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Whys and whats of wandering
Whys and Whats of Wandering Documenting what happens before and during can reveal unmet needs as the cause. SANDRA T. HIRST BARBARA J. METCALF rom the time she is dressed in the morning until bedtime, Ms. Evers is a nonstop wanderer. She pauses only to eat and to take a sho~ nap in the afternoon, and even after She goes to bed, she often rises and walks the corridors during the night. The staff are concerned about her safety because she tends to wander off the unit and out of the nursing home's back door. Wandering is a potentially serious problem that worries nursing staff. What is wandering? Who is the wanderer? What stimuli initiate wandering behavior and how does one intervene to reduce wandering, if indeed one should? Aside from one trait--a wanderer spends more time in motion than the average nonwanderer--little is known about the problem(l). Monsour and Robb, using a comparison study, found that wanderers had participated in high levels of social and leisure activities and had experienced more stressful life events before their illnesses. Additionally, their previous coping patterns had included high activity(2). Another characteristic may be disorientation induced by memory loss. The older individual is often "lost" and may wander to orient himself in his surroundings. The wanderer has also been referred to as demented, possessing limited social skills and strolling free-
F
Sandra T. Hirst, RN, MScNEd, is an assistant
professor, University of Calgary, Canada. Barbara J. Metcalf, RN, MHSc, is an instructor of gerontic nursing, Foothills Hospital School of Nursing, Calgary, Canada.
ly throughout the nursing units, making each area his own. He indiscriminately not only enters the room but explores the personal possessions of other residents(3). The wanderer also may have unmet basic needs. Thus, wandering may be 'a coping mechanism--a search for food, fluids, shelter, or fulfillment of psychosocial needs. For example, wandering at night may be a desire to find a bathroom to relieve a full bladder. The bathroom light is off and the resident wanders toward the light in the hall. He may have left his glasses on the bedside table and is having trouble seeing. As he grows more uncomfortable from the full bladder, his anxiety is compounded by his inability to find the bathroom. The increased anxiety also stimulates a rise in adrenaline levels, which may trigger additional wandering. What appears as wandering may simply be an elderly resident's attempt to satisfy a physiological need. Wandering can be active (also referred to as agitated), where the determined wanderer appears to be searching for something or attempting to keep busy. Passive--or placid-wandering appears to be aimless; such wanderers are easily distracted and thus potentially easier to manage. Nocturnal wandering --often the most troublesome--can be passive or active. Dissecting the Problem Wanderers present a tremendous challenge to provide adequate protection and quality care. The assessment of wandering includes biopsyehosocial behaviors: When does the resident usually wander? Is the wandering associated with a specific time of the day? With the weather?
What environmental and/or human factors contribute to the wandering? What factors appear to reduce the wandering? Answering these questions will assist in identifying the appropriate intervention. A complete written description of the behavior is essential. Keep a daily record of the wandering, much as you might chart fluid intake and output. On the door to a patient's room or at the head of the bed, you can post a sheet of paper divided into four horizontal sections--morning, afternoon, evening, and night. Along the top of the paper make three vertical columns, one to document precipitating factors; one for the apparent goal of wandering, and one for the wanderer's responses. For each of the four time periods, record the characteristics of the wandering. The time spent in systematically documenting the precipitating factors, any identifiable goals, and the wanderer's response is worthwhile. It might, for example, reveal that the elderly female resident wanders off the unit at about 7:00 each evening and always attempts to go to the home where she lived for 20 years. The diagnosis for her might then be ineffective individual coping related to lack of personal security. Based on the assessment, a care plan is developed with the overall goals being to recognize the wanderer as a unique biopsychosocial and spiritual being, meet physiological and psychosocial needs, and intervene to address the cause(s) and effects of wandering behavior. This latter goal reflects wandering as a coping mechanism employed to resolve a homeostatic imbalance. Of additional concern is the fact that wandering is a behavior that is
Geriatric Nursing September/October 1989 237
both caused by a variety of stimuli and is a stimulus itself for other presenting problems. Research on wandering is in its infancy. Among the questions to be answered are: When does wandering behavior become a problem? And, whose problem is wandering? In reality, wandering becomes problematic when the potential for injury exists, when the rights of other residents are infringed upon, when the staff are frustrated because of it, and when tracking residents consumes stafftime that might be spent therapeutically. When any of the
238 Geriatric Nursing September/October 1989
above situations develop, intervention is needed. One avenue is to develop institutional policies and procedures regarding wanderers. Such guidelines provide a commonly understood reference point for the staff about appropriate nursing strategies and also make it easier to see if the procedures are working. The policies must answer such questions as: What procedure is initiated if an individual leaves the unit or the facility? When is security informed? When are the police notified? The family called? The physi-
cian? When are chemical or physical restraints to be employed? Another administrative intervention is education--to reduce staff frustration by giving them the knowledge and skills to intervene when needed. References 1. Hiatt, L. The happy wanderer. Nurs.Ilomes 29(2):27-31, 1982. 2. Monsour, Noel, and Robb, S. S. Wandering behavior in old age: a psychosocial study. Soc.Work 27:411-416, Sept. 1982. 3. Savq'er, J. A Management Programfor Ambulatory lnstRutionali-ed Patients with dlcheimer "sDisease and Related Disorders. Paper presented at the Annual Conference of the Gerontological Society, held in Boston, MA, in 1982.
