Nature Walk: From Aimless Wandering to Purposeful Walking.

Whether residents wander freely with a facility-wide security system in place or the facility maintains a secure unit, wandering behavior remains an ongoing concern for long-term care facilities.

Although Carillon has a secure unit that confines the wandering behavior of its residents, the behavior persists. Residents pace endlessly up and down the hallways despite their fatigue, and have difficulty falling asleep or sleeping through the night. Many of the residents have difficulty sitting long enough to complete meals despite their hunger. Prior to the intervention of this program, 20 residents were identified with a wandering problem that interfered with their ability to eat, sleep, and/or sit/relax (figure 1).

Our interdisciplinary team met repeatedly to discuss the facility's inability to alleviate these residents' self-imposed unrest. The team decided it was time to explore interventions outside the established ones in an effort to find solace for them. The interdisciplinary team met with the psychologist and psychiatrist so that they could better understand the nature of these wandering behaviors.

The interdisciplinary team wanted to implement some interventions that would channel the wandering energy in a positive way. Additionally, the team hoped that the intervention would reduce behaviors that were interfering with the residents' well-being.

The objectives were:

* Eating: 75% (15) of the residents will sit long enough to complete meals.

* Pacing: 75% (15) of the residents will have a decrease in pacing up and down the halls.

* Falling asleep: 75% (15) of the residents will fall asleep within 15 minutes of going to bed at night.

* Remaining asleep: 75% (15) of the residents will remain asleep for the duration of the night.

The team agreed that the residents liked to walk and it would be advantageous to make use of this energy. Since these residents were confined to one area of the building because of their wandering, it seemed propitious to offer them exposure to the "great outdoors" and all that it encompasses. The team members believed that although many of the residents had a diagnosis of dementia or some memory loss, the ability to appreciate nature and remember leaves, snow, flowers and rain would likely trigger memories for them. The team also believed that exposing the residents to warm and cool air would invigorate them and foster a sense of healthfulness.

Once it was decided to pursue a daily "nature walk" with the residents of this unit, the selection process began. The medical director reviewed the medical charts of the residents involved and gave medical clearance for the nature walk.

The nature walk would take place daily at 2 p.m. on the facility grounds and last for 30 minutes. There was no specific distance or speed for the walk. The goal of the walk was to offer the residents the opportunity to experience nature while channeling their energy. Each resident was assigned to a staff person so that one-on-one, hands-on supervision was in place at all times. The walks took place on cold, snowy days, rainy days, cool days and warm days. Appropriate attire was provided by the facility.

Initially, all employees were invited to participate in the walk. Some employees volunteered because it was an opportunity to go outside, while others enjoyed the exercise. Employee participation required approval by department supervisors. Once the participating residents and employees were established, the program began.

Each day at 1:50 p.m., the participating employees congregated on the unit. The charge nurse was responsible for assigning employees to residents. After the employee was assigned his/her resident walking partner, the employee was responsible for dressing the resident in the appropriate weather gear. At 2 p.m., all walkers (employees and their partners) headed outdoors and began the nature walk. Each employee held hands with his/her partner to ensure safety (especially since the walks involved stomping through snow and meandering over uneven terrain such as grass.) A unit nurse always accompanied the nature walkers with a wheelchair in case any resident became fatigued. It was understood that if any resident expressed a desire to return indoors prior to the completion of the 1/2 hour walk, this would be done. All nature walkers were escorted back to their unit at the conclusion of the walk.

The nurses on the unit were responsible for completing a chart designed to measure outcomes of the intervention (figure 2).

The biggest obstacle experienced by the staff was the desire of more residents to participate. Aside from the 20 selected participants, other residents on both the same unit and other units expressed that wish. This was problematic because there were insufficient staff to accompany the residents. The facility decided, therefore, to use feeding assistants as nature walkers in an effort to accommodate more residents.

This program was conceived and developed by the director and assistant director of nursing. In conjunction with the interdisciplinary team and the charge nurse on this unit, suggestions and ideas were batted about and the caregivers, together, worked out the logistics. Specifically, the charge nurse was responsible for developing a list of residents who would most likely benefit from the intervention. She was also responsible for obtaining their medical clearances and was the daily organizer and assignor of employee/resident partnerships. Additionally, the charge nurse was responsible for completing the data sheets illustrated in figure 2.

The interdisciplinary team members were responsible for sharing the purpose of the program with their respective departments and encouraging employees to participate. Employee walkers were themselves responsible for reporting to the unit at 1:45 p.m. to prepare for the walk. CNAs on the unit were responsible for completing an inventory of outer garments for each of their residents so that additional items (gloves, hats, etc.), could be purchased, if necessary, by the director of nursing. The facility absorbed the cost of these items.

This program has been a wonderful success. The residents eagerly look forward to their daily walk. Some of our more reticent residents have become more talkative and some of our more subdued residents have become more animated and full of life. Regardless of the weather conditions, the residents eagerly prepare for their daily outdoor adventure. But aside from the intangible aspects of this wonderful intervention, there have been some significant quantifiable outcomes, as well.

Prior to the inception of the nature walk, 50% (10) of the residents always had difficulty sitting long enough to complete meals. After six months of the "nature walk" experience, only one resident (5%) still had this problem (figure 3). A decrease in pacing up and down the hall was another objective that was achieved. Prior to the "nature walk," seven (35%) of the residents always paced, but only three (15%) always paced following six months in the program (figure 4). The overall impact of the program on residents' sleep habits (both falling asleep and remaining asleep) was tremendous. At the outset of the program, nine (45%) of the residents always had difficulty falling asleep. After six months, none of the residents always had difficulty falling asleep (figure 5). Lastly, before the program's implementation, nine (45%) of the residents always had difficulty sleeping the entire night. Afterwards, only three (15%) continued to always have difficulty sleeping through the entire night (figure 6).

The significant quantifiable results of this program, coupled with the more elusive but tremendously positive emotional responses from the residents, clearly gives credence and validity to this innovative intervention. Residents who wander are frequently anxious, agitated, exhausted and without direction. The "nature walk" serves as a simple, easily implemented program that allows caregivers the opportunity to redirect some of their residents' chaotic energy into a channeled and productive avenue. The opportunity to experience nature and all its sensations is a wonderful one and, as the old adage states, "The best things in life are free."

Program Staff

Joseph Carillo II, Administrator

Gerry Albers, Director of Recreation

Connie Statton, LPN 

Eileen Frederickson, Medical Records

The Unit 1 CNAs

ADDENDA

Recent Developments from The Boston Home

Shortly before publication of the article in the October 2000 issue ("The Boston Home: Growing and Changing With the Times," p. 62), The Boston Home underwent several significant developments that the organization wished to share with readers. These included: planned expansion and renovation of the care facility and designs for independent housing; establishment of a Spasticity Clinic; initiation of mental health services, including neuropsychology; selection as one of 10 nursing homes to pilot an innovative career-ladder program for CNAs; and establishment of a Web site: www.thebostonhome.org.

Price Adjustment

The Vigil[R] Integrated Care Management System can now be installed at a lower price than reported in "The 'Ins and Outs' of Wandering," August 2000, p. 55. Today's prices range from $1,800 to 2,600 per room, and as low as $1,100 per room when integrated with the Vigil Nurse Call.