The purpose of this article is to provide perspectives on the bathing of the elder adult from nurses inside and outside the U.S. The author is a U.S. citizen by birth, and travels often to consult with nurses of western European countries. But the perspectives represented in this article are not only the author's. He has collected nursing vignettes on bathing from Italian, Dutch, Finnish, and Swiss colleagues to provide the reader with national and international themes on bathing. Thus, colleagues provided stories of a bath that they gave an elder adult in response to the following questions or directions:
*Describe a bath that you have provided an elder person.
*What were the environmental conditions of the bath (e.g., what materials and controls did you bring to the bath)?
*How did you nurse the individual through providing the bath?
*Please add comments about your own culture as you describe the bath.
Dutch, Italian, and Finnish colleagues provided vignettes of a bath. The representative of Swiss nursing is the text of basic nursing care used in most German Swiss schools of nursing
A BATH IS MORE THAN CLEANING: A DUTCH PERSPECTIVE
Bathing serves many functions, according to one Dutch colleague (Baartmans, Paul C, personal communication, 1996). It must be distinguished from a shower, because a bath requires human touch and a shower might not. Thus, the environment of the bath is set by the nurse with respect to the intent to touch.
Bathing is not just a way of cleaning someone, of washing someone in a great tub of water. When cleaning was (believed to be) the only function, bath tubs were removed from nursing homes and replaced by showers a long time ago.
Bath and touch became dissociated according to utilitarian purposes, and the architecture of Dutch nursing homes was changed to suit the belief that the bath was nothing more than an exercise in cleaning. Thus, showers replaced bathtubs at some point in the past. However, the change in architecture did not mean that nurses stopped bathing their clients. Rather, it meant that the occasion of the bath was rendered more difficult or inopportune.
Central to the association of bath to touch is the question that the Dutch colleague poses to the elder client: Do you wish to have a bath today? The question implies the understanding that the client consents to be touched by the nurse who poses the question. "Not everyone wants to receive a bath," according to this nurse. So gaining consent is the first and most important element to the nursing exchange.
After gaining consent, the nurse inquires into the preferences of the client regarding water temperature, soaps, shampoos, emollients, and personal tools such as combs and towels. The nurse refers to learning the client's preferences as "adapting the stage" to the bath. It was a curious turn of phrase, "adapting the stage," so I inquired further into its meaning. His explanation drew upon the analogy of the bath to a theater production, with the personal preferences serving as the props of the stage. His work as nurse was to "adapt' the props to the preferences of the client.
If one may extend the license of the stage analogy a bit further, then it is possible to introduce the comparison of this Dutch nurse with a stage hand or lighting expert in view of the bath that was to come. He prepares the water and introduces nice aromas into the room where the bath will occur. "Smells" that are "nice" are essential to the occasion, and must be prepared prior to the start of the bath.
The nurse describes efforts to "introduce" the client to the water of the bath. Elements of the introduction to water include: testing the water for temperature, holding the client to add security, and bringing small talk to the occasion - all in an effort to reduce anxiety and make the bath a pleasant experience. The nurse reflects on his posture and speech during the introduction to the water.
The first minutes of the bath I always start talking about unimportant things. For me this moment is very important. I try to keep the volume of my voice low, to speak quietly and to communicate to the client that I have time. In my opinion, these moments of peace and quiet are very important to both of us. It also gives me the opportunity to concentrate on the person of the client.
He is conscious of the occasion as his opportunity to establish a deeper relationship, one that might not be were the bath not to take place. Lowering the volume of the voice and establishing a peaceful setting enhance the nurse's real goal, which is to form a relationship. He continues:
These moments are very effective in building a relationship with the client. They have something very private in them. The themes that come up in the conversation soon become very personal. There are no clothes to hide the being. The body and its development, the experiences of a lifetime, and all time and no time all come together in this moment. So, you see, the cleaning is not my real goal, although I will accomplish that, too.
There is a profound world view of the being of person in the vignette of this Dutch nurse. The bath is an opportunity to reflect on being, which is to say that the nurse uses the occasion of the bath to enter the door of the soul. The nurse orchestrates the environment to create the right stage for his intended work, all the while gaining the client's consent for the journey into soul that is to come in the bath.
