As the incidence and prevalence of dementia increases at the rate of one case every 7 seconds (Alzheimer’s Disease International, 2009), the need to preserve the dignity of people with dementia also increases. This need is a priority in the residential care environment where more than two thirds of residents have some form of dementia (Meier, Lim, & Carlson, 2010) and have lost the ability to initiate and complete activities of daily living, including bathing. The overall purpose of this research study is to identify and understand factors that influence a successful bathing experience for people with dementia in a residential care facility so this knowledge can be used to understand the barriers to implementation of best practices.
Previous research has identified how people with dementia respond negatively to bathing when they are naked in the presence of others or are exposed to unfamiliar bathing equipment (Rader et al., 2006), and develop resistive behaviors in advance of being bathed (Kovach & Meyer-Arnold, 1997). These behaviors, which can result in harm to staff (Åström et al., 2004; Namazi & Johnson, 1996), contribute to the bathing experience being difficult and potentially traumatic for both health care assistants (HCAs, i.e., unlicensed care providers with no legally defined scope of practice [British Columbia Ministry of Health, 2007]) and individuals with dementia (Sloane et al., 2004; Somboontanont et al., 2004). Despite the ubiquity of bathing, one of the strategies to improve this experience for people with dementia is to individualize the bathing plan (Barrick, Rader, Hoeffer, Sloane, & Biddle, 2008; Cohen-Mansfield & Parpura-Gill, 2008; Sidani, LeClerc, & Streiner, 2009). Although important, following through on an individualized plan of care can be a challenge. In a randomized controlled trial, Sloane et al. (2004) found that didactic training and hands-on coaching to change caregiver techniques to person-centered showering and towel bathing did not completely eliminate negative or resistive behaviors among residents being bathed. Another study found that education to increase the use of a person-centered approach during morning care did not sustain practice change after 3 months (Sidani et al., 2009). Both of these studies found that education focused on person-centered approaches was not sufficient to address the challenges of individualizing care.
This study was designed to explore this gap in the literature by seeking to understand the perspectives of HCAs who bathe people with dementia in residential care facilities. The following two research questions were developed to guide the research design:
- What are the perspectives of HCAs regarding successful and unsuccessful experiences bathing people with dementia?
- What strategies can HCAs provide to improve unsuccessful bathing experiences for people with dementia?
A qualitative exploratory descriptive design (Sandelowski, 2000) was chosen to understand HCAs’ experience bathing people with dementia. The design is suited to this inquiry because of the complexity of the phenomenon of bathing people with dementia, and it provided an opportunity to explore influential factors. Ethical approval for the study was obtained.
The research team consisted of five nurses. Two who were master’s-degree prepared with a gerontology specialization had overall responsibility for the study as the co-principal investigators, and also led the focus groups. Three other nurses, who held educator roles within residential care, provided assistance during the conduct of the study, in particular, acting as recorders.
Participant inclusion criteria included current employment as a HCA in residential care with responsibility for bathing people with dementia, fluency in English, and the ability to provide informed consent.
Participants were recruited from all 81 residential care facilities within a health authority in southwestern British Columbia, Canada. To avoid the possibility of coercion, HCAs were not contacted directly by the research team. Instead, residential facility managers were asked to display recruitment posters throughout staff areas, which provided a telephone contact number for interested HCAs to call for further information. Upon HCA contact with the team, the researchers explained the study requirements to the prospective participants and assured them all interviews and personal information would be kept confidential. Signed informed consent forms were collected at the beginning of the focus group, after any other concerns or questions were addressed. Participants were reminded that their participation was voluntary and they were free to leave at any time. They received salary replacement for 2 hours. No additional incentives were offered.
Setting and Participants
The locations for the focus groups were geographically separate, convenient to transit routes, and held in care facilities away from care areas. Eighteen female HCAs from 12 different facilities participated in the study. All had experience with bathing 1 to 11 people with dementia daily, working individually or on bath teams. The most common type of bath provided was a tub bath and a shower, followed by towel baths, and stretcher showers. The background experiences of the participants are further described Table 1.
Table 1: Bathing Experience of the Health Care Assistant (HCA) Participants (N = 18)
Data were collected from three focus groups using semi-structured interviews. The following four open-ended questions were used to encourage HCAs to describe their experience bathing people with dementia:
- Tell us about an experience you have had bathing an individual with dementia.
