Ann Louise Barrick PhD
Beverly Hoeffer DNSc, RN, FAAN
Philip D. Sloane MD, MPH
Darlene McKenzie PhD, RN
Karen Amann Talerico PhD, RN
Johanna Uriri Glover PhD, RN
OVERVIEW: Older adults who need assistance with bathing often find the activity to be both physically and emotionally demanding, as do their caregivers. Research has identified several contributing factors, including pain; fatigue and weakness; confusion; anxiety resulting from being naked in front of strangers, being afraid of falling, and being in a noisy or unfamiliar place; and discomfort from cold or drafty bathing areas or harsh water sprays. The authors of this article make the case for the elimination of forced bathing. Research supports this change in philosophy and practice, whereby bathing is not a task to be performed but rather a human interaction. Inexpensive, practical, and evidence-based alternatives are discussed.
Bathing independently, one of the most personal and complex of the activities of daily living, requires significant cognitive and physical abilities, including dexterity, flexibility, balance, strength, and coordination. 1 To the person who requires assistance in bathing, the change can represent a decline in well-being and cause emotional and physical discomfort. 2 Indeed, caregivers and recipients alike, in both homes and institutions, often say assisted bathing is difficult and distressing.
A significant number of older adults have difficulty or need assistance with bathing. In one study of 626 community-dwelling older adults ages 73 years and over, 195 (31%) met the criteria for “bathing disability” (those “requiring assistance or having difficulty washing or drying the whole body”). 1 And according to a report issued by the National Center for Health Statistics, Nursing Homes, 1977–1999: What Has Changed, What Has Not? at least 90% of nursing home residents need some assistance with bathing. 3
FIGURE. Older adults resist assisted bathing for a number of reasons: it’s physically painful, it’s embarrassing, or it represents a loss of autonomy. Research has shown that giving older adults a choice about when and how to bathe, as well as the opportunity to bathe themselves, when possible, promotes success. Pictured above, Isaac Donner, age 100, washes his face; on the door is a photograph of him as a young man. Photograph taken from Aging in America: The Years Ahead, by photographer Ed Kashi and writer Julie Winokur.
Our experience, supported by other research, has shown several factors contributing to bathing difficulties, including 1, 4
In our series of studies we’ve found nurses to be critical in improving the bathing experience for older adults. In fact, our recent clinical trial tested two person-centered bathing methods (methods tailored to the needs and comfort level of the person being bathed) aimed at reducing discomfort, agitation, and aggression in nursing home residents with dementia, and we found nurses to play a central role. 5 And with the growth of the geriatric population, particularly those 85 years old and older, nurses will increasingly need to assist with bathing.
Drawing on more than a dozen years of clinical work and research, we suggest the elimination of forced bathing in homes and institutions, a practice we consider on a par with restraint use. Both practices generally went unchallenged and were once thought to be adequate standards of care—some practitioners may still think so—despite the frequent protests and physical resistance of those being restrained or forced to bathe. But solid evidence now disputes the safety and necessity of both of these practices. Bathing people routinely against their wishes—“for their own good”—should become part of nursing history, as person-centered care becomes the norm.
We believe that to bathe people against their wishes, unless there is an acute, compelling health reason to do so, constitutes abuse. We hope to encourage nurses to think creatively about how to individualize care and inform and support those who provide direct care.
Many community-dwelling older adults adapt their bathing methods as they age or become ill, but those who have dementia and those near the end of life usually require assistance and can be particularly challenging. And trying to bathe a person who is very frail, as people often are at the end of life, in a traditional shower or tub can be physically exhausting or impossible.
Since hospital stays have decreased in length and patient acuity has increased, bathing has been less of a focus in facilities. Some acute care facilities are using premoistened, individually wrapped, no-rinse, disposable cloths that can be heated in a microwave oven. Bathing is often delegated to bedside caregivers, with very little professional oversight. Nurses, with their many competing priorities, may not be aware of problems when they arise or are poorly prepared to deal with them.
Most nursing homes in the United States schedule routine showers or tub baths for residents at least twice per week. The bathing method and schedule are usually based on the facility’s routine and not on the residents’ preferences. The vast majority are showered. 6 In our experience, we’ve found that the shower or tub rooms are often cold and noisy, with tubs and shower equipment that may be unfamiliar or look intimidating. Staff have reported to us that they feel rushed to get residents up and showered before breakfast. A high proportion of residents have cognitive impairment and may be easily confused or made anxious by being bathed.
