Journal of Gerontological Nursing

Interdisciplinary Care 

Bathing: Pleasure or Pain?

Joshua C Dunn; Brenda Thiru-Chelvam, RN; Charles H M Beck, PhD

Abstract

Nontraditional methods of bathing may prove less agitating for individuals with dementia. This study examines a modified Thermal bath option.

Abstract

Nontraditional methods of bathing may prove less agitating for individuals with dementia. This study examines a modified Thermal bath option.

Bathing and nursing have gone together since the time of Florence Nightingale. In fact, in 1859 in her "Notes on Nursing" (Nightingale, 1969), Nightingale described how to bathe in terms that incorporated the therapeutic effect of the bath, as well as its purpose to cleanse the body. This was forwardthinking at a time when layers of dirt were considered good insulation.

In the early 20th century, nurses learned every type of bathing in vogue at the time - full bath, half bath, sitz bath (hip bath), Turkish bath, Russian bath, sheet, salt, mustard, vapor. The bath was intended to be part of the healing process. Since then, the bath, which started as a therapy, has often been reduced to a necessary task, often depersonalized, often routine, and sometimes harmful.

Faced with an aging population, an increased incidence of dementia, and an increased concern for elderly clients' quality of life, the responsibilities of the nursing professional have become increasingly difficult (Evans et al., 1989). Along with this challenge is a need to constantly reassess delivery of care in terms of demonstrable measures of outcome and to maintain the highest level of care possible with diminishing resources.

Many factors influence a resident's level of comfort in activities of daily living; however, those involving personal care have been found to produce high levels of discomfort (Aronson, Post, & Guastadisegni, 1993; Beck, Baldwin, Modlin, & Lewis, 1990; Burgener, Jirovec, Murrell, & Barton, 1992). More specifically, the bathing process, for individuals with dementia, has been found to be a major cause of difficult behaviors resulting from discomfort, which often manifests itself in the form of agitation (Burgener et al., 1992; Cox, 1984; Miller, 1997; Namazi & Johnson, 1996; Rossby, Beck, & Heacock, 1992).

Many factors diminish the comfort level of individual residents during a bathing session, including reactions to pain, confusion, embarrassment, and fear (Sloane et al., 1995). These studies emphasize the need to be aware that the sensations and perceptions experienced by elderly individuals with dementia differ not only in the physical realm, but also in the psychological realm.

Although studies have evaluated changes in the bathing setting which attempted to decrease agitated behaviors, such as music (Clark, Lipe, & Bilbrey, 1998), aesthetics of surroundings (Furrow, 1996; Kraker & Valjik, 1997), and personalized care (Miller, 1994; Rader, Lavelle, Hoeffer, & McKenzie, 1996), few studies have compared bathing methods. Elderly residents with dementia showed reduced aggression and agitation in the towel bath compared to showering (Hoeffer, Rader, McKenzie, Lavelle, & Stewart, 1997), but not in the tub bath compared to the shower method (Kovach & Meyer- Arnold, 1997). Data on hospitalized, nonelderly individuals indicated the bed bath compared to the towel bath reduced anxiety, as measured by selfratings on the State-Trait Anxiety Inventory (Barsevick & Llewellyn, 1982). Taken together, these findings suggest the Thermal bath is a promising method for reducing discomfort.

A variant of the bed bath, which we now call the "Thermal bath" was developed at the authors' place of employment This is less time consuming than the traditional bed bath method and, on casual observation, seems to reduce resident discomfort. The process is as follows: A capful of Sproam™ (Coloplast, Mississauga, Ontario), a non-rinse skin cleanser, is placed in the Thermal container. Very hot water (300 mL) is added. Enough washcloths for the bath (nine) are placed in the water until just moistened. The container is then taken to the bedside and the washcloths are removed one at a time to bathe each body part. There is no rinsing required and the skin dries in approximately 30 seconds.

The purpose of the present study was to compare the level of agitation observed during two bathing methods - the conventional tub bath and the aforementioned variant of the bed bath. The working hypothesis was that the Thermal bath would produce less discomfort in elderly residents with dementia than the tub bath, and that this would be manifest in a lower frequency of agitated behaviors during the Thermal bath.