- How do you know the person with dementia has enjoyed the bath?
- How would you describe the “best possible bathing experience” for the staff member and for the resident?
- What would help make every bathing experience for people with dementia a positive experience for both the resident and the staff member?
For each focus group, a record of impressions and nonverbal communication was entered into a journal by the two recorders to develop an audit trail of the interactions during the focus groups. The interviews were audiorecorded then transcribed verbatim, de-identified, and retained in one principal investigator’s locked office to be shredded after 5 years. The audiorecordings were destroyed.
The HCAs’ perspectives were used as the basis for identification of themes and patterns within the data. After reading each transcript, the two co-principal investigators and one additional research team member independently made comments in the margins and developed a summary of the salient points. This stage of the analysis was done independently to prevent unintentional influence on one another. Following this, the co-principal investigators together discussed the data to identify emergent unique themes, synthesize these into higher-level thematic categories, and develop a theoretical framework for nursing implications. All of the research team members then reviewed the themes that were developed. The content validity of the analysis was agreed to by all members of the team. Because all of the team was well acquainted with bathing experiences in residential care facilities, their review reinforced the validity of the analysis, as there was agreement that the themes reflected participants’ comments.
The themes that emerged describe the interactions that occur around the bathing experiences of the HCAs. In relation of the first research question, the HCAs described successful bathing by defining the experience in two different ways and from two different perspectives: (a) the resident is relaxed and happy, and (b) the task is done. The first definition is from the resident’s perspective and focuses on the pleasure experienced by the resident. The second definition is from the HCA’s perspective and focuses on the completion of a difficult task.
With respect to the first definition, some HCAs described the residents’ comments following the bath that were directed toward staff, family, and other residents. Some examples include: “and at the dining table they tell their neighbors, ‘I had a bath you know’” and “they keep saying thank you all the time.”
Success was also measured by residents’ behaviors following the bath, which indicated that the experience was calming. As one HCA stated, “Well, if a bath has gone well, you can tell by the resident, you know... they’re relaxed, you’re relaxed.”
As indicated by the second definition, a number of HCAs defined a successful bath experience quite differently. The following comment highlights that the measure of success was in meeting the challenge or completing the task: “We look at the bath schedule and we go, oh no, we’ve got to do her today. But if you can get that done, then you know your whole day is just going to keep going smooth.”
These two different perspectives regarding what constitutes a successful bathing experience are important to understand as they potentially influence the strategies used to complete a bath. As an example, this strategy focuses on the resident with the outcome of providing comfort: “In the evening what we usually do is give our bath before they go to bed so I can focus more on my residents. I can apply lotion all over. I can massage her hair, and I can massage her head.”
Other strategies focused on completing the task, sometimes in a manner that suggested that the end justifies the means. That is to say, a resident could be upset during the bathing experience but when the experience ended with resident appreciation, success was declared: “But ours are so far gone. We’re on like the lock down unit, so they don’t remember anything.”
These perspectives informed the themes that evolved from the second research question regarding what strategies HCAs can provide to improve unsuccessful bathing experiences for people with dementia. The data that emerged from this question revealed that not all strategies used to improve unsuccessful bathing experiences were within the control of the HCAs. Strategies within and not within their control are discussed below according to the three themes identified: I Know You, I Am All Alone, and I Am Not Prepared.
Theme 1: I Know You
All members of the focus groups agreed it was important to know the resident to ensure the bathing experience was successful. Many HCAs were able to take the information or history about the person and translate that knowledge into a bathing strategy. However, it was found that use of that knowledge varied. As the following example demonstrates, one HCA used her knowledge of the person and of dementia to inform her decision about equipment: “OK, so that is something that they did not grow up with, that’s something they are not used to. So when you turn the jets on, all they see is the bubbling water, and in their mind that’s boiling water.” Another HCA used the information about the person to build trust in the relationship by acknowledging the resident’s uniqueness: “And while you’re doing that, I really am singing all the time, and then because she likes to sing, and she sings with me. And so we didn’t realize that the bath is done.”
In contrast, other HCAs used their knowledge of the individual in a manner that, although it resulted in the bathing task being completed, did not honor the person. For example: “We had a gentleman that was very aggressive; he would not get into the tub. He said he wouldn’t even do that to his cows, because he was a dairy farmer. So we had little toy cows for him.” These participants believed they were providing a bathing experience that was person-centered because they were using information they knew to be true about the resident.
