The Challenges and Problems Posed by Patient Absconding from Teaching Hospitals in Kerman: A Qualitative Study

Background Patient absconding from hospital is one of the permanent crises the hospital face which poses many risks and challenges to the patient, hospital and society. Considering the importance of this subject and numerous problems caused by this phenomenon in the hospitals, the present study aimed to identify the challenges and problems of patient absconding behavior for teaching hospitals of Kerman university of medical sciences. Methods The present study is a qualitative study which was conducted using purposive sampling through semi structured interviews with 63 informants involved in patient treatment process. Data were analyzed using Collaizi content analysis method. Results Two main themes of economic and social factors, and factors related to the hospital covering 36 subthemes were identified to explain the challenges and obstacles of patients absconding behavior. Also, three subthemes of problems for staff, patient and hospital were identified as problems resulted from patient absconding behavior. Conclusion There are many challenges and obstacles to decrease patient absconding from hospitals, and one of the main challenges is the patients’ economic and social problems. The absconding behavior can lead to harm and problems for the patient, 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 can lead to a considerable increase in the public trust and eliminate many problems for hospitals.


Background
The hospitals are one of the main elements of the healthcare system such that no health system can operate on its own without the participation and support of the hospitals [1]. However, the hospitals face many problems and challenges. One of these challenges that are less paid attention to is the patient absconding from hospital. The patient absconding from hospital is one of the important health and security problems facing the health systems [2,3].
Patient absconding behavior is defined as the patient leaving the hospital without informing staff and before completing the courses of treatment and paying up their medical bills which may put them 3 and others at risk [4]. The main reasons for patient absconding may stem from fatigue and hopelessness, inability to pay medical costs, intolerance of hospital, overdose of drugs, addiction and poisoning, drinking of alcoholic drinks, treatment failure, behavioral disorders, unemployment and receiving unpleasant news [5]. This behavior can pose many risks including longer recovering process or uncompleted treatment [6]. Also, it leads to an increase in the hospital expenses and those of the society. For instance, in a study conducted in 2015 in the emergency department of one of the hospitals in Iran, the average medical expenses to be paid by each absconded patient was estimated at about 1.500.000 Rials [1], and the total loss made to the hospital was estimated at about 1.100.000.000 Rials [7].
On the other hand, the patients who abscond the emergency departments of the hospitals are often considered as a great crisis and problem for the treatment staff such that the staff must always seek the best actions to prevent these behaviors. Thus, some extra responsibility and workload are created for some individuals such as the health wards supervisors, hospital managers, security guard of the hospitals [8].
In many studies conducted around the world, the rate of patient absconding from hospital has been reported as 2.5% to 34% most of which has been reported from the psychiatric units [9]. Also, in a study conducted in Iran, the rate of patient absconding from the emergency department of general hospitals has been reported about 2.4% [7]. Considering the studies that have been conducted in other countries, the greatest average rates of patient absconding from hospital were reported in America (8.92), England (6.28), India (5.58), Ireland (4.28), Iran (2.40) per 100 patients admitted to the hospitals [5]. A study conducted to investigate the patient absconding behavior from the inpatient units of a hospital in Hong Kong in 2002 showed that the addicts account for a considerable portion of the patient absconding from hospital constituting 29.3% of the total number of the absconding cases [10]. According to the results of some studies, the absconding patients were mainly male, young people, single people and addicts, and any nursing policy or strategy employed to reduce patient absconding must be aimed at these people considering the fact that most absconding behaviors are exhibited by these people [11]. According to the above-mentioned points, it can be said that the 4 patient absconding behavior is an important issue in risk management on the part of the hospital which creates some economic, social, legal challenges to and consequences for the hospital, and also involves the hospital managers and staff in a new responsibility and task. Thus, it is necessary to conduct the present study considering the critical situation of the hospitals and the existence of patient absconding as a serious crisis for the health system, and the paucity of relevant studies on this issue. Accordingly, the present study was conducted to investigate the challenges of patient absconding from three teaching hospitals of Kerman University of Medical Sciences. The present study is a phenomological qualitative study which was conducted through semi structured interviews with informants. The phenomenological research includes a set of interpretive methods seeking to investigate and describe the experiences of the people with a phenomenon [12].
The informants were selected from people who were in connection with or involved in patient absconding behavior like the managers, physicians, nurses, patients carriers, security guards and social workers from 4 teaching hospitals (table 1). Accordingly, the people with a working experience of more than 5 years in the hospital who were willing to participate in the study were entered into the study. Also, snowball sampling was used to complete the interview and to identify more informants.
The interview was conducted with the staff of private hospitals to investigate this issue more deeply and comprehensively. Interview guide which was first drafted by reviewing related literature() and finalized by research team after several discussions was used for data collection. All interviews were conducted in the workplace of the participants. The interview was recorded with the written consent of the participants prior to the interview, and in cases where the interviewees did not agree to record the interview, the interview was written down. Each interview lasted for 20-40 minutes. Then, the interviews were transcribed, coded and initially analyzed. Colaizzi's content analysis was used to analyze the qualitative [13]: At first, all interviews were transcribed and reviewed several times. In the next stage, the texts were read several times and the important points were underlined to be distinguished from other parts. Then, the important sections were broken into the smallest meaningful units. In the following stage, the less related or irrelevant data were eliminated. The themes were placed in some groups according to their frequency and meaning where name of the groups indicated the content of the group and the purpose of the participants. The groups were reviewed several times and the similar groups were combined. Finally, the researchers agreed upon the meaning of the data and what appeared as the themes and subthemes, contents and their names. No special software was used to carry out these stages and all stages were carried out manually. The initial framework included 2 Themes concerning the challenges and obstacles, 2 themes concerning the courses of action and 1 theme concerning the identification of the created problems that remained unchanged. However, the subgroups of each of these components underwent fundamental changes. In the findings section, the letter "P" along with a number indicates the participant who has been quoted.
To ensure validity and reliability of the study, Lincoln and Guba criteria consisting the following steps was used: The analysis of the qualitative data was carried out using Lincoln & Guba method. For this purpose, four criteria including credibility, dependability, confirmability and transferability were considered to evaluate the results [14]. The following tasks were carried out to achieve each one of these criteria.
Credit: Spending sufficient time to collect and analyze the data to improve the credit of findings.
Thus, the questions of the interview were examined in terms of content through the exchange of 6 research members' views and according to the valid papers. Also, the interviews were transcribed and coded, and they were reviewed and finalized by the members of the research team.
Transferability: the purposive sampling was used to achieve this criterion, and it was achieved through selecting the informed and expert interviewees.
Dependability: All details of the interviews were recorded and coded accurately through the confirmation and review of the members of the research team, and the final codes were extracted.

