Making a big splash

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Making a big splash
Making a big splash
Even the most experienced nursing assistants rank resident bathing among their most challenging, time-consuming tasks. It's no wonder. Some residents consistently put up a fight at bath time, while others require laborious transfers and full assistance, which subtract minutes from an already hectic workday.

  Even if a resident is receptive and requires minimal assistance, the process still calls for caregiver patience and a commitment to building the bathing process around the resident's needs and preferences, as opposed to how much time is on the clock. The bottom line, experts said, is that without an effective bathing strategy, caregivers likely will see frustration levels and risks rise. And valuable minutes slip down the drain.

“Bathing is a challenge every day," admits Stephanie Bushia, a geriatric nursing assistant for Levindale Hebrew Geriatric Center in Baltimore. "You have to have a plan, and that plan will not necessarily be the same for every [resident]."

Scheduling for success
While there's no hard and fast rule on how many baths or showers a caregiver is typically assigned each shift — or even how long it should take to bathe each resident — some experts contend that the best care occurs when quotas and time limits aren't strictly imposed.

"Experience has shown that some facilities do have a quota, and those numbers are sometimes difficult to attain," notes Peace Oke, assistant director of nursing for Renaissance Gardens at Riderwood in Silver Spring, MD. Ideally, a schedule should keep the number of showers assigned to a nursing aide to just two or three per shift. This might mean showers will be spread across seven days.

Fewer residents on the daily bathing schedule makes it easier for caregivers to implement a personalized bathing approach. While some residents may be bathed in as few as 15 minutes, 30 minutes or longer is common.

"Bathing for individual residents will vary significantly, depending on whether the resident is [visually impaired] or the individual has missing limbs or pain, or cognitive decline — all of which will impact the type of adaptive or assistive device or equipment used," Oke reasons. She adds that even if assistive devices are readily available, a bath/transfer might take upward of 45 minutes for certain residents.

As part of the safety culture at Renaissance Gardens, residents are encouraged to wear protective devices, and are prescribed assistive devices as needed.

Strategic planning has helped some facilities streamline the bathing process, while underscoring their commitment to resident-centric care. At Park Valley Inn Health Center, a skilled nursing and rehabilitation facility in Round Rock, TX, certified nursing assistants begin each shift by reviewing the shower schedule. From there, they build their day around the times these residents need to shower.

"The CNA makes adjustments about who to shower first by seeing if anyone has an outside appointment that day and figuring out which residents will be more difficult to shower and may take longer," says Darcel Goeloe, ADON, Park Valley Inn Health Center.

Some caregivers prefer to bathe more challenging residents first, while others save them for last. Bushia, who works the day shift and gives three showers per day in one of Levindale's 14-resident households, prefers to start with the most difficult resident: “I like doing it that way because I know they will take the most time.”

Bushia even changed her shift to accommodate her most challenging resident. Although she was originally scheduled from 7 a.m. to 3:30 p.m., she found that coming in a half hour early to bathe that resident keeps her day on track.

Deborah Wilkerson, another Levindale geriatric nursing assistant who works in the community's main skilled nursing facility, typically bathes eight or nine residents each shift and saves the most challenging residents for last.

Although most of the residents she bathes require “significant assistance,” the 30-year GNA veteran manages to safely and efficiently bathe each in an average of 25 minutes or less. She largely credits her success and efficiency to effective communication and proactive planning.

“I first introduce myself and tell them what we're planning to do with them that day. If they're due for a bath or shower, I let them know and then ask them when they might prefer to do it,” Wilkerson explains. “We let them tell us when they're ready. We never force it.”

Sources agree that this resident-centric approach drives resident and staff satisfaction, and makes bathing more pleasant and efficient. If a resident isn't interested in a bath, sources recommend coming back at a later time to gauge their interest — even if this means reworking the day's schedule.

Sometimes, another caregiver's face and voice is all that's needed to put the process back on track. “We have four permanent GNAs, so if one of us isn't having success, we can see if someone else will,” adds Glanisha Hamm, a GNA who works the 3 to 11 p.m. shift at Levindale.

If a unit is busier than normal and census is particularly high, Park Valley Inn adds shower aides to the staff so nursing aides can focus on other aspects of care.

“Shower aides' sole function is to give residents showers or baths,” notes Goeloe.

Recognizing that a traditional bath or shower isn't going to happen for some residents is also paramount for satisfying residents and keeping bottlenecks out of the bathing process, she explains.

“Some residents may prefer a total bed bath in place of a shower and this is written as part of their care plan,” she says.

Equipment aids process

Because many residents require significant assistance before, during and after a bath or shower, the availability of lifts and transfer devices, and easy-access showers and bathing units can go a long way toward streamlining the process.

When transfers are needed, floor or ceiling lifts with mesh slings that can be easily donned and doffed while the resident is in the seated position is a wise investment, says Candy Wolff, marketing and business development manager for MedCare Lifts. “Having extra mesh slings in the tub room to avoid time loss looking for a new one” is also prudent, as is designating a sling. And because every bathing room is different and poses different challenges, practicing transfers in and out of the tub as part of regular staff training helps promote safety and efficiency, Wolff says.

Many Levindale residents require assistive transfer devices, such as a sit-to-stand lift or Hoyer lift, which may require two caregivers, so GNAs line up help well in advance for a particular time. If the bath is postponed, the GNA promptly informs the other caregiver, so they can work on determining a better time that works for both the resident and staff.

“That way, we don't find ourselves waiting for help or trying to track someone down at the last minute,” Wilkerson observes.

Bathing units with built-in transfer devices can be another time-saver, plus minimize risks to residents and staff, adds Lee Penner, owner of Penner Manufacturing.

Side-entry, walk-in tubs also simplify the transfer and bathing process while helping residents feel more at ease. Units with auto-fill functions and water reservoirs that keep water warm and ready for the next resident can further shave valuable minutes off each bath, Penner notes.

Integrated television and DVD screens can simplify bathing by keeping residents distracted.

“This is all part of making the bathing areas more comfortable and homelike, and less institutional,” he says. “When you do that, bathing can become something that residents look forward to.”

Ceiling lifts also can significantly reduce transfer and overall bathing times, Wolff adds.

Showers with low-threshold entries add to efficiencies and safety, too.

“This allows caregivers to get the chair right in the shower, without having to lift [the resident] over and in,” stresses Stacy Zar, spokeswoman for Aquatic Bath.

Oke advises against giving baths before breakfast, especially on skilled floors where residents have occupational and physical therapy scheduled in the morning.

“It is absolutely O.K. to bathe residents after lunch,” she adds.

Levindale always has towels, washcloths, sheets and clean clothing waiting in the bathing area before the resident enters the room. Bathing supplies are also supplied ahead of time and kept in close proximity.

“The more you can do ahead of time, and the more you can eliminate searching for an item, the easier it is for us and the resident,” assures Hamm.

Slow but steady

While most caregivers welcome time-saving bathing tips, sources agree that speed should never trump quality and safety. In fact, rushing the process could mean overlooking more important aspects of resident care.

“Giving a shower or bath does not only consist of washing,” says Oke. “The CNA looks closely at the resident's skin and immediately reports to the nurse any unusual skin findings, such a bruises, tears or rashes. The CNA is the frontline person for catching or preventing potential skin issues.”