For this issue of the Geropsychiatry column, we are privileged to feature a guest author, Joanne Rader, a renowned gerontological nurse clinician, researcher, speaker, and author. 1 invited Joanne to contribute to this column following a two-day joint consultation last May on a bathing study currently being conducted in North Carolina under the direction of Dr. Philip Shane and colleagues.
Some readers might initially look at the topic of this column and think, ''Bathing? Why, that's a physical task . . . What does it have to do with Geropsychiatry?" To which my response would be, "Plenty!"
As is pointed out in this column, skillful psychosocial approaches are essential to a positive bathing experience. Moreover, many of the "problem" behaviors (i.e. hitting, biting, spitting, pinching) for which we trancfuilize or otherwise restrain older adults at bath time affects us all. Indeed, for the cognitively impaired resident or the mentally ill older adult, the act of bathing can easily be interpreted as an overt physical or sexual assault to which they are repeatedly subjected by "well-meaning" caregivers, over their bitter objections. Small wonder, then that these residents respond aggressively - or worse, come to internalize feelings ofpowerlessness, hopelessness and lack of control over their lives and environment - all of which can lead to depression and despair.
Thus, I hope after reading this column you will agree with me that bathing does indeed have significant psychosocial ramifications, and is an issue all nurses who care for the elderly must address. I hope, too, that readers will accept Joanne's invitation to respond to the ideas set forth in this column, and that this journal can serve as a forum for dialogue and debate about the best possible function, form and frequency of even the most mundane, but potentially high impact, activities such as bathing.
Kathleen C. Buckwalter, PhD
1 recently completed the intervention phase of a study designed to explore ways of decreasing aggressive behavior during the bathing of nursing home residents with dementia. I worked with nursing assistants and aggressive residents during the study to eliminate or decrease the physical and verbal aggression of the residents and create a more pleasant bathing experience for all. Although we have not yet analyzed our data and therefore are not ready to report our findings, I made some clinical observations that I would like to share with my colleagues. My experience raises the question, "Is it really necessary to bathe distressed residents as we have in the past?"
The current standard of care is that most, if not all, nursing home residents are bathed in the shower or tub on routine assigned days. There are many ways to make a bath or shower more pleasant and less stressful, thus decreasing aggressive behaviors. Certainly psychosocial skills are critical. However, if the nursing assistant can use her skills only within the context of the rule that all residents must be bathed on an assigned day, in one of two ways - the shower or tub - we are severely limiting options and the ability to individualize care.
During our study, I participated in and observed many baths and showers. In most cases we were able to decrease aggression by altering psychosocial approaches or time of day, using a more comfortable shower chair or asking whether the shower or tub was preferable. I found myself thinking, "She didn't strike or spit today, she only swore. That's pretty good." Certainly that was progress, but I began to feel it was not enough. For a few individuals it was clear that no matter how or when we approached them, bathing was an unpleasant, distressing experience.
It struck me that from the perspective of a person with apraxia, agnosia, aphasia, and limited insight the standard nursing home bathing experience may be perceived as a physical assault. A person the resident does not recognize comes into her room, wakens her, says something she does not understand, drags her out of bed, and takes off her clothes. Then the resident is moved down a public corridor on something that resembles a toilet seat, covered only with a thin sheet so that her private parts are exposed to the breeze. Calls for help are ignored or greeted with, "Good morning." Then she is taken to a strange, cold room that looks like a car wash, the sheet is ripped off, and she is sprayed in the face with cold and then scalding water. Continued calls for help go unheeded. Her most private parts are touched by a stranger. In another context this would be assault. Yet it remains the standard of care in many settings.
I came to see the resident's behavior as a protective response to a perceived threat. What the person's aggressive behavior is really saying is, "I can no longer tolerate the way you are trying to keep me clean. Please find a better way to do it. I don't know how to change it, and I am depending on you to figure it out." This is our call to challenge the status quo.
All that we've learned about communicating with the person with dementia applies in the bathing situation. Staff must be skilled in verbal and nonverbal communication. In addition, they must be able to "read the resident" - that is, interpret both verbal and nonverbal behavior, sometimes on a minute by minute basis, to determine if the resident is able to tolerate a particular bathing procedure. When staff are skillful in this and adjust their own behavior, most aggressive resident behaviors during bathing can be avoided.
More details on this will be available when we analyze the data from our study. In addition, there are other studies now being done that will identify specific helpful staff behaviors (Sloane, Barrick & Dwyer personal conversation, May 12 1994).
It is important to ask what is the function of this bath or shower? Is it necessary at this time? The functions of bathing are for health, social reasons, and pleasure. Health reasons are related to skin, scalp, infection control, and possibly range of motion. Social reasons are related to odor and appearance. Does the person look and smell clean? Is her appearance pleasing to her and to others? Pleasure refers to the fact that many people bathe for warmth, relaxation, stimulation or positive sensory input. If the person does not enjoy the shower or tub and attempts to improve enjoyment fail, then a person should not be forced to bathe unless there is some compelling health reason. The staffs sense of responsibility, need to complete tasks or desire to have a resident "look good," if that is not important to the individual, are not compelling reasons. I can think of few situations in which health concerns would be so overwhelming that they justify forcing a person to bathe. Being covered from head to foot with diarrhea may qualify. However, less invasive or distressing methods might also be employed to remedy that situation.
Form of Bothing
There are many ways of maintaining adequate health and hygiene without forcing someone to take a shower or tub bath. The use of a towel bedbath, in which the person is covered from head to foot with a warm moist towel, is a marvelous alternative (Wright, L., 1990). Sponge baths at the sink are another option. Hair can be washed in bed by the beautician, using a comfortable, inflatable basin, or a dry shampoo can be used for touch-ups. Once staff move away from seeing the shower and tub as the only options, many other possibilities emerge.
How often is it necessary for someone to wash or be washed? How often does the individual desire to bathe? As we develop an individualized approach, taking into account function and form, it seems obvious that we must move away from standard bath days. Some residents may require or desire more frequent bathing and some less. Some may opt to forego the shower or tub completely and rely on sponge baths and towel baths. I am acutely aware of the tremendous time constraints of nursing assistants. Flexibility in bathing, however, would not create more demand for staff time, but equal or perhaps less.
When I first presented these thoughts to a group of long-term care nurses, I asked if they made sense, were practical or seemed radical. One nurse responded, "They make sense, are practical and are also radical!" I am interested in knowing what others think. Looking at bathing in a new way may offer staff opportunities to put creativity, common sense and kindness back into this area of care.
- Wright, L. Bathing by towel. Nursing Times 1990; 86(4)36-39.