Table

TABLE 1THE SUMMED FREQUENCY OF AGITATED BEHAVIORS IN TWO BATHING CONDITIONS AND THE DIFFERENCES BETWEEN SUMS FOR MALES (#i = 9) AND FEMALES (n = 6)

TABLE 1

THE SUMMED FREQUENCY OF AGITATED BEHAVIORS IN TWO BATHING CONDITIONS AND THE DIFFERENCES BETWEEN SUMS FOR MALES (#i = 9) AND FEMALES (n = 6)

METHODS

Participants

The study participants were 16 residents of an urban continuing care facility. All were diagnosed with dementia. Half of the residents (six men and two women) were from the special care unit (SCU), a secure facility housing individuals with a risk for elopement, and half (four men and four women) were from the Advanced Dementia Unit. All of these residents suffered from advanced dementia, and required assistance for mobility. Qualified staff administered the Brief Cognitive Rating Scale (BCRS) to assess the cognitive function in all participants (Reisberg, Schneck, Ferris, Schwartz, & deLeon, 1983). None of the participants were deemed able to give informed consent, so consent was obtained from family members or responsible agents before observations commenced.

One male participant in the SCU died before the end of the study, so his data were excluded from the data analysis, leaving nine men and six women participants. The age of participants ranged from 67 to 93 years (M = 81, SD = 7). The BCRS scores ranged from 3.8 to 7, where 7 represents the highest level of measurable impairment.

Procedure

Agitation was measured using a checklist containing 14 observable behaviors formulated from a combination of the Cohen-Mansfield Agitation Inventory (CMAI) (Cohen-Mansfield, 1986), the Ryden Aggression Scale (RAS) (Ryden, Bossenmaier, & McLachlan, 1991), and observations in preliminary trials. The behaviors were:

* Noisy breathing.

* Distressed facial expression (e.g., looking fearful).

* Pained facial expression (e.g., looking hurt or troubled).

* Frowning.

* Grabbing.

* Hitting.

* Strange noises (e.g., unwarranted crying)

* Pushing.

* Repetitive mannerisms.

* Retracting (i.e., pulling back indicating reluctance).

* Screaming.

* Shivering.

* Verbal aggressive behavior (e.g., cursing).

* Negative vocalization (e.g., expression of hurt, discomfort).

A crossover design was used in which all participants were involved in four consecutive sessions in each of the two methods - the tub bath and the Thermal bath. The order of the methods was determined randomly with half of the participants receiving the tub bath first and other half receiving the Thermal bath first. The sessions were conducted over an 8-week period at the participants* regularly scheduled bath time. The two authors observers.

Table

TABLE 2SUM, M AND SD OF FREQUENCY OF ALL AGITATED BEHAVIORS FOR EACH PARTICIPANT IN TWO BATHING CONDITIONS

TABLE 2

SUM, M AND SD OF FREQUENCY OF ALL AGITATED BEHAVIORS FOR EACH PARTICIPANT IN TWO BATHING CONDITIONS

The frequency of agitated behaviors for the male participants were recorded by either the male or female observer, but only the female observer was present for the female participants' baths. Several sessions were jointly recorded at the beginning and the mid -point of the study. Inter-rater reliability for identifying and counting behaviors showed significant agreements of more than 96% for the 14 behaviors. Percentage agreement was calculated as the number of agreements divided by the number of agreements plus disagreements (Cohen, 1960).

Observations began when the resident was undressed at the bathing site (i.e., the tub room for the tub bath and the resident's room for the Thermal bath). Observations were discontinued after the resident was out of the bathtub lift from the tub bath and after all body parts were washed in the Thermal bath. Behavior events were recorded using a checklist. One behavior was deemed to have occurred when there was a discrete, observable pause in that behavior before it reoccurred. The cooccurrence of two behaviors was recorded as separately occurring behaviors. Finally, a record was kept of whether participants refused to take a bath, whether they were on psychotropic medication, whether there was incontinence during the bath, the identity of the primary attendant during bathing, and the bath duration.