Pain during bathing is also common in people with dementia. One study found that 88% of 17 subjects had a history of arthritis, osteoporosis, or joint pain. 7 The movements required during bathing (such as transferring out of bed into a shower chair and raising and lowering the arms and legs) can cause pain, fear, and discomfort. In our experience it’s not uncommon to hear residents’ screams and profanities from the shower or tub room, and many staff and residents’ families have told us that they believe such behaviors and other signs of discomfort during bathing are inevitable. Caregivers tell us that they worry about ensuring hygiene in a safe and comfortable way. It’s stressful to residents and professional and family caregivers to give care that results in pain, exhaustion, and agitated reactions such as hitting, biting, crying, and screaming.
The good news is that the stressors associated with assisted bathing can be modified. Bathing can be pleasant and without harm to older adults in the home, the hospital, and long-term care facility.
We recently worked with other members of a research team to study two bathing methods in nursing home residents with dementia. 5 We discovered several solutions that benefited both caregivers and residents. (Although we studied people with dementia, most of our ideas and principles are relevant to all older adults who require bathing assistance.) The study was a randomized, controlled trial with two experimental groups and a usual-care control group, conducted in nine nursing homes in Oregon and six in North Carolina. Two interventions were evaluated: person-centered showering and towel bathing in bed. We worked with 73 residents (69 completed the study) and 37 certified nursing assistants (CNAs). To be included in the study, residents had to be age 55 or older, have a diagnosis of Alzheimer disease or other dementia, have moderate or severe cognitive impairment, be able to be showered, and demonstrate agitation or aggression during bathing.
The focus of both bathing methods was the resident’s comfort and preferences. Participating CNAs and nurses were encouraged to view resistance and other behavioral symptoms as expressions of unmet needs. They were taught to employ appropriate communication techniques, apply problem-solving approaches to identify causes of and potential solutions for behavioral symptoms, and adapt the environment to the residents’ comfort and security.
Showering uses a wide variety of person-centered techniques, such as covering the resident with towels as much as possible during the shower, distracting the resident with food and interesting objects, using favorite soaps and no-rinse products, modifying the shower spray, and providing choices (such as whether hair is washed first, last, or not at all).
The towel bath, a person-centered, in-bed method adapted from the Totman technique in which the caregiver uses a large towel, one or two regular-size towels, washcloths, a bath blanket, no-rinse soap, and water. 8 Many nurses remember this procedure from obstetrics and hospital practice 30 years ago. 9
Of the 15 nursing homes participating in our study, five served as control and 10 as experimental homes. Recruited facilities were randomly assigned to three groups of five facilities each. One treatment group received the towel bath during the first intervention period and showering during the second period. The other treatment group received the same interventions in reverse order. In the control group, consent and data collection occurred as in the treatment groups, but no intervention took place. In the 10 treatment facilities, clinicians (a clinical nurse specialist in Oregon and a licensed psychologist in North Carolina) worked with participating CNAs to understand the causes of agitation and aggression and to develop an individualized bathing plan designed to address those causes. The clinician and CNAs worked together one or two days per week for four weeks with each resident in the study during each of the two intervention periods.
In conducting the interventions, the team learned the following:
Focusing on the person and the relationship rather than the task greatly reduces discomfort and behavioral symptoms. We found that caregivers assisting with bathing often felt rushed and frustrated, while residents felt a loss of control and even attacked. One of us (Rader) was showered in a nursing home during a preliminary study and found the accepted practice to be cold and distressing. Taking the resident’s point of view, we realized that the behaviors we had previously labeled “aggressive” or “resistive” were often defensive actions residents took when feeling threatened and anxious. (For more information, see “Making Sense of Aggressive/Protective Behaviors in Persons with Dementia” by Talerico and Evans in the October–December 2000 issue of Alzheimer’s Care Quarterly. )
We found that by shifting the focus to getting to know the resident, communicating clearly (by reassuring or apologizing for any discomfort caused, for example), and thinking creatively, behavioral symptoms lessened. There was a marked reduction in all behavioral symptoms (by 32% in the shower group and 38% in the towel-bath group). Aggression declined by 53% in the shower group, 60% in the towel-bath group, and only 7% in the control group.