These examples demonstrate that knowledge of the person can be used in different ways, depending on what is important to the HCA—getting the job done or achieving a positive experience for the resident.
Theme 2: I Am All Alone
One of the important aspects identified by the HCAs was the lack of support and recognition when met with challenging bathing experiences. HCAs’ comments portrayed a sense of aloneness emerging from emotions such as fear, a sense of internal conflict, distress, a sense of isolation during challenging bathing experiences, and a lack of control over their environment.
In some situations, the participants expressed fear for their own safety, as well as the resident’s. This sense of fear emerged as a result of the unpredictability of residents’ responses and a corresponding lack of support and assistance in these situations. The lack of clinical support and limited ability to call for assistance in times of potential crisis left the HCAs feeling alone in their struggles. As one participant noted:
Because I don’t want anything happening, you know, to that resident or myself. Because you know, you get the biggest fear if they grab your head and they put your head under water. You can go ahead and try to reach for that call bell, but once your head is under, that’s it.
A sense of internal conflict and distress emerged with another significant subtheme, as the HCAs reported struggling with how to provide care in a way that they believed was “right.” They also struggled with the right of the resident to say “no” and the expectations of other team members to support the decision to stop the bath and complete it at a later time. As one HCA noted:
I am conflicted when I am not able to make them feel comfortable. Not the task, the task can be done another time. But they become upset, I feel conflicted, because I feel that there’s got to be a way that I can make them feel more comfortable, but I just don’t know it yet.
Another HCA commented:
I get upset when they do, you know, get angry and you have to walk away and then you feel like, well am I doing something bad by not helping them with the shower or am I doing something good by letting them calm down? So it’s kind of like a catch 22.
When bathing experiences were challenging, a sense of isolation from the team often emerged. The comments from HCAs highlighted the importance they placed on communication and problem solving with other HCAs. On the other hand, communication and problem solving with nurses or nurse leaders were rare and usually only occurred with respect to obtaining medications. The HCAs also gave examples that indicated feeling invalidated in their work by the nurse leaders when family members complained about their care. They described an inability to explain their circumstances to family members and relied on the nurse leaders to respond. The HCAs indicated they felt alone in these struggles when there was no support from nurse leadership. One participant described her lack of involvement with the team: “We’re supposed to send them off to the person in charge. And we’re doing the hands-on and we’re really the people that know what’s going on, but we can’t really say too much.”
HCAs described a need for control over their work schedule. They accomplished this by implementing creative strategies, such as adjusting the bath schedule or timing of the bath and changing the number of people involved in the bath. On the other hand, participants also described challenges in not having the authority to alter the schedule. When they did make changes, the consequences included unhappy colleagues or more work for them the next day. One participant noted that, “I have to talk in a nice manner to my person next to me, the shift coming after me, because I know that they’re not going to be happy.” Another participant described her challenges in altering the bath schedule:
Some care aides are task oriented, some are compassionate and, you know, more flexible with their times. So it depends on your coworker. But a lot of the times the coworkers, if you take one of their baths…then it looks better and then it works out. But other times, you know, you’re stuck doing it the next day when you come in.
Theme 3: I Am Not Prepared
HCAs identified a belief that the environment, as well as the type and availability of equipment, influenced the outcome of the bath. HCAs indicated they were ill prepared to meet the complex needs of the resident in a way that supported the resident in a safe manner. Two subthemes emerged related to the availability of the “right” equipment and the need to modify the environment to best suit the unique needs of the resident.
HCAs identified that the right equipment was often not available and that the equipment that was available, in some cases, contributed to the resident’s physical and emotional discomfort. When it was recognized that the equipment was not suitable, inventive but potentially unsafe alternatives were created:
When they are in the tub and they start sliding. Sometimes we are using techniques that we are not suppose to. You know, like you will go and lift them up, like you were putting your back at risk. But is it my back, or is it them drowning, right?
In addition, lack of equipment meant that staff were not able to access equipment when needed or were interrupted when other staff wanted the equipment. One participant stated that, “We don’t have all the equipment we need at our facility. We’re sharing bath chairs…when you can find a bath chair and somebody’s not knocking on the door saying, ‘Hurry up, I need the bath chair,’ you know.”