RESULTS

Normally, alpha levels of ? < .05 are considered significant. However, given that multiple statistical comparisons were made, a more conservative criteria of ? < .01 was used for this study.

For all male and female participants, the sum of all 14 agitated behaviors was significantly smaller (t = 4.18, /> < .001) in the Thermal bath (M = 49.47, SD = 33.72) than in the tub bath condition (M = 98.00, SD = 49.13) (Table 1). However, on specific behaviors, the Thermal bath showed a significantly lower frequency (t = 3.07, ? < .008) only for shivering (Thermal bath M = 3.13, SD = 6.40; tub bath M = 11.67, SD = 14.37) (Table 1). Marginal differences were obtained for three other behaviors: noisy breathing (t = 2 A4, ? < .029), where Thermal bath (M = 4.73, SD = 9.85) had a lower frequency than tub bath (M = 9.27, SD = 16.26); facial grimacing (t = 1.99,/) < .065), where Thermal bath (M =1.00, SD = 2.47) had a lower frequency than tub bath (M = 3.47, SD = 6.03); and negative vocalizations (t = 2.03, ? < .062), where Thermal bath (M = 9.87, SD = 9.86) had a lower frequency than tub bath (M = 22.20, SD = 24.99).

Table

TABLE 3DEMOGRAPHIC AND PROCEDURAL INFLUENCES ON THE SUM OF FREQUENCIES OF ALL AGITATED BEHAVIORS

TABLE 3

DEMOGRAPHIC AND PROCEDURAL INFLUENCES ON THE SUM OF FREQUENCIES OF ALL AGITATED BEHAVIORS

When the frequency of agitated behavior for all participants was summed, there were fewer behaviors in the Thermal bath patients than in the tub bath patients for all the behavioral categories, except hitting (Table 1). Men, considered together, displayed either no difference or a lower summed frequency on all of the 14 agitated behaviors, in the Thermal bath relative to the tub bath (Table 1). However, female participants showed higher summed frequencies in five behaviors (i.e., frowning, grabbing, hitting, retracting, verbally aggressive behavior) in the Thermal bath than in the tub bath (Table 1).

All of the participants except one woman displayed fewer total agitated behaviors in the Thermal than in the tub bath condition (Table 2). One participant, a man, had significandy lower frequencies of summed agitated behaviors in the Thermal compared to the tub bath condition (Table 2). A total of 12 refusals to bath were noted, all by two male participants and only for the tub bath.

Factors other than gender and bath procedure were examined for possible effects to account for differences in behaviors (Table 3). No significant effect was found for the participant's residential unit (SCU or Advanced Dementia Unit), whether the participant received the Thermal or the tub bath first, whether the participant was incontinent or receiving psychotropic medication, the age category of the participant, or the level of the BCRS scores of the participant (Table 3).

The time of day of the bath had no effect (data not shown). Nor did the number of different individuals serving as primary attendants for the bathing sessions relate to the difference found in agitation between the Thermal and tub baths. Few participants required more than one attendant. However, fourteen different attendants bathed participants in the SCU, whereas one person did all the bathing in the Advanced Dementia Unit. The duration, in minutes, of the bathing sessions was not significantly correlated with the frequency of agitation, nor were there any statistically significant differences between the duration of the Thermal bath, (M = 20.2, SD = 5.07), and the tub bath, (M = 21.17, SD = 5.66).

The four participants, all men, in whom the difference between conditions was most pronounced, were examined for consistencies in the pattern of factors that might influence the agitation effect. None of the factors that could have influenced bathing (i.e., number of different individuals serving as primary bathers, residential unit, condition sequence, whether they were incontinent, or were receiving psychotropic medication, age or BCRS score) was common to these four individuals (Table 4).

DISCUSSION

The efficacy of variations of the bed bath in an elderly dementia population has received continued support in the areas of cost effectiveness, hygiene, and skin care (Carruth, Ricks, & Pullen, 1995; Gooch, 1989; Kovach, 1995; Martin, 1997; Skewes, 1994, 1997). The results of the study demonstrate another advantage in using the bed bath or its derivatives. The findings support the hypothesis that this bed bath variation (Thermal bath) generates less agitation than the conventional tub bath method. The Thermal bath was lower in the overall frequency of agitated behaviors compared to the tub bath by 49.8% (Table 1). Taken with the findings of Hoeffer et al. (1997) and Kovach and Meyer- Arnold (1997) noted previously, the results indicate that bed bath variations result in less discomfort (i.e., fewer negative behaviors) than bathing in tubs or in showers.