Confirmability:
The interviews were transcribed, and the documents of research process are available.
The collected information was saturated in the sixty-third interview; thus, the interviews stopped in this stage. The reason for the greater number of interviews is the deeper investigation and achieving greater number of challenges in connection with the research topic.

Results
In the present study, two Themes and 36 subthemes were identified explaning the challenges and obstacles relating to patient absconding behavior (tables 2 and 3).

First class: Economic and social factors
This section consists of the economic and social factors relating to the challenges and obstacles posed by patient absconding from teaching hospitals in Kerman where 11 subthemes were identified ( Table 2). Compulsory hospitalization and lack of support of the family Lack of health insurance was one of the most important factors which contributed in patient absconding behavior. In this regard some of participants believed "The patients do not have health insurance coverage" (P.3). "The main reason for the patient absconding is that they do not have insurance and cannot afford to pay for the medical expenses" (P.1).
Even in many cases and in spite of the health insurance coverage, the patients could not pay the medical expenses because of not receiving a complete support and appropriate insurance coverage, and they absconded the hospital without paying for the medical bills. One of the participants in the study stated that: "Some patients need an immediate and emergency treatment including the cases of suicide and struggles whose costs create some problems for the hospitals where these patients have to pay for the medical expenses that are not paid by the insurer; however, they usually abscond without paying for the costs. As for the trauma patients who cannot afford to pay the overhead costs, the costs are very high while they have no supporting insurance coverage so that they become more willing to abscond" (P. 42).
Also, there was fewer absconding behavior in some hospitals as they were compensated by the social works department in this regard an interviewee believed: "In our hospital that is a psychiatric hospital, most of the problems relating to the payment of the medical bills is solved through social work. Therefore, there is no absconding patient here because of the treatment costs" (P.8). Or 8 another participants stated that "The inpatients in this psychiatric hospital do not have any financial problem because the social work solves their problems" (P.10).
The admission of foreigners by some hospitals for the high costs of treatment and lack of insurance coverage have created many problems which have led to absconding of these patients without paying for the medical bills in some cases. In this regard, the participants in the study stated that: "The patient absconding from our hospital are foreign patients whose medical expenses are very high and cannot pay their medical bills" (P.46). "The illegal immigrants are not insured by any insurance company, so they are very willing to abscond and there are a many of these patients" (P.42). In one of the studied hospitals, the participants pointed out two social problems that were the main reasons for the patient absconding from hospital: "The reason for the most of patient absconding cases is poisoning, the patients who commit suicide and can be taken to the hospital abscond mostly for the social problems" (P.62). "Our greatest problem is the illegitimate pregnancy where the mother leaves the baby somewhere and abscond. This imposes many legal problems and costs on the hospitals, and we spend much time to address these cases" (P.63).
A group of participants pointed out some social and behavioral problems of the patient absconding from psychiatric hospitals that were a little different from those of the patients of other hospitals.
Most of these patients do not accept that they are ill, and the families hospitalize them against their will, and sometimes they do not return to take back their patients. Also, the patients become restless and impatient, and they do not like to stay in the hospitals, so they seek to abscond. Also, some regulations and limitations imposed by the psychiatric hospitals can lead to patient absconding in the participants' view. In this regard, one of the participants stated that: "The patients abscond for a series of limitations imposed on them that they do not consider to be legal, some of these limitations include ban of smoking, drug abuse etc." (P.8).

