Background
Elopement is a problem in the inpatient mental health community. Elopement can have serious and long term effects for the patients and staff.
Objective
The purposes of this paper are to present a review of the literature regarding elopement and to provide recommendation for practice.
Design
Using several databases, a search of the existing literature was conducted.
Results
Elopement occurs due to a number of factors, including: psychosocial issues, staff–patient interaction, the patient's attitude toward hospitalization, and their mental illness.
Conclusion
It is important to understand why patients seek to elope from treatment facilities to prevent further occurrences.
Background
ELOPEMENT, ALSO COMMONLY referred to as absconding, is the unauthorized absence of a patient from a mental health facility without permission. It has been identified as a significant issue by the psychiatric nursing community (
Muir-Cochrane, Mosel, Gerace, Esterman and Bowers, 2011
). Some patients object to being in the hospital, often on a locked unit. Some, because of the nature of their illness, object to being offered medications. Patients who are involuntarily admitted often feel the need to elope, despite the fact the courts have mandated they require treatment. This felt need for elopement is true even for patients who present voluntarily.Psychiatric patients often display impaired judgment, which has the potential to place them in potentially dangerous situations if they elope from the hospital. The effects of an elopement can have long-term negative consequences on the patient, the staff caring for the patient, and the institution (
Bowers, Simpson, et al., 2006
, Bowers, Brennan, Flood, Lipang and Oladapo, 2006
). There have been legal judgments where the courts have held hospitals responsible for the behavior of patients who have eloped. For example, in the case of the Estate of Hollon-v-Brookwood Medical Center, the family of a man from Alabama successfully won a judgment of $12 million, after the patient fell and died while trying to elope (Legal Eagle Newsletter for the Nursing Profession, 2007
). In another case, a woman from Australia who was admitted involuntarily to a psychiatric facility, filed suit for breach of duty of care, after she eloped and conceived a child while away from the hospital. The patient cited that she was unable to provide physical, emotional, and financial care for the child. In similar cases, breach of duty of care and breach of patient's rights have been cited as the reason for the suit (Cardy, 2012
). Elopement is a serious sentinel event and must be reported to .Psychiatric patients who elope are more likely to engage in suicidal and homicidal behavior. Elopements can have serious consequences, with one study reporting a 20–30% suicide rate, as well as harm to others (
Yasini et al., 2009
). A national clinical survey found that the most common forms of suicide, once a patient has eloped, are hanging, jumping from a height, or stepping in front of a moving vehicle (Hunt et al., 2010
).It is believed that elopement is related to other forms of non-compliant patient behavior, such as medication refusal and involvement in violent incidences (
Bowers et al., 1999a
, Bowers et al., 1999b
). The consequences of elopement include physical harm, prolonged treatment time, and substantial economic costs (Muir-Cochrane & Mosel, 2008
). Recently, O'Driscoll, 2010
suggested that elopement be viewed as resistance and that clinicians reframe the patient's difficult behavior as a display of opposition.To help one hospital's department of behavioral health meet its goal of zero elopements, an evidenced-based practice project was initiated to examine the topic. The purpose of the project was to educate the staff about the causative factors for elopement and develop evidence based practice guidelines to assist staff in assessing and preventing them. The goal of this paper is to highlight the issue of elopement and serve as a reference for other facilities to decrease elopements.
Methods
Electronic searches were conducted to locate empirical data in English using CINAHL, PubMed Central, and ArticleFirst databases. A search of the key words “psychiatric,” “elopement,” and “absconding” produced 129 articles using CINAHL, 236 articles using PubMed Central, and 62 articles using ArticleFirst databases for a total of 427 articles. Articles were included in the review if they were published between 1998 and 2011, if they were research-based, and if their sample population was similar to our psychiatric units in age and diagnosis. Reviewing the literature, we attempted to utilize the most frequently cited sources on the topic of elopement, as well as articles that represented similar patient populations to ours. Articles were excluded if they were not written in English, and did not reflect similarities in unit demographics and diagnoses. We examined studies and articles that measured the frequency and etiology for elopement behaviors.
