Wi illie K., 90 years old, was one of the sturdily independent men and women in a small village who were interviewed by Doris Schwartz ... He lived with his niece Elda, 80, and was as vigorous as a young man, but he was becoming forgetful. Willie could climb a towering oak and saw off a branch, but when he climbed down, he couldn't remember the way home. Aware of his wanderings and Elda's worry, the entire village held a meeting and made a plan. If Willie was missing, Elda was to phone the firehouse and the fire bell would be rung twice to alert the town to start hunting. Whoever found Willie was to invite him home for a glass of wine, call Elda, and tell the firemen to sound the all clear. Their plan succeeded, and Willie K. lived contently for another two years.1 This is creative control of the wanderer, resulting in contentment rather than the frustration caused by other methods of control, such as restraint.
Wandering behavior can be misunderstood and frustrating to a nursing staff. Some think of wandering as aimless activity that holds many potential hazards for the wanderer. Be aware that there may be underlying reasons for wandering, such as boredom, tension, hunger, pain, or need for warmth. There also may be an underlying pathology such as deteriorative diseases of the central nervous system or cardiac decompensation. Other possible causes include neurotic disorders, restlessness associated with depression, and organic brain syndrome. Wandering behavior should not be confused with pacing and hyperactivity for which the main nursing objective would be to safeguard the individual from exhaustion. The fear that an accident or a fall may occur during wandering episodes is realistic. There are, however, many options for staff other than restraint, when dealing with a wanderer.
Assessing the Wanderer and the Environment
Assessment of the wanderer should be the first step. What is his or her ambulatory ability? Is a walker or cane used? If so, staff must always be sure it is within reach. It should never be removed, even at night, and should always be kept in the same place. Do me person's shoes or slippers fit properly? How is the person's vision; are glasses worn? When was the last eye exam? Does the wanderer have an ID bracelet? Is the person incontinent? Many falls occur when a person slips in his or her own urine on the way to the bathroom. Is there a history of falls, dizziness, or orthostatic hypotension? If so, has the person been warned to stand up slowly or request help when going from lying or sitting to a standing position? Be sure to document all nursing assessments and interventions.
The next step should be assessment of the environment. Does the environment provide for protection and allow freedom? Is it structured on a philosophy that is supportive and caring and allows the ability to explore? Is the wanderer's room labeled clearly? Are there door buzzers on outer doors or in stairwells to alert staff of a wanderer leaving unattended? Is the area well lit? Is there a sufficient number of night lights? Are rest areas provided, such as chair placement at the nurses' station, at the end of hallways, and even midhall, if necessary? Perhaps there are rooms with half doors (Dutch doors) to allow safe wandering within a designated area and allow staff observation. There may be a fenced-in courtyard with a locked gate, but check it for safety. Are there loose stones? What about raised sidewalk squares? Unlevel concrete is just as hazardous as loose throw rugs in the home.
When assessing the home, all the above considerations apply in addition to such measures as providing covers over stove burners and over the thermostat. Plugs should be installed in electrical outlets that are not being used. Rooms that contain hazards or that have not been wander-proofed should be locked off. Lock up medications or dangerous articles. Complications can be reduced by environmental assessment and changes.
When a thorough assessment of the wanderer and his or her environment is completed, the staff should document any appropriate changes that were made to increase the wanderer's safety.
Approaching the Wanderer
After assessing the wanderer and the environment and making necessary changes, the problem of how to approach the wanderer remains. Never confront or argue with the individual. Therapeutic approaches should be used. Although one-to-one interventions appear to be ideal, the staff- topatient ratio rarely allows for this.
Constant attendance can create inhibition, and the patient can view this as a restraint. Observation from a distance may be the best approach. If redirection is needed to encourage attendance at a meal or bedtime, one staff member falling into step with the wanderer, striking up a nonthreatening conversation, and using eye contact can be more successful than two staff members approaching the wanderer. Confrontation with two people could automatically create a defensive, resistive manner in the patient. A second person can remain slightly behind and out of direct view if two people are needed for staff safety.
Maintain a matter-of-fact attitude. Never use force; it will bring out resistance and result in a fight. Cajole, humor, and befriend the wanderer. Use eye contact, and do not challenge confused statements. Your motive is to increase the wanderer's trust. If you argue with the wanderer, you increase his or her desire to get away. The following example illustrates effective use of intervention techniques with a wanderer.