F
Sandra T. Hirst, RN, MScNEd, is an assistant
professor, University of Calgary, Canada. Barbara J. Metcalf, RN, MHSc, is an instructor of gerontic nursing, Foothills Hospital School of Nursing, Calgary, Canada.
ly throughout the nursing units, making each area his own. He indiscriminately not only enters the room but explores the personal possessions of other residents(3). The wanderer also may have unmet basic needs. Thus, wandering may be 'a coping mechanism--a search for food, fluids, shelter, or fulfillment of psychosocial needs. For example, wandering at night may be a desire to find a bathroom to relieve a full bladder. The bathroom light is off and the resident wanders toward the light in the hall. He may have left his glasses on the bedside table and is having trouble seeing. As he grows more uncomfortable from the full bladder, his anxiety is compounded by his inability to find the bathroom. The increased anxiety also stimulates a rise in adrenaline levels, which may trigger additional wandering. What appears as wandering may simply be an elderly resident's attempt to satisfy a physiological need. Wandering can be active (also referred to as agitated), where the determined wanderer appears to be searching for something or attempting to keep busy. Passive--or placid-wandering appears to be aimless; such wanderers are easily distracted and thus potentially easier to manage. Nocturnal wandering --often the most troublesome--can be passive or active. Dissecting the Problem Wanderers present a tremendous challenge to provide adequate protection and quality care. The assessment of wandering includes biopsyehosocial behaviors: When does the resident usually wander? Is the wandering associated with a specific time of the day? With the weather?
What environmental and/or human factors contribute to the wandering? What factors appear to reduce the wandering? Answering these questions will assist in identifying the appropriate intervention. A complete written description of the behavior is essential. Keep a daily record of the wandering, much as you might chart fluid intake and output. On the door to a patient's room or at the head of the bed, you can post a sheet of paper divided into four horizontal sections--morning, afternoon, evening, and night. Along the top of the paper make three vertical columns, one to document precipitating factors; one for the apparent goal of wandering, and one for the wanderer's responses. For each of the four time periods, record the characteristics of the wandering. The time spent in systematically documenting the precipitating factors, any identifiable goals, and the wanderer's response is worthwhile. It might, for example, reveal that the elderly female resident wanders off the unit at about 7:00 each evening and always attempts to go to the home where she lived for 20 years. The diagnosis for her might then be ineffective individual coping related to lack of personal security. Based on the assessment, a care plan is developed with the overall goals being to recognize the wanderer as a unique biopsychosocial and spiritual being, meet physiological and psychosocial needs, and intervene to address the cause(s) and effects of wandering behavior. This latter goal reflects wandering as a coping mechanism employed to resolve a homeostatic imbalance. Of additional concern is the fact that wandering is a behavior that is
Geriatric Nursing September/October 1989 237
both caused by a variety of stimuli and is a stimulus itself for other presenting problems. Research on wandering is in its infancy. Among the questions to be answered are: When does wandering behavior become a problem? And, whose problem is wandering? In reality, wandering becomes problematic when the potential for injury exists, when the rights of other residents are infringed upon, when the staff are frustrated because of it, and when tracking residents consumes stafftime that might be spent therapeutically. When any of the
238 Geriatric Nursing September/October 1989
above situations develop, intervention is needed. One avenue is to develop institutional policies and procedures regarding wanderers. Such guidelines provide a commonly understood reference point for the staff about appropriate nursing strategies and also make it easier to see if the procedures are working. The policies must answer such questions as: What procedure is initiated if an individual leaves the unit or the facility? When is security informed? When are the police notified? The family called? The physi-
cian? When are chemical or physical restraints to be employed? Another administrative intervention is education--to reduce staff frustration by giving them the knowledge and skills to intervene when needed. References 1. Hiatt, L. The happy wanderer. Nurs.Ilomes 29(2):27-31, 1982. 2. Monsour, Noel, and Robb, S. S. Wandering behavior in old age: a psychosocial study. Soc.Work 27:411-416, Sept. 1982. 3. Savq'er, J. A Management Programfor Ambulatory lnstRutionali-ed Patients with dlcheimer "sDisease and Related Disorders. Paper presented at the Annual Conference of the Gerontological Society, held in Boston, MA, in 1982.