Results
Results of this review will be presented as follows: understanding why patients elope, identifying patients most at risk to elope, understanding how patients elope, and preventing elopements. It bears stating that oftentimes there is not one single, identifiable reason why patients elope from psychiatric units, but often two or more reasons. Identifying the stressors that patients face while in the hospital requires accurate assessment skills.
Understanding Why Patients Elope
There are many reasons why patients elope from psychiatric facilities.
Bowers et al., 1999a
, Bowers et al., 1999b
conducted interviews with a sample of 52 patients who returned to their wards after elopement. Common reasons for and themes associated with elopement are summarized in Table 1.Table 1Reasons Patients Give for Eloping.
| Boredom |
| Frightened of the other patients |
| Feel trapped and confined |
| Have household responsibilities they feel they must fulfill |
| Feel cut off from friends and family |
| Worried about the security of their home and property |
| Impulsivity or anger about not being discharged |
| Patients describe a “sense of meaninglessness” when referring to their hospitalization |
| Stigma of being on a psychiatric unit |
| Disliking the staff or the food |
| Medication side effects |
| They feel neglected by staff |
| Desire to use drugs or alcohol |
| Did the patient return or brought back? If so, were they debriefed? |
| What can we do differently to prevent future elopements? |
Understanding Patients Most At Risk to Elope
In an attempt to identify patients most at risk to elope,
Bowers et al., 2000
conducted a prospective study of patients who had previously eloped from 12 acute units in three English National Health Service Trusts. Comparisons were made to a control group matched for diagnosis and unit size, using data collected from case records and from nursing staff. This research constructed a profile of a patient at high risk to elope: young, male, single, and from a disadvantaged group. Meehan et al., 1999
, however, concluded that situational and environmental factors are more likely than patient characteristics to be predictive of elopement.Some patients are bored with being in the hospital. They are accustomed to their daily routines at home and find that having to change the pattern of their life to comply with the unit's routine intolerable. Some find the unit a confining place with not enough activities. For some, the stigma of being hospitalized can be overwhelming, particularly patients for whom this is just one of numerous hospital admissions (
Link, 2001
).Feeling unsafe on the unit has been identified as another reason patients leave the hospital (
Bowers, Simpson, et al., 2006
, Bowers, Brennan, Flood, Lipang and Oladapo, 2006
). Although some patients may be paranoid, others sometimes have to deal with psychotic patients who invade their personal space. While the psychiatric professional is typically able to manage this behavior on the unit, it can be very disconcerting for someone who is constantly in the proximity of another patient behaving inappropriately. Staff are often separated from patients by the nurses' station, which can offer some measure of false security. Some nurses' stations are enclosed or semi-enclosed in plexiglass. A given patient, however, may encounter a peer who may be psychotic without the convenience of these protections. Many may feel bullied by some of the more aggressive patients (Ireland, 2006
).Some patients feel the need to be at home to protect their belongings. Many staff reside in comfortable, secure neighborhoods; however, this is not always the case for the patients they serve. Many patients live in subsidized housing or in less than desirable neighborhoods due to the fact that their illness has robbed them of their ability to work. Security is often a constant concern for this population. The issues surrounding living in a lower-socioeconomic neighborhood is something that many staff have never experienced and cannot fully understand (
Miranda et al., 2008
).One important consideration is that staff and patients seem to view the hospitalization process very differently. Staff can sometimes lose perspective of exactly what an inpatient admission means to the patient. Many staff view the unit as a safe and secure environment where all the patients gather for a common goal: recovery. points out that this belief is often not shared by the patients. Some perceive a delay in their discharge or denial of a leave of absence to be extremely discouraging and confining ().
Among the dually diagnosed, the desire to use substances can be a powerful motivator to elope. Patients who present with substance abuse diagnoses or substance-induced mood disorders sometimes face the challenge of withdrawal, both physical and psychological. Many patients feel that they are not getting enough medication or the right combination of medications to adequately satisfy their withdrawal symptoms (
Hoxmark et al., 2010
). Psychological withdrawal can be even more devastating than its physiological counterpart, and yet some staff lack the knowledge or experience to recognize and understand this phenomenon. Alcohol withdrawal has been identified as one of the prime reasons patients abscond from psychiatric units (- Hoxmark E.