HCAs also identified challenges in modifying the environment to be suitable for each resident. Conflict was identified between meeting the needs of the HCA versus the needs of the resident. For example, when bathing environments were made warm enough for the resident, they became uncomfortable for the bath team. One person indicated that, “We start our bathing at 0600 until 2, because in the summer the tub room gets really hot. So if you get the majority of your bathing done earlier, it’s easier.”
I Know You
Many of the HCAs in this study recognized that knowledge of the resident was essential to a successful bathing experience. However, this knowledge was used in two different ways: Some strategies honored and others dishonored the person. None of the strategies carried a tone of intent to harm. What was seen to be lacking, in some cases, was the recognition of how to enact person-centered care. This finding was consistent with Kitwood’s (1997) thinking where he noted that although the intent of the HCA may be to offer kindness, disablement and depersonalization can occur.
The philosophical underpinning of person-centered dementia care involves knowing and valuing the uniqueness of each individual. Care is more than meeting physical needs but attends to the whole person, enabling him or her to live to the fullest potential as a social being (Kitwood, 1997). People living in residential care have a common need for assistance and a need to be accepted as individuals with a unique identity. This is vital to the well-being and happiness of individuals with dementia (Cook, 2010). Therefore, a person-centered approach involves recognizing and responding to individualized needs and preferences. Such an approach is particularly important during personal hygiene activities, such as bathing, given that it is such a private, intimate, and potentially vulnerable moment for the person with dementia. Although some HCAs were using their knowledge of the person, it was recognized that they need support in understanding how to integrate this knowledge into practice in ways that honor the person.
I Am All Alone
The HCAs’ sense of aloneness stemmed from several sources. The study participants described emotions of distress and a sense of conflict, wondering if they were doing the “right” thing. They also described fear for their own, as well as residents’, safety. These emotions stemmed from a lack of control over their environment and isolation from other team members. This finding is supported by Cooke and Gutman (2005), who found that nurse leaders were disconnected from the experiences of the bathing staff. Forty-five percent of surveyed HCAs identified bathing as somewhat stressful, whereas the majority of their nurse leaders (56.3%) believed it to be a minor issue.
The HCAs also articulated the need for emotional support from nurse leaders when working with families. They described feeling defenseless when families were critical. Abrahamson, Anderson, Anderson, Suitor, and Pillemer (2010) identified that dissatisfaction and burnout are significant after only 10 to 20 episodes of conflict with families.
This lack of emotional support and control, along with the other emotional and physical stressors described in this study, has the potential to influence HCAs’ attitudes over the long-term. Maintaining a positive attitude, specifically one of compassion, is fundamental in supporting the use of knowledge and skill in a way that meets the needs of residents, especially those with dementia. “That is, when the nurse addresses basic care needs in a compassionate way, patients are left psychologically intact” (Perry, 2009, p. 18). However, compassion is an attitude that cannot be learned from textbooks. “As important as knowledge and skill, compassion allows you to act in a deliberate and skilful way while keeping the patient’s well-being front and centre” (“Nurse to Nurse,” 2010, p. 20). When there is a lack of shared vision, or inadequate emotional and professional support, compassion may be easily put aside and the staff become task focused rather than relationship based. This was evident in some of the HCAs’ definition of successful bathing experiences. Those who defined a successful bathing experience as “the resident is relaxed and happy” were able to maintain their compassion and focus on the relationship rather than the task. Conveying compassion potentially has a positive effect on the resident but also benefits the HCA (Perry, 2009). In times of increasing workload and growing complexity, opportunities to provide compassionate care are more important than ever.
I Am Not Prepared
A great amount of research has focused on the importance of a homelike environment in promoting successful bathing experiences (Brawley, 2002) and in understanding what aspects of bathing create stress for individuals with cognitive impairments. Consequently, it is well understood that the bathing room—more than other resident spaces—contributes to fear and anxiety in residents. Not only can the equipment be frightening for people with dementia, it also needs to be appropriate for their physical abilities. The ability to modify the environment to meet the unique needs of each resident was identified as a key element for HCAs. This included the availability of suitable equipment, as well as a comfortable, familiar environment, that addresses the needs of both the staff and the resident. Further, it was identified that HCAs require the time and space to ready the environment for each resident in order to create a sense of calm and familiarity.