Flex bathing for all
A more spa-like environment can make bathing less traumatic for residents with dementia.
Most long-term care nursing assistants would agree that giving residents baths or showers is one of the most difficult aspects of caregiving. It also can be tough on residents, particularly those with dementia — who may become combative during the bathing process — as well as those who are obese, inflexible or fragile, who might find the whole experience exhausting.
But it doesn't have to be that way, says Margaret Calkins, Ph.D., president of I.D.E.A.S. [Innovative Designs in Environments for an Aging Society] Inc., a research, education and consulting organization based in Kirtland, OH. By designing bathrooms that are adaptable enough to serve differing residents through the years, and by putting more of the decision-making about the experience in individual residents' hands, bathing can be enjoyable for everyone, she says.
“There has been a fair amount of evidence showing that if you have the right approach with the right environmental support, it can be a very pleasing experience — easier for the staff and more comfortable for the residents,” Calkins says.
Selecting a system
It is often difficult for facilities to foresee all the possible challenges in resident bathing they may encounter long term, says Mark Godfrey, vice president of business development at Apollo Corporation. Therefore, it's important to select a bathing system with a high degree of flexibility to give the facility the agility to respond to changing needs.
For instance, if residents are fairly self-sufficient, administrators may want to consider barrier-free showers that will help maintain independence. These showers offer accessible features such as low threshold heights for wheelchair access and easy step-in, increased clearances, accessible control locations, grab bars and folding seats.
“These en-suite showers generally provide more open floor space in the bathroom for maneuverability, which can be very helpful to residents who use a walker or wheelchair or who need a lift transfer device,” Calkins says. “Having that extra floor space also makes using the rest of the bathroom — the toilet and the sink — much easier.”
As residents become more dependent on others for their care, products such as side- or front-entry or height-adjustable bathtubs might be more practical. These systems allow for easier tub entry for residents, and the height-adjustable models can be raised and lowered to place the tub at a comfortable height for caregivers. Many of these systems also offer other features that make bathing safer, more efficient and more comfortable for residents, including whirlpool or hydrotherapy options, integrated disinfecting systems to help with infection control, electronic water temperature control and handheld shower wands.
Many manufacturers also offer lift systems designed specifically for these tubs, making transfers easier and safer for both resident and caregiver, Godfrey points out. Modular options allow for a standard bath system to be used throughout a facility but with varying configurations to cost effectively meet the range of resident needs through a long-term care campus.
“It also allows for uniform maintenance and service training and a single system for the caregiver staff to learn to safely operate,” Godfrey says. Upgradable modules then let a facility make relatively inexpensive renovations as resident mix changes, he adds.
He also recommends that facilities invest in a bathing trolley, which serves both to transport residents to the bathing area and as a surface to support a resident's body in a reclined position during showering.
When it comes to flooring, safety and “cleanability” should be top of mind, Godfrey emphasizes. It must be slip-resistant, easy to maintain and have the ability to support wheelchairs, transfer systems and lifts.
“Other considerations include its resistance to absorption from water and incontinence and mold and mildew resistance,” he adds.
Beyond the varied equipment options related to bathing, administrators also should give some thought to the bathing environment itself, says Lee Penner, president of Penner Patient Care Systems. Many traditional tub rooms, for example, are dreary, sterile and uninviting, and can often seem intimating to residents with dementia.
“The facilities that are thinking more long term are really taking a look at the ‘eye appeal' of their bathing areas, and the type of impression that the space leaves with potential residents and their families,” Penner says. “An aesthetically appealing design in which the bathing system looks like it really belongs in the room can transform the bathing area into a marketing tool.”
One of the best ways to assess a bathing area's ‘eye appeal' is to take a photo of it, Calkins says.
“When you take a picture of something, it puts it in a two-dimensional separateness that allows you to ask yourself and others if the space looks like a place of comfort or if it looks more like a torture chamber with lots of very unfamiliar equipment,” she explains.
In an effort to improve residents' bathing experiences, Calkins recommends that facilities try to create a more spa-like environment by installing soft lighting, painting the walls a warm color, and using calming music, aromatherapy and appealing artwork. Some bathtubs even come equipped with televisions and DVD players to help residents relax while watching a favorite TV show or movie.
During the bathing process it's also important to make sure that residents are able to stay warm, she says, particularly when using a handheld shower wand.
“The part of the body that's wet but isn't in the water gets chilly very quickly, so caregivers should do their best to use warm towels while bathing residents and only uncover to the air an arm or leg at a time,” she says.
Using a radiant heat panel or heat lamp in the bathing area — even if the overall temperature in the room is already warm —also may keep the resident more comfortable.
“Some older adults are so sensitive to chills that even if the room is 85 degrees, just having their skin exposed for a few seconds can really affect them,” Calkins points out.
When the bathing experience is unpleasant — or worse yet, traumatic — for residents, particularly those with dementia, they may be upset for hours. This eats up staff time spent trying to calm them and likely is upsetting other residents in the process, says Joanne Rader, RN, MN, PMHNP, who has worked in long-term care for 35 years and authored the book “Bathing Without a Battle.”
“A lot of people jump straight to making changes in a bathroom's physical environment, but they don't make the organizational changes that allow staff to deviate from a twice-a-week bathing schedule, in an effort to promote choice and comfort,” Rader says.
First and foremost, she adds, any decision-making about how (bath or shower), when (morning or evening) and how often people get clean should be made at the bedside between caregiver and resident.
It's also important to make sure residents understand they are about to be bathed or showered, Calkins notes. Caregivers can do this by carrying a washcloth and towel when they approach the resident, using visual cue cards with a picture of a bath or shower on it or even taking the residents into the tub or shower area to let them see it.
“It's important not to rush the process so the resident isn't approaching the experience from a state of anxiety,” Calkins says. During a bath or shower, she also recommends giving the resident the sponge or washcloth and having them do some of the cleaning themselves, as opposed to making it seem like a “car wash,” with the goal being to complete the task as quickly as possible.
“If staff goes into it with that approach, they're bound to have residents who rebel by lashing out, kicking or biting, and that's not a fun scenario for anyone,” she says.
Administrators also might consider installing an adjustable- height shampoo bowl in a larger bathing area, to allow residents with limited mobility to have their hair shampooed more easily, says Dave Shusterich, president of Accessible Systems. It's particularly helpful for residents who don't have the ability or desire to bathe on a regular basis and just need to have their hair washed, he says.
For a resident who really cannot tolerate the bathing process, it may be best opt for rinse-free soap alternatives such as disposable cloths that can be heated in the microwave and used to wipe a resident down without having to undress them or get them out of bed. There are also rinse-free soap concentrates and foams that can be used with regular washcloths.
What's most important, Calkins says, is figuring out what makes the experience as agreeable as possible for the resident and honoring his or her wishes in a way that facilitates good health and hygiene.
“It's really about expanding our understanding of what the goal is,” Calkins says. “If the goal is being clean, managing skin integrity and managing body odor, there are lots of ways of doing that that don't require a bath or a shower.”