- Nivison M.
- Wynn R.
Predictors of mental distress among substance abusers receiving inpatient treatment.
Substance Abuse Treatment Policy. 2010; 5 (Retrieved from:)https://doi.org/10.1186/1747-59x-5-15
Andoh, 1999
).Failure to adequately assess between classes of polysubtance withdrawal can have devastating effects for both the staff and the patient. Treating alcohol, benzodiazepine, or opiate withdrawal demands an understanding of the effects that each of these different classes of drugs has on the body. The clinician must be able to differentiate between the different types of withdrawal (
Stern et al., 2010
). In the case of polysubstance use, the clinical picture may become much cloudier. Some dually diagnosed patients may present as demanding, hostile, or what staff typically describe as “med seeking.” Occasionally, because of their persistent negative behavior, some staff may react non-therapeutically. The patient may interpret this as “the staff doesn't like me.” It is important to separate personal feelings from professional responsibility, and maintain a professional demeanor. Patients' feeling that “the staff doesn't like me” has been identified as one significant reason that patients elope (- Stern T.A.
- Celano C.M.
- Gross A.F.
- Huffman J.C.
- Freudenreich O.
- Kontos S.H.
- Repper-DeLisi
- Thompson B.T.
The assessment and management of agitation and delirium in the general hospital.
Primary Care Companion Journal of Clinical Psychiatry. 2010; 12( (Retrieved from:)https://doi.org/10.4088/PCC.09r00938yel
Bowers et al., 1999a
, Bowers et al., 1999b
).Conversely, there may be occasions where patients take a dislike to, or focus on, a particular staff member. Perhaps the staff member has had to set limits on a particular behavior, or perhaps the staff member reminds them of someone they have encountered during past hospitalizations. Nursing staff can sometimes be the scapegoat for patients' perceptions of inadequacies in hospital accommodations, food, or other matters for over which they have little or no control. When feeling attacked, it is important for the clinician to remain professional and reassure the patient that they will advocate for that patient and their needs (
Morgan, 2001
).Medication non-compliance is one of the issues that psychiatric nurses face on an ongoing basis. Many patients dislike how the medications make them feel, whether because of side effects or the sedating properties of some drugs. Sexual side effects continue to be an issue with some psychotropic and anti-depressant medications. Patients who are on forced medications are also a high elopement risk. Forced to take medications as the result of a psychiatric medication panel, they are often very difficult to treat because of their resistance and their lack of insight into their mental illness (
Currier, 2003
).The influence of the social environment needs to be acknowledged and examined when attempting to decrease the number of patients who elope.
Meehan et al., 1999
has suggested a correlation between the negative, non-therapeutic attitudes of staff, elopements and assaultive behaviors by patients. In other words, staff that display negative attitudes may be more likely to become victims of patient assault and patient's who experience those negative attitudes may be more likely to abscond.Nursing is an integral part of the psychiatric interdisciplinary team. It is important for nurses to identify and communicate patients who they believe are at risk to elope to the rest of the team. Other members of the team may recognize behaviors that may be the result of patient dissatisfaction as well. This multi-disciplinary approach appears to be essential in reducing the number of potential elopements (
Bowers et al., 2000
).Although most evidence indicates that elopement is a negative incident for patients, their families, and staff members, some patients do appear to benefit, if only temporarily. The patient may gain a sense of independence and liberation as a result of their actions, and/or a decrease in paranoia due to no longer being under constant staff observation. If the patient has responsibilities to others, those dependants might gain companionship and support from the absconder who returns home (
Bowers et al., 1999a
, Bowers et al., 1999b
). It must be noted, however, that these benefits are far outweighed by the potentially negative consequences that occur as the result of elopement. Stewart & Bowers, 2011
point out that one quarter of all inpatient suicides occur post-elopement.Understanding How Patients Elope
Many patients successfully elope even after staff become aware of their intention to leave, circumventing locked doors or special observation. There are several reasons why this occurs. Patients often take advantage of shift change when the staff's level of vigilance is reduced. They leave mostly through the front door.