Factors relating to the hospital
In the present study, the absconding challenges associated with hospital were identified in 7 main class and 26 subclass ( Table 3).  With regard to the participants' views, there is no process of addressing the patient absconding completely and clearly in the hospitals. Therefore, the effective planning, coordination and actions are not conducted well to decrease this problem in the hospitals. In this regard, some participants stated that: "There must be regulations to enable us to deal with the absconding patients and address their cases more effectively" (m.46). "There is no appropriate process for this, neither the security guard nor the supervisors of the wards do not shoulder the responsibilities, also the lack of cooperation and coordination between the security guard and nurses are one of the effective factors contributing in patients absconding" (m.62).
The hospitals have some extensive in terms of environmental conditions to be able to provide a wide range of services and activities. The existence of different wards, the crowdedness of the wards and numerous doors in the hospitals decreases the ability to control and supervise the hospital properly, and this makes it possible for some patients to abscond from the hospitals. In this regard, one of the participants believed that: "The dispersion of the wards and numerous doors in the hospitals can be a cause for the patients absconding" (m.1).
According to the findings of the present study on the identification of the problems connected with the patients absconding, three main class of problems (problems created for the hospital, patients and staff) and 13 subclasses were identified (Table 4). Table 4. Relationship between the main classes and subclasses of the problems created by patient absconding

Main class Subclass
The problems created for the hospital Unpaid and uncompensated medical expenses and increasing the financial bu be incurred by the hospital Creating responsibility for the hospital Legal problems for the hospital in case of any damage to the absconding pa Distrust to the treatment in the hospital Disrepute for the hospital The problems created for the patient Providing incomplete treatment or the aggravation of the disease after the re Creating stress and concern for the patients' families Legal and judicial problems Damaging oneself or others The problems created for the staff However, some interviewees said that the patients who abscond at the time when they are to be 13 discharged and after complete recovery, do not have much problem. One of the interviewees said: "There will be no problem facing the absconding patients except for the fact that they will not be admitted again to the hospitals where they absconded from. This depends on the patients' awareness of the fact that whether they have been completely treated or not. However, most of the absconding patients are in the last treatment stage when they can be discharged" (m.42).
On the other hand, the patient absconding creates further responsibility for the hospital staff and involves them in this issue and wastes their time. Also, this behavior leads to the deduction from their salaries and merit pays. In this regard, one of the interviewees said: "Sometimes patient absconding wastes the staff time and sometimes it leads to physical altercation and beating between the absconding patients and the staff" (m.22).