FAMIUES, THE CITY, AND EDUCATION: AN ITAUAN PERSPECTIVE
The bath in Italy is a family affair, according to one Italian nurse (Paola Stowell-McClure, personal communication, 1996). She states that "...nurses and patients are like family." She explains that being like family is the framework for the bath, which means that her Italian patients view the nurse as an extension of family. But the patient's view is no accident, as nurses create an atmosphere of familial understanding and culture within health care institutions. Thus, nurses observe family rituals and beliefs when families visit the hospital or nursing home. Their observations, in turn, create alterations in nursing actions associated with bathing. Special oils, personal items, the timing of the bath, and related issues will vary according to the nurse's observations of the family in contact with the patient.
Particularly interesting in the reflections of the Italian nurse was her association of the bath in the hospital or nursing home with the communal baths of ancient Rome:
In the bathtub the elder patient mobilized joints that were too stiff to mobilize outside of water. The nurse stayed near the patient to wash his back and feet as well as talk to and teach the patient while he was relaxed and refreshed. This goes back to the tradition of bathing in ancient Rome, which was one of communal bathing as a place for communication and learning.
Exploring the association that the nurse made to ancient Rome, I asked her about subjects that she discussed with her patient. Politics often entered the discussion, she said, noting that everyone wanted to talk about the state of affairs not only in Italy but also across the globe. Just as often, however, the patients wanted to talk about their families, such as where their children were located, how often they were in contact with friends and family, and what they planned to do with family members during upcoming holidays. In fact, the nurse continued, the bath was the occasion for the patient to "feel right" with the world, as the soothing experience of the bath became connected with the family, the city, and world.
The Italian nurse, whose story appears in this vignette, presents a southern European picture of the bath. The nurse becomes a member of family in the sense that the family is much larger than a nuclear unit or even an extended family unit. Rather, the family is a composite of members of the city, which uses the bath as the occasion for education, socialization, and feeling right about one's personal place in the grander scheme of family.
SEASONS OF THE YEAR IN SAUNA AND TUB: A FINNISH PERSPECTIVE
Finns adapt their bathing patterns to the seasons of the year (Terttu Pohjolainen, personal communication, 1996). From September through May, they bathe less due to the inchmate weather and the belief that cold symptoms occur due to exposure to cold temperatures after bath or sauna. Many houses and apartment buildings contain saunas and communal tubs where household members share them. Apartment dwellers rotate through sauna or communal bath up to twice weekly.
There are special events connected with the sauna according to the season of the year. For example, there are special sauna events at Christmas and in the middle of summer. Each of these events carries its own name, such as Christmassauna. Seasonal saunas provide a "special feeling" to the elder person, and draw upon memories of families and friends with whom the event may have been shared in years past.
Most facilities for the elderly are equipped with sauna, showers, and communal baths. However, many of the newer facilities provide sauna and shower only, because the elderly have trouble entering and exiting the bathtub. Whether the facility is old or new, the typical pattern for the elderly is to shower first, followed by bathing and then, entering the sauna.
The shower that the Finnish nurse provides the elderly person involves the use of shampoo for the hair and bar soap or liquid soap for the "armpits" and more "intimate places" of the body. After completion of the shower, the elderly person enters the communal pool, which is never deeper than the chest or shoulders. But the individual is able to walk through the water, talk with others present in the pool, and relax prior to entering the sauna. Men and women may be present in the bathing pool at the same time, and there is little compunction associated with the clothing. The nurse states, "We go naturally without clothes."
Clothing is also not required in the sauna, lime spent in the sauna lasts approximately ten to fifteen minutes, which consists of sitting or lying on benches inside. "If you want to have a really good sauna, you must have birches." Birch branches are used to strike oneself, which further heightens the sensual pleasure of the experience. The nurse states that the result is best when one works up a good sweat, and birch draws out the sweat.
The sauna is followed by another walk through the bathing pool, and concludes with quiet time in a chair while wrapped in warm, big towels. At the end of the quiet time, the elder drinks something provided by the nurse, and they talk about social things or the elder person's state of health. The nurse and the patient discuss that which is most important, whatever that is, because of the cultural belief that it is easier to speak about things that are important while in the sauna. Therefore, this belief of what to say and the importance of it is carried into the nurse-patient dialogue.
