, including aspects of the clinical care they received.

METHODS

We carried out a national clinical survey based on a 10-year (1997-2006) sample of people in England and Wales who had died by suicide. Detailed data were collected on those who had been in contact with mental health services in the year before death.

RESULTS

There were 1,851 cases of suicide by current psychiatric in-patients, 14% of all patient suicides. 1,292 (70%) occurred off the ward. Four hundred and sixty-nine of these patients died after absconding from the ward, representing 25% of all in-patient suicides and 38% of those that occurred off the ward. Absconding suicides were characterised by being young, unemployed and homeless compared to those who were off the ward with staff agreement. Schizophrenia was the most common diagnosis, and rates of previous violence and substance misuse were high. Absconders were proportionally more likely than in-patients on agreed leave to have been legally detained for treatment, non-compliant with medication, and to have died in the first week of admission. Whilst absconding patients were significantly more likely to have been under a high level of observation, clinicians reported more problems in observation due to either the ward design or other patients on the ward.

CONCLUSION

Measures that may prevent absconding and subsequent suicide amongst in-patients might include tighter control of ward exits, and more intensive observation of patients, particularly in the early days of admission. Improving the ward environment to provide a supportive and less intimidating experience may contribute to reduced risk.

A replication study of the City nurse intervention: reducing conflict and containment on three acute psychiatric wards

Conflict and containment on acute inpatient psychiatric wards pose a threat to patient and staff safety, and it is desirable to minimize the frequency of these events. Research has indicated that certain staff attitudes and behaviours might serve to accomplish this, namely, positive appreciation, emotional regulation and effective structure. A previous test of an intervention based on these principles, on two wards, showed a good outcome. In this study, we tested the same intervention on three further wards. Two 'City nurses' were employed to work with three acute wards, assisting with the implementation of changes according to the working model of conflict and containment generation. Evaluation was via before-and-after measures, with parallel data collected from five control wards. While simple before-and-after analysis of the two experimental wards showed significant reductions in conflict and containment, when a comparison with controls was conducted, with control for patient occupancy and clustering of results by ward, no effect of the intervention was found. The results were therefore ambiguous, and neither confirm nor contradict the efficacy of the intervention. A further intervention study may need to be conducted with a larger sample size to achieve adequate statistical power.

Absconding: A review of the literature 1996-2008

Absconding is a significant problem with potential for harm to patients or the general public. The consequences of absconding include physical harm, prolonged treatment time, and substantial economic costs. The aim of this systematic literature review is to synthesize quality literature about absconding from psychiatric facilities, identify gaps in knowledge, and make recommendations for practice. An electronic search yielded 39 journal articles that met the review criteria. Findings demonstrate that a single definition of absconding remains elusive, making the prevalence of absconding difficult to establish. Absconding events are multifactorial, with environmental, psychosocial, and organic aspects. Negative consequences exist including violence, aggression, and self-neglect and harm to self and others. Papers are clustered around the following themes: harm and risk, absconder profiles, absconding rates, and perceptions of nurses and patients. Nursing interventions designed to decrease absconding have been implemented with success, but only in a few studies and in Australia, none have been reported in the literature to date. Further research is required to identify appropriate nursing-based interventions that may prove useful in reducing the risk of absconding.

A prospective study of patients absconding from a general hospital psychiatry unit in a developing country

Characteristics of patients absconding from an open psychiatry ward in a developing country may be different from both those in developed countries and a mental hospital setting. The aim of this paper is to study the incidence and characteristics of patients absconding from an open psychiatric ward in a general hospital-based psychiatric unit in India. We studied patients consecutively admitted to an open psychiatric ward over a 2-month period. We compared those who absconded with those who did not. Out of 231 patients admitted, 33 absconded. Among those who absconded, 15 had bipolar disorder, 11 had schizophrenia and five had substance-related disorders. Nine had indicated their intention to do so at admission. Ten patients had absconded by the second day. The treatment cost was the likely influencing factor for seven patients who absconded after deemed fit for discharge on clinical grounds. Only 10 patients were readmitted to the hospital within 2 weeks of absconding. The risk of absconding is highest in the early days following. Absconding patients did not differ significantly from others in many socio-demographic and clinical features. Treatment costs are an important consideration in India.

Adverse incidents in acute psychiatric inpatient units: rates, correlates and pressures

OBJECTIVE

This paper reports findings from a multicentre service evaluation project conducted in acute psychiatric inpatient units in NSW, Australia. Overall rates of aggression, absconding and early readmission are reported, as well as length-of-stay profiles and associations between these outcomes and selected sociodemographic and clinical characteristics routinely collected by health services.

METHOD

Data from the 11 participating units were collected for a 12month period from multiple sources, including electronic medical records, routine clinical modules, incident forms, and shift based project-specific logs. For the current analyses, two admission-level datasets were used, comprising aggregated patient-level events (n=3242 admissions) and basic sociodemographic, clinical, admission and discharge information (n=5546 admissions by 3877 patients).