It doesn’t take a lot of water to get clean. Dry skin is a problem for about three-quarters of people age 65 or older. 10 In planning our study, we knew several of the bathing strategies had the advantage of managing dry skin (for example, reducing the frequency of bathing can prevent scaling or cracking of the skin). First, we reduced the frequency of total-body bathing from twice per week to once per week for most subjects. Second, we switched from standard soaps to a no-rinse cleanser, Septi-Soft, with a soybean-oil base. Third, no rinsing was performed during the towel bath, which further reduced exposure to water.
We were concerned that less frequent bathing and using less water in bathing might compromise hygiene. The study demonstrated that the towel bath doesn’t adversely affect skin condition or lead to the accumulation of pathogenic, odor-causing bacteria. Skin condition was significantly improved, in fact, and less debris and dirt were left on the skin. A person doesn’t have to be doused or dunked to be really clean. A bed bath can safely substitute for a shower.
Most nurses and CNAs are taught to start a bath at the head and work down because it’s assumed that the head and face are cleaner than other areas. But for people with dementia, water dripping in the face and having the head wet are generally the most upsetting parts of the bath; this causes distress at the beginning of the bath. One alternative is to wash the face and hair at the end of the bath or at another time. Another is to use no-rinse products that can shorten and simplify bathing. Infection-control concerns can be addressed by the caregiver washing her hands and using a fresh, clean cloth after cleansing a part of the body that might cause contamination. Although many have been taught to cover the person during a shower or tub bath, few actually do this, possibly leaving the person cold and feeling exposed, embarrassed, and without dignity. Covering the person with a towel and washing beneath it alleviates this distress. These changes are simple, practical, and do not increase the length of bathing time.
The prevalence of pain or potentially painful conditions among institutionalized older adults has been estimated to be between 43% and 71%, 11-13 with mus-culoskeletal conditions the most common source. Many nursing home residents with dementia can’t describe their pain verbally, leading to behavioral symptoms such as aggression, resisting care, and vocalizations. The movements necessary in routine bathing, such as walking, standing, transferring from bed or wheelchair to tub or shower chair, and moving joints and limbs, can often exacerbate chronic pain or precipitate acute pain. We also found that pain is particularly common when washing between the toes, under the arms, and on sensitive areas such as the genitals and face. In our study, residents’ discomfort declined significantly in both intervention groups, but not in the control group; the largest decline was with the towel-bath intervention (26%).
To reduce pain associated with bathing, nursing home staff and other caregivers should explore the need for routine analgesia or nonpharmacologic approaches such as applying hot packs to sore joints before a bath. During the bath or shower, caregivers should move the limbs carefully, warn the person before moving or washing a potentially painful body part, and be aware of signs of discomfort. Letting the person assist in cleansing a painful area can diminish aggravation, as well as instill a sense of control that can diminish distress. And while it’s not always practical in all settings, giving a person time to soak in a tub without being rushed can help reduce chronic pain from muscular tension. Also, caregivers in all settings should be familiar with and use universal precautions with any bathing method, wearing gloves when appropriate for protection and infection control.
Nurses should think about bathing others as they would think about bathing themselves. When you had a particularly pleasant bath or shower, what made it enjoyable?
Nurses should think about bathing others as they would think about bathing themselves. When you last had a particularly pleasant bath or shower, what sensations made it enjoyable? When asked this question in a workshop setting, nurses have mentioned specific preferences: time of day, shower or tub, water temperature, length of shower or bath, music playing (or not), and scent. It’s rare that anyone mentions the process of washing or the goal of getting clean.
This is in stark contrast to the experience of many frail older adults, who depend on others for bathing and whose distress and discomfort can bring them to the point of resistance and aggression. Nurses and other caregivers have traditionally identified these behaviors as the problem and reducing or eliminating them as the goal. But such behaviors should be thought of as symptoms of the real problem: unpleasant bathing.