Table

TABLE 4DEMOGRAPHIC AND PROCEDURAL FACTORS FOR FOUR MALES SHOWING A SIGNIFICANTLY LOWER SUMMED FREQUENCY OF 14 AGITATED BEHAVIORS IN THE BED COMPARED TO THE TUB CONDITION

TABLE 4

DEMOGRAPHIC AND PROCEDURAL FACTORS FOR FOUR MALES SHOWING A SIGNIFICANTLY LOWER SUMMED FREQUENCY OF 14 AGITATED BEHAVIORS IN THE BED COMPARED TO THE TUB CONDITION

The finding that 14 of the 15 residents evinced a tendency to less agitation in the Thermal bath indicates that the Thermal bath advantage was generalizable across individuals - a major issue for caregivers interested in reducing stress (Rader, 1994). The robustness of the effect in different individuals is also supported by the fact that the effect was independent of the resident's age, degree of cognitive impairment (BCRS), physical mobility, and continence level, and whether or not the patient was receiving psychotropic medication.

The effect was apparent in both genders, but tended to be somewhat stronger in men, with the appearance of some hints of gender specificity of the Thermal bath effect for particular agitation behaviors (i.e., screaming and making strange noises in women; frowning, pushing, repetitive mannerisms, and shivering in men). The gender difference is worth pursuing to determine if genuine gender differences exist in the observable manifestation of agitation. The data suggest that the beneficial effect of the Thermal bath, compared to the tub bath, has good external validity with respect to the characteristics of older adults (Table 3) and, therefore, should be replicable for a range of individuals.

A collateral conclusion is that the frequency of agitated behaviors observed depended on the bathing technique and not on confounding differences among participants. This was assured by the crossover within group design, which minimized the systematic effect of participants on bathing conditions by having every resident serve as their own control.

The possibility remains that incidental procedural differences accounted for the Thermal bath effect. However, the experimental design also minimized the effect of the order on the conditions by randomly assigning half the participants to each order. Nor did other procedural factors have any measurable effect on agitation, including the time of day bathing occurred, duration of bathing, or the number of individuals serving as primary attendants. Because primary caregivers varied across sessions, it is not likely that behaviors unique to particular primary caregivers contributed to the Thermal bath effect (Burgener et al., 1992).

Anecdotal reports from caregivers in this study indicated they would have preferred giving the tub baths in the morning (as indeed they did), and the Thermal baths at any convenient time of day because Thermal baths were judged easier to provide. For this study, the Thermal baths were prescheduled to occur at the participant's regular bath time, rather than on a flexible schedule. Some attendants also had reservations about the hygienic efficacy of the Thermal bath.

The literature suggests these concerns can affect attendants' performance negatively, and result in difficult-to-manage behavior in residents (Kovach & Meyer- Arnold, 1997). However, any such effects in the present study would have worked against the current hypothesis, and would have made the results less likely. There is little evidence these extraneous factors contributed significantly to the effect of the bathing technique on agitation.

In the present study, the list of agitated behaviors was not exclusive. Thus co-occurring behaviors were indistinguishable in the data record from the same behaviors occurring sequentially. Consequently, it is not possible to conclude whether the Thermal bath effect was caused by less frequent instances of specific behaviors, or by a lower frequency of co-occurring complexes of agitated behaviors. This lack of distinction has implications for drawing inferences about the amount of time spent expressing discomfort, the severity of the discomfort expressed, and predicting the imminence of more serious outbreaks of agitation (i.e., hitting, grabbing, pushing). This shortcoming in the methodology could be remedied by employing continuous behavioral coding of an exclusive, exhaustive list of behaviors with a larger sample size.