Bowers et al., 1999a
, Bowers et al., 1999b
found that most elopements occurred during the first few weeks of admission, and most patients simply went home and engaged in everyday activities. Other reported methods of escape include climbing over a high fence or gate, leaving a ward when left unsecured by workmen, stealing keys to escape, and leaving via a window (Dickens & Campbell, 2001
).Keys are symbols in psychiatry, and moreover, they are instruments in a very practical sense as well (
Hazelton, 2006
). Some patients feel that locked doors highlight the staff's power, making them feel more depressed and anxious (van der Merwe et al., 2009
). Most keys that are taken appear to be ones that have been left unattended. A literature search using several databases did not yield any studies that referred to staff having keys stolen by patients for the purpose of elopement.The majority of inpatient units are locked wards. This has both advantages (preventing illegal substance entry, patient elopement) and disadvantages (patients feeling confined, extra work for staff). Locked wards, however, are also associated with increased patient aggression, poorer patient satisfaction with treatment, and more severe symptoms (
van der Merwe et al., 2009
). Many patients view locked doors as a symbol of mistrust by staff (Muir-Cochrane, Mosel, Gerace, Esterman and Bowers, 2011
, Muir-Cochrane, van der Merwe, et al., 2011
), while some patients stated that the locked doors make them feel safer, more secure and protected against unwanted visitors. Others stated that locked doors highlighted the staff's power and make them feel anxious and depressed (van der Merwe et al., 2009
).The use of containment methods such as special observation, sedating medication, seclusion, etc. can become excessive to the degree that it dominates practice and draws attention away from treatment. Finding the right balance between risk and containment is complicated after staff experiences a serious untoward incident, such as elopement (
Bowers, Simpson, et al., 2006
, Bowers, Brennan, Flood, Lipang and Oladapo, 2006
). Special observation can be beneficial in providing additional staff contact, which may be therapeutically beneficial. Conversely, it may make patients feel as if they are being constantly watched, which further increases their feeling of incarceration. Although there is a challenge in achieving a balance between patient safety and patient autonomy, safety of patients must remain the primary behavioral health objective (Hunt et al., 2010
). Bowers et al., 2002
note that there are higher levels of security maintained within inner-city psychiatric units, possibly because of their proximity to sources of danger. It may be the case that rural and semi-urban hospitals can allow patients more freedom without compromising safety. These investigators conducted a survey of 70 psychiatric units (urban and non-urban) and discovered that there appeared to be wide variations in practice (Bowers et al., 2002
).Researchers have examined the effectiveness of different interventions to reduce the rate of elopement, but this work is limited and not sufficiently strong enough to guide current acute psychiatric unit policy in the prevention of absconding (
Bowers et al., 2003
). Bowers et al. note the need for stable staffing and good leadership as a necessity when initiating an anti-elopement package.Preventing Elopements
One intervention that has been studied is the implementation of a self-training package, which consists of a handbook for unit managers. The handbook comprises a 19-page guide to implementing the interventions, a 40 page anti-absconding handbook detailing each intervention and its rationale, a color mnemonic poster listing six key interventions; and a pocket- sized laminated card containing indications of elopement risk. The six key poster interventions were: rule clarity through the use of a signing in and out book, identification of those at high risk for absconding, targeted nursing time for those at high risk, careful breaking of bad news, post-incident debriefing, and multi-disciplinary review after two elopements. As a result of the implementation of this training package, 15 units reported a 25.5% decrease in elopements (
Bowers et al., 2005
).There may be a significant link between elopement and the way in which psychiatric nurses think and behave (
Nijman et al., 2005
). Three important factors for the production of low-conflict, high therapeutic units are: the positive appreciation of patients by staff, the ability of the staff to regulate their own emotions towards patients, and the creation of effective structure (rules and routines) for unit life. The creation of such a unit may be dependent on a number of factors: the psychiatric philosophy of staff (how they see the nature of mental illness and their role in care and treatment), their moral commitments (e.g. non-judgmentalism, nursing professionalism, humanism, honesty), their use of cognitive–emotional self-management methods (interpersonal skills), teamwork (the achievement of cohesion, consistency and mutual support, within and across disciplinary boundaries), and organizational support (provision of clinical supervision and learning opportunities). Bowers, Brennan, Flood, Lipang and Oladapo, 2006
conclude that low-conflict environments are not achieved through high levels of containment, but through better staff attitudes and working practices.Recommendations
We have identified a number of questions that may help nurses and other members of the interdisciplinary team identify patients at risk to elope (Table 2, Table 3). By addressing patient's concerns, allowing the patient to participate fully in their plan of care, and utilizing the recovery-based principles, several of the causative factors that result in elopements can be decreased or eliminated (
Caldwell et al., 2010
).Table 2Nursing Questions to Consider—Post Elopement.