In the home, if the person is having difficulty getting into and out of the shower or tub, have a physical or occupational therapist perform an assessment. A hand-held showerhead, a bath bench, and properly placed grab bars can be of great help and also foster independence. 4 Some spouses report better results when they shower along with the person, if space permits and doing so is customary. When older adults find getting in and out of bathtubs and showers difficult or frightening, despite environmental adaptations, the next step is often to do sponge baths at the sink. Families and other direct caregivers should be made aware of the wide variety of no-rinse products available, since they often make the process quicker, less complex, and less likely to cause agitation. In our study we found that Septi-Soft, when diluted, was useful in shower or tub.
The typical plastic-pipe shower chair used in institutions often adds to pain and discomfort in the shower. Such chairs usually have an unpadded seat, a rather large opening, and no support for the feet. One of us (Rader) found that when she was showered in this type of chair, she sank in the opening and her feet dangled unsupported and turned blue-purple from impaired circulation. Before this personal experience, she had assumed that the foot discoloration she’d often observed in frail older adults was the result of irreversible physiologic changes.
In a preliminary study we purchased a shower chair with a padded seat and foot support. 14 Staff members reported that residents who weren’t cognitively impaired requested this chair specifically once they’d felt how comfortable it was. Since purchasing new shower chairs isn’t always an option, try these adaptations:
In assisted living facilities and nursing homes, a trusted staff member (and the same staff member) assisting with bathing is very important. Think about how difficult bathing would be if someone different were to bathe you each time. If the facility has consistent assignments, and the same person cares for the same resident over time, the caregiver and resident can develop a relationship and tailor the method, time, and frequency of bathing according to the resident’s needs.
Hospitalized patients, unlike nursing home residents, may wish for more frequent bathing or a soothing bath or shower as a way to feel better. Family members can help with this, which can minimize fear and misunderstandings and also allow the patient to schedule bathing according to his energy level and other preferences.
Professional and family caregivers should consider routine bathing options outside the bath or shower. Here again, the use of no-rinse products can make bathing more pleasant and easier. Prepackaged “bath-in-a-bag” products, consisting of up to eight premoist-ened, presoaped, no-rinse, disposable cloths, can be used in all settings. The following is a checklist for using them:
Drying isn’t usually required because there’s minimal moisture. A “bath in a bag” does not require water, so a person can be washed in a variety of places. People living at home at the end of life can be adequately bathed while resting comfortably in a recliner. Even the toilet can be an appropriate place for this type of cleansing; for example, if the person has limited energy, requires an extended period on the commode, or feels pain when transferred, this method might be useful.
If disposable products are too expensive, create the equivalent using a diluted no-rinse product, a number of clean washcloths, and a small plastic bag. Be sure the person is warm and covered before you prepare your equipment:
If a more relaxed way of bathing is desired, the towel-bath method can be very comforting and enjoyable (see The Towel Bath, page 44). This method can be presented to the person as a “nice, warm massage” in bed rather than a “bath.” Avoiding the words “wash” and “bathe” can be helpful to people with dementia, who often associate the words with a cold, frightening, and uncomfortable experience. Once the caregiver is familiar with the procedures, the towel-bath technique is simple, quick, and easy to perform. In facilities that routinely use this technique, it’s useful to have the bags and towels prepackaged by laundry or central supply and place them in the linen closet for staff use.
Going to the beauty parlor or barber is a pleasant experience for many people. Continuing this activity in people with dementia is desirable because it’s familiar, it enhances the person’s physical appearance, and it gives an opportunity to socialize. But a traditional beauty salon may overwhelm a person who has dementia. When a beautician is no longer appropriate or available, separating hair washing from the shower or bath is often useful in preventing agitation.
When hair washing is the most dreaded part of bathing, it’s helpful to wash the hair only when it’s absolutely necessary, using a method that has been found to be the most pleasant and tolerable. For example, if you choose to wash the hair as part of a shower or tub bath, wait until the end, cover the person with dry towels, and then wash the hair, as follows:
When washing the hair outside of the shower room, a basin-and-washcloth method allows the person to remain fully clothed. Here is one:
An in-bed inflatable basin is useful when hair-washing is performed separately from the bath or shower. Other options include a dry or no-rinse shampoo or a no-rinse shampoo cap.