Limitations

The results of the present study raise several research issues. Bed bath variations are relatively new procedures, and, therefore, studies are needed to explore the advantages and disadvantages related to hygiene and cost-effectiveness when bed baths are used routinely over a period of time. Because Sproam (and other non-rinse cleansers) are not traditionally used as the primary cleaning agents for elderly individuals, the long-term effects of their use need to be explored. For example, the emollient properties of Sproam may not be effective for cleaning oily hair when used repeatedly.

To fully explore the efficacy of this bathing method, the reservations of staff and families need to be addressed. Further comparisons of agitation elicited by the Thermal bath and other bathing methods using continuous coding of behavioral events will help provide an empirical base for understanding the appropriateness of the Thermal bath method.

Clinical Implications

The results suggest the Thermal bath method may be a viable bathing alternative. The method is easily taught to caregivers because it deviates only slightly from the conventional bed bath. Therefore, the Thermal bath method described here can be introduced into any continuing care facility with minimal training. Because caregiver satisfaction is often correlated with the resident's comfort level, it is conceivable that a decrease in agitation may benefit staff in a variety of ways (Burgener et al., 1992).

Use of the Thermal bath method can avoid many of the negative aspects of the conventional tub bath, such as transportation to the tub room (which in itself may cause agitation), raising and lowering the resident in the bath lift, unfamiliar dials, a drafty, cavernous institutional setting, varying water temperatures, increased potential of microorganism contamination, and an abrasive washing style (Namazi & Johnson, 1996; Sloane et al., 1995). In the past, many caregivers have restricted bathing to either the shower or tub, but the findings of the present study should encourage more caregivers to explore this other bathing option.

Nursing Practice Implications

Experienced caregivers often witness negative behavior when bathing elderly residents who have a dementia. Staff members regularly face this task with trepidation because of the behaviors it may evoke from many residents. Bathing does not need to be such an unpleasant experience for either resident or staff.

By interviewing family members and discovering the past personal habits of each of the residents, the nurse has a framework for how to approach the resident in terms of which bathing methods are acceptable for each person. For example, nurses should not expect that an elderly woman who always bathed at the sink would respond favorably to a tub bath.

The continuing care center where this study was conducted is one of nine continuing care centers under the umbrella of The Capital Care Group in Edmonton, Alberta. Although there was already an interest in improving the bathing process in the centers, the results from this study created an impetus to create a corporate-wide vision for improving the bathing experience for residents. From the work of a Bathing Committee, corporate Resident Personal Hygiene Standards were developed, as well as "Options for Providing Personal Hygiene," a caregiver's guide to various bathing methods. For each bathing method, a specific procedure was created. Further work of the committee has also produced Environmental Standards for Bathing Rooms and a spreadsheet for selecting bathtubs. For information on obtaining these documents, contact The Capital Care Group, #500, 9925-109 Street, Edmonton, Alberta T5K 2J8 Canada, call (780) 448-2400, or access http://www.capitalcare.net.

The focus for every nurse responsible for the care of the elderly resident with dementia should be to provide a method of personal hygiene that is comforting, relaxing, and stress-free, without sacrificing residents' personal control, dignity, privacy, and pleasure. This can be accomplished if nurses look beyond the tub.

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TABLE 1

THE SUMMED FREQUENCY OF AGITATED BEHAVIORS IN TWO BATHING CONDITIONS AND THE DIFFERENCES BETWEEN SUMS FOR MALES (#i = 9) AND FEMALES (n = 6)

TABLE 2

SUM, M AND SD OF FREQUENCY OF ALL AGITATED BEHAVIORS FOR EACH PARTICIPANT IN TWO BATHING CONDITIONS

TABLE 3

DEMOGRAPHIC AND PROCEDURAL INFLUENCES ON THE SUM OF FREQUENCIES OF ALL AGITATED BEHAVIORS

TABLE 4

DEMOGRAPHIC AND PROCEDURAL FACTORS FOR FOUR MALES SHOWING A SIGNIFICANTLY LOWER SUMMED FREQUENCY OF 14 AGITATED BEHAVIORS IN THE BED COMPARED TO THE TUB CONDITION

10.3928/0098-9134-20021101-05

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