Discussion
In the present study, the challenges and obstacles facing the patient absconding from hospitals that are connected with the economic and social factors, and the factors connected with the hospital were investigated. The economic and social factors included the lack or lack of complete insurance coverage, lack of insurance support provided by the insurance companies for the patients whose problems are caused by struggles or traffic accidents, the problems concerning inability to pay the medical costs, the problems of the foreigners and the high costs they impose on the nation's health system, and patients' behavioral and social problems were determined.
In the studied hospitals, mostly the rough sleepers and the people who have been involved in struggles and the foreign nationals faced insurance problems which caused them to abscond. The Mosel, most of the absconding patients used illegal drugs [17]. Also, according to the study conducted by Ajli et al. most of the absconding patients were reported to use illegal drugs [18]. A study conducted in a psychiatric hospital showed that the patients with a record of illegal drug abuse who stayed for a long time in the hospitals, were most likely to abscond and had the greatest record of absconding [3].
Poisoning and suicide were important factors involved in patient absconding in one of the studied hospitals. These patients absconded from the hospitals after receiving the healthcare services and when being transferred to the ward or at the time when the wards were crowded, because of the dissatisfaction with being transferred to the psychiatric hospitals and the fear of the stigma of mental illness or the lack of the separate ward or rooms for the psychopath in the wards.
The compulsory hospitalization and the lack of support of the patients' families were the main reasons for the patient absconding from the psychiatric hospital under study because these patients are not often informed of their illness and require to be hospitalized; however, they do not accept that they must be treated, and most of the families of these patients hospitalize their patients compulsorily.
Also, in the present study, the inappropriate behavior and disrespect towards the patients were absconding [19].
The illegitimate pregnancy and the rough sleeping, as social problems, also led to patient absconding in the hospitals under study which necessitates creating social safety nets in order to reduce this type of social problems. One of the studies showed that the characteristics of the absconding patients do not differ much from those of the non-absconding patients in the control group, and this shows that the tendency to abscond from the hospitals does not exclusively relate to the behavioral and personal characteristics of the patients, but they also relate to some other factors such as the social context of the place where the patients live [20].
The results of the present study showed that the dissatisfaction with the facilities and environmental conditions of the hospital lead to the patients absconding. Some limitations such as smoking in the psychiatric hospitals and the closed areas without any recreational and happy space for these patients make them abscond. It is probable that a special motivation for absconding is generated in the psychopaths caused by hopelessness when facing with long hospitalizations and restrictions of the social freedom. According to the study conducted by Cochran et al. the psychopaths mentioned the closed environment of the hospital and creation of an anxiety-provoking environment that disturbs the psychopaths' peace as the reasons for their absconding. One of the common methods to prevent the patient absconding is locking up the doors of the wards where there is not much evidence to support this intervention [9].
The investigation into the present conditions showed that the delay in discharging the patients as they are ready to be discharged, long discharge process and lack of awareness on the part of the patients and their companions of the discharge process in some hospitals under study made the patients grow impatient which led to not passing the process, and most of these patients left the hospitals without obtaining the discharge card and completing the discharging process. These patients did not fully pay the medical bills and they could be considered as the absconding patients.
Some problems in discharge process have been pointed out, in most of the studies conducted in Iran, which lead to patients and staff's dissatisfaction. Also, not being aware and lack of notification of the costs and treatment process have created the misconception that the hospital services are provided for free which is one of the secondary subjects addressed by the present study that was found to be effective in the patient absconding from the hospitals under study, though no previous study addressed this subject.
In the present study, the inattention and irresponsibility of the staff, extra organizational incoordination in discharging the duties on the part of the main partners involved in patient absconding in the form of work commitment is a challenge that has been pointed out to solve the problem of patient absconding from the hospitals. The lack of a special process to address the patients absconding, and the lack of relevant law and executive courses of action to deal with patient absconding were some important challenges in this regard from the viewpoint of many interviewees in the study especially the security guards of the hospitals.
Another result of the present study that align with those of other studies on this subject is the problems created by the patients absconding. The patient absconding is an issue which has raised concerns both in the society and hospitals. Also, it has decreased the public and family trust to the hospitals considerably. It has also made the hospitals face some financial and legal problems. In this regard, the study conducted by Wilkie et al. showed that the decrease in treatment progress, treatment prolongation and delay in the rehabilitating goals of the absconding patients may lead to families' distrust of the hospitals [3]. The patient absconding has been considered as a defect and error in the public healthcare services provided by the hospitals which eliminates the trust of the society in the hospitals [11,21]. The patient absconding raise concerns and fear among the staff and waste their time especially the nurses and security guards' time, and it probably leads to their involvement in this issue and deduction from their salaries. Patient absconding will probably lead to nurses' anxiety and concerns and they may also be blamed and criticized by their colleagues and managers. In some cases, they may even lose their jobs [9,22].

Conclusion
Patient absconding is one of the important issues facing the hospitals that can lead to some social consequences as well as the economic consequences. Considering the findings of the present study, the absconding behavior can lead to damage to and problems for the patients themselves, and some emotional and occupational consequences for the hospital staff and nurses. This issue is considered along with a considerable decrease in the public trust and many other problems for the hospitals where some actions must be taken in this regard. The present study contributes to the better understanding of the importance of patient absconding and also to prevent and reduce the patient absconding from the hospitals.

Abbreviations
Not applicable.
assistance in collecting data.

Authors' contributions
MM, MA and MNM designed the study. MM conducted interviews with the study participants. MM transcribed the interviews. All authors contributed to the interpretation of the results. MM drafted the manuscript. MNM and TD revised the manuscript. All authors read and approved the final manuscript.

Funding
Not applicable.

Availability of data and materials
Anonymised transcripts are available from the corresponding author.

Consent for publication
Not applicable.