Sample Case: You just came on duty. Mr N. (an 89-year-old male with opening dx. OBS) is hostile, agitated, and chasing nursing staff. He is attempting to enter the nurses' station by pounding on the half door and swearing. You have been given a synopsis by the nursing staff of his behavior. He has been trying to leave all evening and is angry because he feels he is being kept against his will. As the introduction of a new person into a hostile situation may alleviate the tension, you are in a position to defuse the situation and redirect the wanderer.
As you approach from the front, you attempt to make eye contact. "Hello Mr N., it looks like you're upset." Mr N. responses angrily, "You bet I'm upset!" Mr N. stops pounding and makes eye contact; he appears tense. You respond, "We don't want you to be upset," speaking slowly and calmly, with a tone of voice that conveys concern. Mr N. is still angry, and states, "They won't let me in here." "Mr N., that's because it's the nurses' station. They can't let you behind the desk; it's against the rules. They're just doing their job; we wouldn't want to get them into trouble."
Continue eye contact with Mr N., touch the back of his hand, which is still on top of the half door. (The use of the pronoun "we" begins to let him see you are not the enemy. The use of touch plays a therapeutic role by decreasing the feeling of aloneness.) "They won't let me leave." Mr N. states. You respond, "This isn't the way out," as you walk through the half door. You now have positioned yourself next to is side holding his arm. You state, "Let's walk." Mr N. begins to follow. "I have to go home; my mother doesn't know where I am," Mr N. states. Let Mr N. know you have heard what he is saying without arguing the point that his parents are deceased. Respond with, "You're worried." Mr N. then nods in agreement. "Yes, I have to go home."
Allow the patient to verbalize without argument. Continue to walk with the patient and show concern for his distress. Let the wanderer do most of the talking and send clues that you are listening (eg, make eye contact, repeat key words).
After you see a decrease in tension, attempt to relieve the wanderer's distress and provide reorientation with a generalized statement. At the same time, give the patient a reason why this isnotagoodtimetoleave. "MrN., you are in the hospital; you came here so that we could help you. Your relatives know you're here, and they would want you to keep the appointment you have tomorrow." (This statement tells him 4'here he is and avoids the argument in regard to his parents' death by using the vague term "relatives." He is reassured that no one is wonying about him.
By reminding him that he chose to come to the hospital and has an appointment set up, he is given a feeling of control.) "It's very nice that you don't want anyone to be worried," is a statement of admiration, which will increase the patient's self-esteem and, therefore, self-confidence. The statement, "I work here and will be here all day," tffers reassurance that a concerned person is nearby.
Gradually direct the walk to the wanderer's mom. "Mr N., this is your room; why don't you make yourself comfortable, and I'll be back as soon as I check on all the other patients." This parting comment continues to reinforce where he is, gives him control, lets him know of your continued concern. "Okay, thank you," states Mr N. as he calmly enters his room with a slight smile.
Restraints versus Benefits of Wandering
It may appear that restraining the wanderer is the ideal answer, but creative control of the wandering behavior actually cuts down on staff time and holds many benefits. There is an increased need for nursing care on a continuous basis when a restraint is used (eg, repositioning, skin care, toileting, hydration needs, additional charting). Dignity is lost with the use of a restraint which can create frustration, irritation, and mental anguish. Sometimes a confused state or disorientation is created. Within a safe environment, wandering can have many benefits. Wandering stimulates circulation, stimulates oxygenation, promotes exercise, and decreases contractures. The increase in exercise reduces stress and promotes a general feeling of freedom that provides dignity.
The following guidelines for creative control of wandering patients can serve to maximize the benefits of wandering behavior.
1. Assess the wanderer (including ambulatory and physiological needs);
2 . Assess the environment and remove hazards or implement changes;
3. Approach the wanderer in a nonthreatening manner;
4. Document all assessments, plans, and implementations; and
5. Evaluate the techniques of creative control.
- 1. Kelly C: Quoting Doris Schwartz, editorial. Geriatric Nursing 1980;1(July-August):2.
- Abrahams JP, Crooks VJ: Geriatric Mental Health. Orlando, Fia, Grune & Stratum, 1984.
- Rader J, Doari J, Schwab M: How to decrease wandering, a form of agenda behavior. Geriatric Nursing 1985; 6(July-August): 196-199.
- Steffi BM: Handbook of Gerontological Nursing. New York, Van Nostrana Reinhold, 1984.
- Whitehead JM: Psychiatric Disorders in Old Age. New York, Springer Publishing Company, Ine, 1974.