| What was the experience and skill mix of the staff at the time of the elopement? |
| What was the acuity of the milieu? |
| What other environmental or operational factors were present? |
| Did the patient have a history of eloping from psychiatric facilities? |
| How many close observations were there at the time they eloped? |
| What time did the elopement occur? Was it near change of shift? |
| Were drugs or alcohol involved in their decision to elope? |
| Do you think the elopement was opportunistic or pre-planned? |
| What is the security plan when a patient elopes? |
| Did the patient have visitors, and if not, did they feel alienated from friends and family? |
| Did the patient have adequate insight into their illness? |
| Did the patient meet the high risk profile for elopement? |
| Were they involuntary admitted? |
| Was the patient paranoid or fearful? |
| Did the patient feel bullied? |
| Does the staff feel responsible? |
| Did they have financial obligations they felt they had to address? |
| Was the nursing staff able to establish effective communication at any point with the patient? |
Table 3Questions for the Interdisciplinary Treatment Team—Post Elopement.
| What was the relationship of the treatment team like with the patient? |
| Did the patient feel as if the team was listening to their concerns? |
| Was the patient going through substance withdrawal? |
| Did the patient have a pain management issue and if so were they being adequately treated for their pain? |
| Did the patient feel as if the doctors were meeting with them daily and listening to their concerns? |
| Did the patient have input into their treatment plan? Was the patient's input realistic? |
| Was there a medical concern that the patient wanted addressed? |
| Was the patient asking to be discharged? |
Assessing for the risk of elopement should be a part of the intake process, and risk should be reassessed periodically throughout the hospitalization (
Bennett, 2008
). Mental health professionals have a duty to protect patients by providing them with the best possible care through integrating evidenced-based findings into their current practice (Fisher & Happell, 2009
). Too often, staff can become myopic in their views and a closed system culture develops. Using evidenced-based principles can make the staff more open to changes in practice (Rose & Glass, 2008
).Treatment programs and nursing models that utilize recovery-based principles not only encourage the nurse to treat the patient with dignity and respect but invite the patient to be an active partner in their recovery process. Recovery-based program values have been identified as: person orientation, hope, functioning, involvement, self-determination, outcome orientation, support and safety (
Fagan-Pryor et al., 2009
). Participating in the creation of a recovery-based culture can decrease some of the risk factors for elopement.Research implications and conclusions
Patient elopement can have several negative effects on staff. Staff generally express a sense of failure and acknowledge that the event should have been foreseen and prevented (
Clark et al., 1999
). Sudden untoward incidents, such as suicide and elopement, can have long-term negative consequences on staff and their practice for up to 10 years (Bowers, Simpson, et al., 2006
, Bowers, Brennan, Flood, Lipang and Oladapo, 2006
). In one post-absconding study, nurses described feelings of fear, guilt, responsibility, and anxiety. Involved staff felt anxiety because they feared that they were going to be blamed for the elopement, both by management and peers. Many were concerned that, as a result, harm was going to come to the patient; they felt a sense of relief when the patient was returned to the unit safely. It then becomes imperative to examine every elopement and understand how any future incidents can be avoided (Bowers et al., 1999a
, Bowers et al., 1999b
).Suggested areas for research include: research on the post-traumatic effects of elopements on staff (particularly inexperienced versus seasoned staff) and the effect of implementation of the recovery model of care on elopements.
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Article info
Publication history
Published online: September 24, 2012
Footnotes
No conflicts of interest exist.
Identification
Copyright
© 2013 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
