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).
Table 2. Themes explaining patient absconding behavior
Themes
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Subthemes
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Lack of insurance coverage
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Lack of insurance coverage and impossibility of insuring some patients specially the rough sleepers (New act of Iran's Health Insurance)
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Lack of insurance coverage for the patients admitted for struggle, and having to pay the expenses not paid by the insurer
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Not providing complete insurance support for the trauma patients
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Problem of inability to pay the medical costs
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Problems of accepting the foreigners
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Large number of foreign nationals
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High expenses and lack of insurance for foreigner or illegal immigrants
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Social problems and patient behavior problems
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Addiction and its treatment process
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Illegitimate pregnancy
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Not identifying the patient’s identity, and patient’s families ignorance of the patient’s conditions
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Poisoning and suicides
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Compulsory hospitalization and lack of support of the family
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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 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).
The patients’ absconding is a deviant behavior where many factors can lead to such a behavior. Most of these factors may relate to the behaviors of the patients themselves. Another group of participants in the study pointed out these social and behavioral problems: “The people who do not like to leave any record about them like the people who have committed suicide. Some absconding patients face legal obstacles to their discharge where their parents must give their consent to the discharge of these patients, where it is a suicide case and these patients do not like others to know about this” (P.1). “Some absconding patients have social problems or they are addicted or they have social and family problems” (P.26). “Most of the patients have mental problems and cannot stand the treatment process” (P.48).
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).
Table 3. Hospital related factors affecting patient absconding behavior
Main class
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Subclass
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Weak supervision and control
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Shortage of security guards and high work load and lack of proper training
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Weakness of the security guard systems and their improper performance
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Improper control of the inputs and outputs
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Not identifying and controlling the patients who intend to abscond
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Lack of cooperation on the part of the security guards and nurses in controlling and monitoring the patients
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The hospital security guard not being equipped with the necessary instruments
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Lack of education and notification
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Not being aware of the treatment costs and processes
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Not providing the costs for training the patients and families
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The misperception of the hospital services to be provided for free
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Patients’ dissatisfaction
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Inappropriate behavior and disrespect towards the patients as they are admitted to the hospital
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Lack of good relationship with the patients on the part of the doctors or nurses
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The poor performance or social work in seeking to solve the patients’’ problems in paying the medical expenses
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Patients’ satisfaction with the hospital facilities and conditions
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Lack of work commitment
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Inattention and irresponsibility of the staff concerning the patient absconding
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Lack of extra organizational coordination concerning patient absconding
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Lack of coordination and not discharging the duties of partner organizations
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Problems of discharge process
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Long discharge process and patient’s impatience at the long process
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Not discharging the mentally ill patient from the non-psychiatric hospital
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Not discharging the patients immediately at the appropriate time and certain times (not addressing the patient’s case immediately)
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Lack of the special process for addressing the patient absconding
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Lack of relevant law and executive courses of action to deal with patients absconding
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Lack of a certain process to address the process of patient absconding
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Lack of a certain measure and method of investigating the hospital performance
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Physical environment of the hospital
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Multiple doors and different sections in the hospitals that are widely spread out
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Extensiveness of volume of physical resources and lack of appropriate physical conditions of the hospitals
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Lack of a separate psychiatric ward for the hospital
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Lack of windows railings of the hospitals
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The security guard of the hospital has an important duty to enforce law in the hospitals. It is difficult to control and supervise the hospital due to environmental conditions and large number of clients where sometimes these staff face problems in doing their duties, and sometimes the inattention or perhaps the slacking on the part of the security guard leads to the less control and supervision in the hospitals. In this regard, some participants believed that: “Nurses’ carelessness can be one of the factors involved in patients absconding, and the inattention on the part of the security guard is another factor in this regard” (m.51). “The entrance and exit of the hospital is not controlled, so the patients feel that they can easily abscond, so the security of the hospital diminishes” (m.26). Also, some other participants pointed out the shortage of security guards in the wards, as a result, the decrease in control and supervision in the hospitals: “There is not enough security guards in the hospital, if there were more security guards, there would be a greater watching and guarding” (m.8). “There is a smaller number of security guards in the hospital and they do not discharge their duties properly” (m.35).
Low knowledge of the patients and their companions on the health related issues and hospital costs was identified as another factor contributing in patients absconding behavior. In this regard, some participants stated: “Not being informed and educated is one of the factors involved in patients absconding” (m.27). “The patients struggle with the hospital because of not being informed of the importance of treatment continuity” (m.2). Moreover, other participants believed: “Most people are not informed of the medical costs, administrative process and patients health record that is used for paying off the medical bills” (m.31). “The main factors involved in patient absconding is the lack of notification of the costs” (m.53). “The patients are not informed enough, if we inform the patients and their companions, this decreases the dissatisfaction and it also decreases the patients absconding. The patient absconding somewhat stems from avoiding to pay the medical bills, and the patients’ conversation with the social workers and informing the patients and explaining to them about the discounts can prove effective in this regard” (m.28).
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
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Subclass
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The problems created for the hospital
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Unpaid and uncompensated medical expenses and increasing the financial burden to be incurred by the hospital
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Creating responsibility for the hospital
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Legal problems for the hospital in case of any damage to the absconding patient
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Distrust to the treatment in the hospital
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Disrepute for the hospital
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The problems created for the patient
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Providing incomplete treatment or the aggravation of the disease after the recovery
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Creating stress and concern for the patients’ families
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Legal and judicial problems
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Damaging oneself or others
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The problems created for the staff
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Wasting the time of the staff, specially the time of nurses and security guards
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Making the staff concerned and stressful
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Probability of deducting from the staff salaries or merit pays
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Probability of physical altercation and beating the staff
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In the section allocated to the problems created for the hospital, the participants have pointed out the expense problems, legal liability and undesirable performance indicator. The participants believed that: “The large number of absconding patients is not considered to be a good feature for the hospitals” (m.20). “This is not considered to be a desirable index for the hospitals, and it does us some damage in terms of security and financially. Most of the absconding patients are the ones who stay in the hospitals for a long time and have to pay much medical costs” (m.26).
Of course, the patients admitted to the private hospitals do not have much problem in paying the medical costs, since they are charged at the point admission. One of the participants said that: “We do not have patient absconding in the private hospitals because they cannot afford to pay the medical bills, and we take from the patients a down payment in the private hospitals when admitting the patients” (m.53).
The patient absconding can create many problems for the patients themselves, and in this regard most of the participants pointed out some issues including not seeking further treatment or incomplete treatment, the probability of damaging themselves and others, legal problems, stress and concerns of the patients and their families. In this regard, the interviewees said that: “The patients who have to return to the hospitals with the same symptoms and be hospitalized must pay the same treatment costs again” (m.37). “The patients may damage their families and the people around them” (m.10). “The problem facing the patients themselves is the incomplete treatment. The problem facing the patients’ families is the fear of being injured by the absconding patient and the problem created for the hospital is that the condition of the absconding patients aggravates after they return to the hospital” (m.13).
Concerning the patients who have absconded from the psychiatric hospital under study, there were greater number of probable problems and damages. In this regard, one of the participants said that: “The absconding patients are exposed to the risk of accidents and life hazards. The patients who abscond at night mostly come from other cities, and they may fail to reach home. Half of the families of these patients do not like them to return home at all, and the rest of the families are worried that whether their patients can return home after absconding from the hospitals or not (m.18).
However, some interviewees said that the patients who abscond at the time when they are to be 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).