An interactive CD-ROM and video package, Bathing Without a Battle, produced by three of us (Barrick, Rader, and Sloane), was sent to all federally funded nursing homes in January 2004. It is available for purchase online at www.bathingwithoutabattle.unc.edu . 4 A book by the same name (and authors) is also available in stores and online.
Also, a streaming-video Internet broadcast from the Center for Medicare and Medicaid Services in September 2002 was shared with federal and state nursing home surveyors. Entitled Innovations in the Quality of Life, the program presented bathing in the context of a caring relationship rather than as a task to be completed, thereby improving the quality of direct care. Video and DVD copies are available for purchase online at www.pioneernetwork.net .
Another film, produced by the Alzheimer’s Association and developed by two of us (Sloane and Barrick), Solving Bathing Problems in Persons with Alzheimer’s Disease and Related Disorders, is available at www.terranova.org/Title.aspx?ProductCode=SBPVHS .
Nurses in all settings should work with families so that they can better understand the many ways that hygiene can be maintained. Family members may think the person should be showered or bathed more often than is actually needed, desirable, or is actually tolerable. Without information, family members may see less-frequent showering as a way for nursing home staff to get out of doing the work, for example, rather than as a method of individualizing care.
A caregiver is preparing a nursing home resident for bathing and the resident, an older woman with dementia, is resisting. “You think you know more about my own body,” she says, grabbing at the caregiver’s arms and twisting the collar of her blouse. “You don’t want me to live in my own body.” The caregiver says it isn’t so, and the resident counters with, “Well, why don’t you keep your hands off of me?”
This is a scene from a CD-ROM and video package, Bathing Without a Battle: Creating a Better Bathing Experience for Persons with Alzheimer’s Disease and Related Disorders, created by three of us (Rader, Barrick, and Sloane), which depicts actual scenes of assisted bathing that unfold with varying degrees of success. The familiar forms of resistance, such as hitting, biting, and shouting, are shown, as are strategies that caregivers might use.
In another sequence, a caregiver offers a washcloth to an older woman. The woman takes the washcloth and washes her own face. The caregiver then asks the woman’s permission before removing her hospital gown and lets the woman test the temperature of the water before wetting her skin. These actions help the person feel that she has some control, which helps make for a smoother process.
1 large plastic bag containing:
2-to-3-quart plastic pitcher filled with water (approximately 105°F to 110°F), to which you add:
Explain the bath to the person. Make the room quiet or play soft music and dim the lights if this calms the person, while ensuring privacy. Wash your hands. If necessary, place one bath blanket under the person to protect the linen and provide warmth. Undress the person, keeping her covered with the bed linen or the second bath blanket. You may also protect the covering linen by folding it at the end of the bed.
Pour the soapy water into the plastic bag and work the solution into the towels and washcloths until they are uniformly damp but not soggy. If necessary, wring out excess solution through the open end of the bag into the sink. Twist the top of the bag closed to retain heat. Take the plastic bag containing the warm towels and washcloths to the bedside.
Expose the person’s feet and lower legs and immediately cover the area with the large warm, moist towel. Then gently and gradually uncover the person while simultaneously unfolding the wet towel to cover the person. Place the covers at the end of the bed. Start washing at whatever part of the body is least distressing to the person. For example, start at the feet and cleanse the body in an upward direction by massaging gently through the towel. You may wish to place a bath blanket over the towel to hold in the warmth. Wash the backs of the legs by bending the person’s knee and going underneath. Bathe the face, neck, and ears with one of the wash-cloths. You may also hand a washcloth to the person and encourage her to wash her own face. Turn her to one side and place the smaller warm towel from the plastic bag on the back, washing in a similar manner, while warming her front with the bath blanket or warm moist towel. No rinsing or drying is required. Use a washcloth from the plastic bag to wash the genital and rectal areas. Gloves should be worn when washing these areas. Remove the damp towel before you wash the back or when done with towel bath, depending on the person’s wishes and tolerance.
If desired, have the person remain unclothed and covered with the bath blanket and bed linen, dressing at a later time. A dry cotton bath blanket (warmed if possible) placed next to the skin and tucked close is comforting. Place used linen back into the plastic bag; tie the bag, and place it in a hamper.
Adapted from Towel-bath—Totman technique, St. Louis: Calgon–Vestal Laboratories, 1975. Copyright ER Squibb and Sons, LLC.
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