The nurse provides a picture of the bath that is connected with the rituals of bathing within the Finnish culture. Decisions and conversations made in the sauna reflect the essence of what it means to be a person within Finnish society. The communality of the experience is not entirely different from the Italian perspective. Yet the emphasis on nature and the seasons of the year is a significant difference from Italy.
The elder person engages in the stages of the bath, even as learned and practiced by every Finn. Therefore, to feel well or to regain health from illness necessitates the ritual of the shower, the bath, and the sauna. Such rituals connect persons one to another, as evidenced by the central placement of the sauna in most elder apartments and assisted living facilities in Finland.
THE ONE WHO BATHES ANOTHER CANNOT FORGET SELF: A SWISS PERSPECTIVE
The Swiss perspective presented here comes by way of a standard nursing text used in most Swiss schools of nursing. It has been the standard introductory text of professional nursing for the past 20 years, and may, therefore, be said to be the formation for nurses in their education about bathing the elder client.
The introduction for the chapter entitled, "Sich waschen und kleiden" (Bathing and clothing others), shows a photograph of three women dressed in white bathing an elder woman. The caption for the photo reads: Wer andere pflegt, darf sich selbst nicht vergessen (Who cares for another, may not forget [him/herl self.)
Three principles guide the text's author (Juchli, 1991) in her discussion of the bath. The first principle is the statement that the care of the skin is an expression (Ausdruck) of an inner spiritual position (Haltung). The second is the principle that the bath serves the maintenance of the structure and function of the skin. The third is the principle that the language of the body (Koerpersprache) is associated with one's social group, social status, and normative patterns of society and culture. Thus, in the care of the skin during a bath, the nurse must be attuned to observe the language of the body, which includes gestures, facial expressions, and positioning of the eyes, as well as any and all non-verbal clues.
In reference to the elder adult, Juchli applies the principles of bathing and clothing to her perceptions of elder adults. She states that the elder adult may no longer experience concern for dirt on clothing or the condition of the teeth. While not directly linking such changes in attitude to her first principle about the spiritual position of the elder adult, one cannot help but reflect on the role of the spirit in the care of skin and the work that nurses perform in bathing others.
In particular, Juchli emphasizes self-care and attention to the self in the goals that nurses set when deciding how and when to bathe their clients. Moreover, attention to the self was represented in the photograph of the elder woman that she placed at the start of the chapter. Thus, she relates the self to the inner spiritual position of the elder client. It is the nurse's goal, then, to keep conscious of her own self, and thereby to assist the elder client to restore or maintain consciousness of self with the goal of rendering self-care.
I have been associated with Swiss nurses for more than five years, and have taught in schools of advanced nursing education in Switzerland for the past two years, having spent an entire year on the staff of one of them and returning later to provide supplemental courses. The self-care deficit theory of nursing associated with Dorothea Orem (1995) figured prominently in many of my discussions with Swiss nurses and, to this day, remains of great interest to nurses practicing in hospitals in the German sectors of the country. Thus, Juchli's interest in self is not only a reflection of German Swiss beliefs in the primacy of privacy and selfreliance but also a reflection of what nurses think about during the bathing of their clients. To care for another leads one to recall the self.
This article has provided several glimpses into bathing from the perspectives of Dutch, Italian, Finnish, and Swiss nurses. It has provided material for researchers to use in designing questions concerning international differences and similarities in bathing practices. The perspectives must not be read as general reflections of nurses who practice in the countries from which the nurses come. Rather, they are unique to these nurses and may reflect, however well, the cultures and societies in which they are embedded.
You may be interested in giving a bath differently to Dutch, Italian, or German Swiss elder adults after reading the perspectives of the nurses here. The article may also spark further inquiry into the bathing practices of other cultures, particularly those outside the western European realm.
- Juchli, L. (1991). Krankenpflege: Praxis und théorie der Gesundheitsfoerderung und Pflege Kranker (6th ed.). Stuttgart, Germany: Georg Thieme Verlag.
- Crem, D.E. (1995). Nursing: Concepts of practice (5th ed.). St. Louis, MO: C.V. Mosby.