Rough waters: rethinking bathing in long-term care
Resident bathing has long been a source of angst and frustration for caregivers and residents alike.
In fact, bathing has historically and consistently ranked at the top of nursing assistants’ least-favorite lists. In many cases, caregivers are assigned the task with the understanding it must be completed by the end of their shift. Impeding that goal, however, may be a resident who is averse to a bath or shower that day or prefers it at a different time than scheduled (or, perhaps, even by a different caregiver).
It’s an all too common scenario that creates anxiety and conflict – a tug-of-war of sorts where caregiver and resident are fighting to stand their ground. Only in this case, no one wins.
“Many times, the resident and caregiver become pawns in the machinery that cranks out tasks. When bathing, or any other [caregiver-assisted activity] is viewed as a task that must fit into a set schedule and checked off a list, the resident’s own needs get lost,” stressed renowned bathing expert Joanne Rader, RN, MN, FAAN, independent consultant and author of the book “Bathing Without a Battle.”
“People are working with the kindest of hearts and best intentions, but they just get used to doing things the same old way, even if what they’re doing clearly isn’t working.”
Yet some providers have broken through to success.
Focus on flexibility
Experts agree that an individualized, resident-directed approach is the key to a pleasant bathing experience. Although, by definition, such an approach will vary from resident to resident, it’s the willingness to abandon rigid rules that drives success.
It certainly worked for Baltimore’s Levindale Hebrew Geriatric Center and Hospital. The Eden Alternative facility – with 172 nursing home beds, 20-subacute beds and a 26-bed dementia care unit – strives to provide care based upon each resident’s needs instead of trying to fit them into the organization’s schedule. The process starts upon admission.
“Resident-centered care means we put the needs of residents first, and when it comes to bathing, that’s a big deal,” said Heather Allen, Levindale’s Hall Two neighborhood leader and director of desk relations. “We look at the resident’s previous routine. Did they prefer a shower to a tub? How often did they bathe and when did they like to shower or take a bath at home? It’s about working with their schedules, not ours.” 
Even then, staff must recognize that resident needs and preferences can change dramatically from day to day, or even hour to hour. For that reason, it’s important that the organizational structure allows decision making to occur between caregiver and resident at the bedside, according to Rader. 
“Caregivers need to have the skill set in place on how they can alter the bathing experience to meet that resident’s needs at that time,” she said, adding that the more bathing options staff can give the resident the better.
“It may be a shower instead of a bath, it may be a towel bath at the bedside, or it may mean no bath at all that day. It’s essential to empower the caregiver and the resident to make the decision that makes the most sense in that moment.” 
Without that type of structure in place, caregivers and residents face an uphill battle. Oftentimes, when nursing assistants find themselves in an environment where they must force a resident to bathe, they either quit the job or harden their hearts – neither of which is good for the resident, stressed Rader.
Scratch the sacred cows
Overcoming longstanding bathing-related misconceptions is also important, beginning with the notion that residents must be washed at least twice a week in either a bath or shower. Although that frequency may be standard practice, some believe it’s a sacred cow that should be sent to pasture.
“The standard should be what the resident asks for, and if the resident can’t tell you, then it’s a discussion that needs to take place with the family. For some residents it could be daily, and for others it might be every two weeks,” explained Susan Misiorski, director of organizational culture change initiatives for PHI, a Bronx, NY-based organization that aims to improve long-term care residents’ quality of life by strengthening the direct-care workforce. 
Evidence-based research confirms that residents who are towel-bathed just once a week using a mild, no-rinse cleanser actually have healthier skin than those who shower with regular soap. Rader, who conducted the research, said the skin culture study wasn’t intended to limit the frequency of bathing, but rather demonstrate that more infrequent, non-traditional bathing does not negatively impact skin health.
“If a resident loves taking a bath or shower, then, by all means, find a way to accommodate them and make it a pleasant experience. If a bedside towel bath is what they prefer, though, then facilities need to let go of the idea that this isn’t going to be adequate,” she explained. 
Staff rotation is another common practice that can sink a successful bathing experience. Part of Levindale Hebrew Geriatric Center’s approach to resident-centered care involves not switching assignments. The idea, Allen said, is to foster enduring, trusting relationships between caregivers and residents.
It’s an effective strategy that both Rader and Misiorski routinely teach.
“There are a lot of people who defend staff rotation. They tell me they rotate staff to keep caregivers from getting burned out or overburdened, but they haven’t considered that there are more effective means of mitigating those concerns,” Rader said.
Misiorski said facilities may want to reconsider allowing temporary agency staff to assist with bathing, as well as having designated “bath aides” who lack a consistent schedule. She recalled one resident who spoke about how violated she felt, having to disrobe in front of a person she didn’t know. “[This particular resident] mentioned how some staff didn’t even introduce themselves. Put yourself in the place of the resident and ask yourself how you’d feel in the same situation.”

Make a splash
Aesthetics can also make or break a positive bathing experience. After all, a sterile, stark and cold bathing facility is anything but welcoming for residents and caregivers.
ACTS Retirement-Life Communities Inc., West Point, PA, is undergoing a culture change initiative in some of its communities’ special care units to revamp the bathing areas. The first part of the initiative involves meeting with nursing assistants to determine how to make the “spas” less institutional and more inviting. From there, the assistants solicit input from the residents, allowing both caregivers and residents to take ownership of the process. 
In one community, the residents requested an aquatic theme. The assistants purchased framed photos, colorful wallpaper border, plush colored towels and rugs, plants, a beach-inspired wicker chair, and other spa-like touches.
Also, high-glare fluorescent lights were replaced with warmer ones and the lifts and chairs once stored in plain sight were either relocated or discreetly tucked away in a designated area when not in use.