Re-designing Absent without Leave (AWOL) Guideline
Improving safety, clarity, and equity in inpatient care protocols
In early 2024, Ara Manawa 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. 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 (excluding Mental Health).
A formal review was initiated following an event where a patient went missing from care. The AWOL guideline, last updated in 2016, was identified as a priority for redesign to ensure clarity, safety, and alignment with Te Tiriti o Waitangi obligations.
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 kaimahi across services. I conducted interviews, synthesised 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 and work obligations with patients.
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Equity concerns: Māori and Pacific patients were overrepresented in AWOL incidents, highlighting cultural safety gaps.
- Language issues: The existing guideline used terminology that did not reflect patient-centred or mana-enhancing communication.
Our Approach
We collaborated with over 30 kaimahi through interviews and user testing, including CNMs, NUMs, ward nurses, SMOs, Māori and Pacific Health teams, security, contact centre staff, and police. We also analysed a sample of Datix 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 kaimahi and tested the flipchart-style visual guideline prototype with another 15 kaimahi for usability.
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Critical Te Tiriti Analysis: Applied CTA to ensure the guideline reflected whakawhanaungatanga, wairuatanga, and patient-centred 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 Ko Awatea and Te Toka Tumai intranet
- Education support: flipcharts and an education pack to help onboard new nurses
- 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 & Te Whare Tapa Whā strengthened cultural safety
The bi-weekly working group with nurses and our sponsor were instrumental in the success of this project. By grounding this work in relationship building between the designers and the nurses, we were able to effectively document and understand the nuances of this process.
What was particularly exciting for us was the ability to apply Critical Te Tiriti Analysis (CTA) to the guideline supported by our wonderful Māori Health Lead, Lizzie.
CTA is a five-step process, developed by Community Research Org, which is used to strengthen and review public policy in relation to the articles and provisions of te Tiriti o Waitangi.
This really allowed us to transform this guideline into something that upholds the wairua of everyone involved in the process and hopefully stands out as a benchmark for other guidelines and policies.
There was an opportunity to align this work with related Policies which helps streamline knowledge.
Conclusion
This work not only delivered a clearer, more equitable guideline but also supported systemic alignment across related policies, ensuring safer and more culturally responsive care.The result I designed and developed two versions of the guidelines as printed flipcharts that will sit in every ward (one for Adults and another Child inpatient services).
Project Leads:
Jenna Hagan
Elina Ashimbayeva
Contributer:
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