RESULTS

The participating units were under considerable strain: 23.3% of admissions were high acuity; 60.4% had previous hospital stays; 47.6% were involuntary; 25-30% involved adverse incidents; bed occupancy averaged 88.4%; median length of stay was 8 days (mean=14.59 days); and 17.4% had a subsequent early readmission. Reportable aggressive incidents (11.2% of admissions) were intermittent (averaging 0.55 incidents per month per occupied bed) and associated with younger age, personality disorder, less serious aggression, longer periods of hospitalization, and subsequent early readmission. Less serious aggressive incidents (15.0% of admissions) were maximal in the first 24h (averaging 3.73 incidents per month per occupied bed) and associated with younger age, involuntary status, bipolar and personality disorders, the absence of depression, and longer hospital stays. Absconding (15.7% of admissions) peaked in the second week following admission and was associated with drug and alcohol disorder, younger age, and longer periods of hospitalization.

CONCLUSIONS

By examining relationships between a core set of risk factors and multiple short-term outcomes, we were able to identify several important patterns, which were suggestive of the need for a multi-level approach to intervention, shifting from a risk management focus during the early phase of hospitalization to a more targeted, therapeutic approach during the later phase. But the latter approach may not be achievable under current circumstances with existing resources.

Psychiatric care behind locked doors. A study regarding the frequency of and the reasons for locked psychiatric wards in Sweden

The general aim was to describe the frequency of and the reasons for locked doors at wards within Swedish psychiatric care. A questionnaire was answered by 193 ward managers. The findings demonstrated that 73% (n = 193) of the wards were locked on the day of investigation. Wards were sometimes locked in the absence of committed patients and sometimes open in the presence of committed patients. Wards were more often locked if at least one committed patient was present. Fewer wards for children and adolescents, than for adults and old people, were locked. More wards in the areas of Sweden's three largest cities, than in the rest of the country, were locked. Fourteen categories of reasons for locking wards were generated by a content analysis of answers to an open-ended question. Most answers were categorized as: prevent patients from escaping, legislation, provide patients and others with safety and security, prevent import and unwelcome visits, and staff's need of control. Staff working in psychiatric care ought to reflect upon and articulate reasons for, and decisions about, locking or opening entrance doors, with the limitation of patients' freedom in mind.

Psychiatric wards with locked doors - advantages and disadvantages according to nurses and mental health nurse assistants

AIMS AND OBJECTIVE

To describe nurses' and mental health nurse assistants' perceptions of advantages and disadvantages about working on a psychiatric ward with a locked entrance door.

BACKGROUND

Psychiatric staff sometimes needs to protect patients from harming themselves or others. To keep the entrance door locked may help staff to achieve this goal. How locked entrance doors at psychiatric wards are experienced by staff, working on these wards, has been investigated to a very limited extent.

DESIGN

The study was explorative and descriptive.

METHOD

Audio taped, semi-structured interviews with open-ended questions about advantages and disadvantages about working on a psychiatric ward with a locked entrance door, were conducted with 20 nurses and 20 mental health nurse assistants. Data were analyzed with content analysis.

RESULTS

A content analysis revealed eight categories of advantages and 18 categories of disadvantages. Most advantages mentioned by nurses and mental health nurse assistants were categorized as providing staff with control over patients, providing patients with a secure and efficient care and protecting patients and staff against 'the outside'. Most disadvantages mentioned by nurses were categorized as causing extra work for staff, making patients feel confined, making patients feel dependent and creating a non-caring environment. Most disadvantages mentioned by mental health nurse assistants were categorized as causing extra work for staff, making patients feel confined, causing emotional problems for patients, making staff's power obvious and forcing patients to adapt to other patients' needs. Nurses and mental health nurse assistants mentioned more disadvantages than advantages and nurses mentioned more disadvantages than mental health nurse assistants.

CONCLUSION

Nurses and mental health nurse assistants perceive a number of advantages and disadvantages for themselves, patients and significant others with a locked door at a psychiatric ward. Most of these concern patients' experiences.

RELEVANCE TO CLINICAL PRACTICE

It is important for staff working within psychiatric care to reflect upon the fact that a locked entrance door is connected with a range of negative as well as positive perceptions and to minimize patient and own concerns connected to the locked door.

Real world application of an intervention to reduce absconding

Absconding by acute psychiatric inpatients is associated with risk of harm to self and others, and creates considerable emotional as well as tangible burdens for staff. Previous research has led to the development of an effective nursing intervention to reduce absconding. In this project, that intervention was encapsulated in a self-training package, and offered freely to wards across the UK who agreed to implement it and audit the results. Fifteen wards completed this distributed audit, and achieved overall a 25.5% decrease in their absconding rates, as measured by official reports. The results support the efficacy of the intervention, and indicate that significant reductions can be made in absconding rates from unlocked or partially locked acute psychiatric wards.

