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

Abstract

Accessible summary 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. AbstractIntroductionAbsconding 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.AimTo identify and review evidence pertaining to the experience of patients who abscond from hospital, paying particular attention to their reasons for doing so.MethodA systematic review and thematic synthesis of eight peer‐reviewed studies.ResultsThe 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.DiscussionPerspectives 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 practicePatients 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.

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

“…This rate is low compared to previous studies, where the rate ranged from 1.85% to 17.2%. 20 , 22 , 23 , 30 , 31 A systematic review found the rates to be substantially lower for locked wards (1.34/100 admissions) compared to open wards (7.96/100 admissions). Despite being an open ward system, comprehensive management, including continuous risk assessment, monitoring, and supervision by treating teams consisting of a psychiatrist, clinical psychologist, psychiatric social worker, psychiatric nurse, and ward attendants might have reduced absconding, accounting for the lower rate in our study.…”

“…Absconding has been viewed as a means of seeking freedom. 20 A few studies from India also have investigated this. 19 , 21 – 24 A literature review by Stewart and Bowers 3 has shown that a few studies had included control groups but very few among them had used matched controls to examine absconding events.…”

Containment is not the cure: Least restrictive approaches to the management of absconding

“…Nurses are also concerned about how others will respond, such as their managers, colleagues and other agencies involved, including police (Clark, Kiyimba, Bowers, Jarrett, & McFarlane, ; Grotto et al, ). Many of these emotions in fact echo those that motivated the patient to abscond in the first place (Voss & Bartlett, ). With this in mind, absconding could be conceptualized as a transfer of power from the nurse to the patient; whilst the patient reclaims power and agency by liberating themselves from the restriction of hospital, the nurse loses some sense of control and experiences greater vulnerability to external scrutiny.…”

“…There is good, or at least well‐intentioned, reason for this approach, and it reflects the inherent conflict between individual autonomy and a duty of care to protect, which lies at the heart of not only mental health nursing, but medical ethics in general. However, as a systematic review on patient perspectives on absconding (published in the current issue of JPMHN) has identified (Voss & Bartlett, ), such responses can and will increase the sense of frustration and powerlessness, which motivated the person to abscond in the first place. By increasing restriction on those who feel entrapped, dehumanized and frustrated, we may temporarily manage the symptom of their distress, whilst exacerbating its cause.…”

Absconding: A qualitative perspective of patients leaving inpatient psychiatric care

“…Despite the above trends, our understanding of absconding is hampered by variations in definitions of ‘absconding’ and ‘absconders’, in legal frameworks between countries and regions around admission to psychiatric care, and in recording of incidents (Voss & Bartlett 2019). Studies furthermore vary as to whether they include both voluntary and involuntary patients (Stewart & Bowers 2010).…”