Redesigning Absent Without Leave (AWOL) Guideline
Improving safety, clarity, and equity in inpatient care protocols
In early 2024, Ara Manawa, the design and innovation studio within Health New Zealand, supported a cross-directorate working group of Clinical Nurse Managers to review and update the AWOL (Absent Without Leave) Guideline for Te Toka Tumai Auckland (the Auckland metropolitan health district). This guideline helps staff respond when a patient unexpectedly leaves an inpatient setting without notifying staff, across Adult, Women’s, and Child Health services at Auckland City Hospital and Greenlane Clinical Centre (excluding Mental Health).
A formal review was initiated after an event where a patient went missing from care. The guideline, last updated in 2016, was identified as a priority for redesign to ensure clarity, safety, and alignment with Te Tiriti o Waitangi (the Treaty of Waitangi, New Zealand’s founding agreement with Māori, which carries obligations around partnership and equity in public institutions.
My Role
Collaboration is at the heart of Ara Manawa’s interdisciplinary work. I co-led this project from the start: scoping the opportunity, facilitating co-design workshops with nurses, and engaging more than 30 staff across services. I conducted interviews, synthesized insights in Miro, and mapped real AWOL journeys to uncover system gaps.I designed the new printed flipchart guidelines, updated the policy text, and shared drafts across stakeholder forums for feedback. Midway through the project, when my colleague transitioned off, I took full responsibility and delivered the work through to completion.
The Opportunity
Our goal was to simplify the guideline, align it with current best practice, and assess it through a Te Tiriti o Waitangi lens.Key Challenges:
Through interviews, journey mapping, and data analysis, we identified several systemic issues:- Inconsistent pathways: Staff responses varied across wards, creating uncertainty during AWOL events.
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Knowledge gaps: Many new graduate and overseas-trained nurses were unfamiliar with the AWOL process.
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Communication barriers: Missed opportunities for building trust and to discuss outside whānau (family) and work obligations with patients.
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Equity concerns: Māori (the indigenous people of New Zealand) and Pacific patients were overrepresented in AWOL incidents, pointing to gaps in cultural safety.
- Language issues: the existing guideline used terminology that was not patient-centered or mana-enhancing (mana refers to a person’s dignity and standing).
Our Approach
We collaborated with over 30 staff through interviews and user testing, including Clinical Nurse Managers (CNMs), Nurse Unit Managers (NUMs), ward nurses, Senior Medical Officers (SMOs), Māori and Pacific Health teams, security, contact center staff, and police. We also analyzed a sample of Datix (incident reporting system) AWOL entries to identify trends and safety risks.Key activities included:
- Data Review: Analysed historical qualitative data and Datix reports to understand trends and safety risks.
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Journey Mapping: Documented a real AWOL scenario from a senior nurse’s perspective to identify system gaps.
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User Interviews and Testing: Conducted interviews with 15 staff and tested the flipchart-style visual guideline prototype with another 15 staff for usability.
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Critical Te Tiriti Analysis (CTA): Applied CTA to ensure the guideline reflected whakawhanaungatanga (building relationships and connection), wairuatanga (spirituality), and patient-centered language.
- Guideline Redesign: Updated the guideline structure, references, and roles involved in the process for clarity and alignment with best practice.
Key Outcomes
- Patient-centred language: e.g., “patient absconded” changed to “patient missing from our care”
- Improved accessibility: printed flipcharts for every ward and updates to staff intranets and learning platforms.
- Education support: flipcharts and an education pack to help onboard new nurses with the support of Nurse Educators office.
- Process improvements: revised documentation to align with current best practice and more consistent data reporting
- Te Tiriti alignment: incorporated CTA recommendations and included Māori health leads in design and review
Our Learnings
- Key relationships mattered (working group, sponsor)
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Critical Te Tiriti Analysis as a transformation driver
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Foundation in whakawhanaungatanga (relationship building) & Te Whare Tapa Whā (a Māori model of health describing four dimensions of wellbeing) strengthened cultural safety
The bi-weekly working group with nurses and our sponsor was instrumental to this project’s success. By grounding the work in relationship-building between the designers and the nurses, we were able to document and understand the nuances of the process.
What was particularly exciting was applying Critical Te Tiriti Analysis to the guideline, supported by our Māori Health Lead, Lizzie. CTA is a five-step process, developed by Community Research Org, used to strengthen and review public policy against the articles and provisions of Te Tiriti o Waitangi. This allowed us to transform the guideline into something that upholds the wairua (spirit) of everyone involved, and that we hope sets a benchmark for other guidelines and policies. There was also an opportunity to align this work with related policies, which helps streamline knowledge.
The guideline sits on the foundation of whakawhanaungatanga and Te Whare Tapa Whā model, which will help new nurses build better relationships and trust with their patients, in the hope that this supports patients to remain in hospital care.
Conclusion
This work delivered a clearer, more equitable guideline and supported systemic alignment across related policies, ensuring safer and more culturally responsive care. The result: I designed and developed two versions of the guideline as printed flipcharts that sit in every ward, one for Adult and one for Child inpatient services.Project Leads:
Jenna Hagan
Elina Ashimbayeva
Contributor:
Deepa Swami
Sponsor:
Jo Wright, Nurse Director, Cardiovascular Directorate, Te Toka Tumai Auckland
Māori Health Leads:
Lizzie Kanivatoa, He Ara Whiria (Adults)
Hera Watkinson, TamaAriki Ora Team (Child)
Other Collaborators:
Pacific Health Team, CNMs, NUMs, Nurses, Security, Contact Centre at Te Toka Tumai Auckland