Reasons for admission and their implications for the nature of acute inpatient psychiatric nursing

The purpose of acute inpatient psychiatric care, and nurses' role within that, are in need of clarification and restatement in order to provide a framework for practice, education, research and development. Inpatient psychiatry has suffered from a paucity of research in recent years. In addition, being a complex system, involving multiple professions with differing ideologies, means that widely accepted succinct descriptions of its purpose are hard to achieve. Yet such a framework is essential to support positive attitudes to patients and for good staff-management relationships. Using an oblique strategy, this paper defines the function of acute inpatient psychiatry, and the role of psychiatric nurses, via a structured examination of the literature on reasons for admission to acute inpatient psychiatric wards. Seven such reasons were discovered and are described: dangerousness, assessment, medical treatment, severe mental disorder, self-care deficits, respite for carers, and respite for the patient. Acute inpatient psychiatric nurses are therefore: providing safety for the patient and others; collecting and communicating information about patients, giving and monitoring treatment; tolerating and managing disturbed behaviour; providing personal care; and managing an environment where patients can comfortably stay. The implications for psychiatric nursing are discussed.

Locked entrance doors at psychiatric wards--advantages and disadvantages according to voluntarily admitted patients

Entrance doors at wards where psychiatric care is provided are sometimes locked, which is not the case at wards where somatic care is provided. How locked entrance doors at psychiatric wards are experienced by patients has been investigated to a very limited extent. The aim was to describe voluntarily admitted patients' perceptions of advantages and disadvantages about being cared for on a psychiatric ward with a locked entrance door. Audio-taped, semi-structured interviews were conducted with 20 patients voluntarily admitted at psychiatric wards. Content analysis revealed six categories of advantages and 11 categories of disadvantages. Most advantages were categorized as "protects patients and staff against 'the outside' ", "provides patients with a secure and efficient care" and "provides staff with a sense of control over the patients". Most disadvantages were categorized as "makes patients feel confined", "makes patients feel dependent on the staff" and "makes patients feel worse emotionally". Patients perceive a variety of advantages and disadvantages, for themselves, their visitors and staff, connected to locked entrance doors at psychiatric wards. A locked door may make the ward appear as both a prison and a sanctuary. It is important that staff try to minimize patients' concerns connected to the locked door.

A trial of an anti-absconding intervention in acute psychiatric wards

Absconding from acute psychiatric wards is a significant clinical problem that can place patients and others at risk, as well as being burdensome and anxiety provoking for staff. Previous studies have not convincingly demonstrated the best way to minimize the frequency of absconding. The aim of this trial was to evaluate the impact of an intervention to reduce absconding by patients from partially locked acute psychiatric wards. Five acute psychiatric wards in one hospital were entered into a stepped, before-and-after controlled trial. Following 3 months at baseline, nursing staff on the wards were trained in the intervention and monitored in its execution for the next 3 months. Absconding and violent incidents were recorded by nursing staff through shift reports and validated against officially collected forms. Absconding reduced by 25% overall during the intervention period, a fall which was statistically significant. Three out of the five wards implemented the intervention effectively and two of these achieved decreases in their absconding. The other two wards were not able to consistently implement the intervention, and their absconding rates remained unchanged. The findings support the efficacy of the intervention in reducing absconding. Further research is now required to replicate these findings, and to confirm that any reductions are maintained over time.

Absconding of patients from an independent UK psychiatric hospital: a 3-year retrospective analysis of events and characteristics of absconders

The need for accurate local information on the scale, nature and outcome of absconding or Absence Without Leave (AWOL) from an independent UK psychiatric hospital led to this 3-year (1997-1999) retrospective analysis of of AWOL data. One hundred and forty-eight AWOL incidents involving 88 patients were identified. Absconders were found to be significantly younger, more likely to be detained upon admission and more likely to be unmarried than a control group (n = 1378) of non-absconders. There were no significant differences for sex, length of admission or ethnicity. Descriptive data on the circumstances surrounding AWOL events are given, with at least 24 (16.2%) incidents having serious adverse outcomes. Baseline absconding rates are presented for the specialist clinical divisions within the hospital. There is a need for more detailed studies of absconding by patients within the Adolescent Mental Health Service subgroup where the absconding rate was relatively high and engagement in risk activity whilst AWOL relatively frequent.

Determinants of absconding by patients on acute psychiatric wards

Determinants of absconding by patients on acute psychiatric wards Absconding by patients from acute psychiatric wards is a high risk behaviour and has been linked to harm to self and others. Previous research on the characteristics of absconders has been overly reliant on officially generated statistics and small numbers of variables, limiting the conclusions that may be drawn. This paper reports on a prospective study of absconders from 12 acute admission wards in three English National Health Service Trusts over 5 months, compared to a control group matched for ward. Extensive data on absconder and control characteristics were collected from case records and from nursing staff. Absconders were significantly different from controls in many respects. Absconding is linked to other forms of non-compliant patient behaviour, e.g. medication refusal and involvement in violent incidents. Significant variations in the rates of absconding were found between different wards, and between different consultant psychiatrists. Predictive factors were identified by logistic regression. Study in the diverse fields of non-compliance should be brought together as these phenomena are likely to be interrelated. Further investigation is required to determine exactly what it is that consultant psychiatrists and ward nurses do that affects absconding rates.