Designing bathing rooms that comfort.

Many caregivers find giving baths or showers one of the most difficult aspects of caregiving. It's a time when residents with dementia are often most combative. But it doesn't have to be that way. While both the caregiver approach and the design of the bathing room are important, this article focuses on the latter. Because the environment is experienced primarily through our senses, this article is organized by the different sensory modalities. The greatest emphasis is always given to how the resident is experiencing the setting, with a secondary focus on the ways the environment can support the caregiver.

Visual Environment

Bathing rooms in most long-term care settings are sterile, institutional, and frightening spaces filled with unfamiliar equipment--tubs with mechanical lifts or sides that open up and look like they might swallow you, chairs on wheels, or gurneys with arms that look like construction cranes. Soiled utility carts, lifts, scales, extra wheelchairs, and boxes of supplies may also be stored here and there. It's not surprising that the person who needs some assistance with bathing resists.

The first step is to keep it simple. Find another location to store the extra equipment and supplies. If absolutely no other room is available for the carts and lifts--or if they are necessary for bathing purposes--find a way to hide those visual distractions behind a partition or curtain. They can still be physically accessible, just not visually accessible.

Once you've eliminated the clutter of extra equipment and supplies, the next step is to make the room itself more visually pleasing. Think about where the resident's eyes focus throughout the bathing process. What do you see as you first enter the room, as you get into the tub or shower, as you are being bathed, and as you are getting out and being dried? Do signs and notices about how to use different pieces of equipment constitute the only "art" in the room? If so, make them less conspicuous to the person being bathed. Laminate any attractive posters or prints that might be hanging to keep them dry in the moist atmosphere of the room, and hang them where the resident is likely to see them during different stages of the bathing process (undressing, bathing, and dressing). Add small decorative shelves with knickknacks such as shells, decorative bottles, pretty hand towels, or tissue boxes.

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Pay particular attention to where people look during the bath or shower. If they are reclined, could you put a print on the ceiling? In the shower, laminated photos may provide something more interesting to look at than bare walls. Some facilities even put up photos or drawings of the different steps in the bathing process to cue the resident as to what will happen next.

Another strategy that can help--both in downplaying institutional features and highlighting residential-looking features--relates to using visual contrast. Many older people, and particularly those with dementia, have decreased contrast perception. Therefore, when necessary institutional features are present (such as signs or equipment), the more you can make them the same color as the background, the less they will be perceived. For residential features--such as art or knickknacks--that you are adding to the environment, make sure they stand out visually in the environment by giving them a brighter color that contrasts with the background color of the walls.

Finally, lighting is very important in bathing rooms. It needs to be sufficient--particularly near the tub and shower--so you can see that the person is getting clean. If the person being bathed is looking up (in a reclined position or lying supine on a bath gurney), be sure no lights shine directly into the bather's eyes. Get into the tub or lie on the bath gurney yourself and see what the bather is looking at. If you need to add lights, consider cove lighting, which bounces light off the ceiling (this is called indirect lighting), or wall sconces. While lighting needs to be adequate, it should not be so bright that it feels overly clinical. Some people may actually be more comfortable in a room with softer lighting. Therefore, the best solution is to put the lights on a rheostat so they can be individually adjusted for each person's preference.

Auditory Environment

With tile or solid-surface floors and walls, noise reverberates in bathing rooms. These hard surfaces can also cause echoes, which may make noise even more overwhelming. There are two basic techniques to minimize noise in the bathing rooms. The first is to stop the noise at its source. For example, don't let others walk into the bathing room when someone is being bathed. This is why it is so important to try to get extra carts and equipment out of the bathing room when possible. Even if the carts and equipment can't be seen, just the sound of someone opening the door and coming in to retrieve them is enough to set some people off, fearing even more for their already compromised privacy.

The other basic technique to minimize noise is to add materials that will absorb sound. More fabric in window and shower curtains and lined window or shower curtains will absorb more noise. As a general rule of thumb, the fabric should be three to four times the width of the opening to have sufficient folds to make an acoustic difference. Alternatively, add water-resistant acoustic panels. These can be plain or decorative.

Once negative noises and echoes are under control, you can consider the therapeutic benefits of adding positive sounds, such as music. A small collection of CDs that includes classical, New Age, some oldies, and possibly country music will suit almost anyone. Better yet, try to find a few tunes you can both sing along to ("I'm Gonna Wash That Man Right Outa My Hair" from South Pacific comes to mind as especially appropriate).

Tactile Environment

As mentioned above, bathing rooms are typically full of hard surfaces. This is important to the facility because of the presence of moisture and the need to clean the area between different residents' baths. But it does not make for a very comfortable experience. When you think of being comfortable, you typically think of being surrounded by warm, soft materials. Few people at home have neither carpeting or at least a bath rug on the floor to stand on. That's because tiles are cold and uncomfortable underfoot. Try it at home in your own bathroom--stand around naked and wet on a tile floor and see how comfortable (or rather uncomfortable) it is. While carpeting a bathing room in a long-term care facility may be impractical, providing something soft on the floor, like a (washable) rug, can make a big difference in the experience.

Another important aspect of flooring to consider is how slippery the floor gets when wet. In installing a new floor, select a flooring material with a high coefficient of friction (COF), ideally above 80. A number of coatings can be used with existing floors that will substantially increase the COF.

For some people, nothing is more wonderful than being wrapped in a warm towel or blanket. Commercial towel warmers are available that can make bathing a much more luxuriant experience.

When people are using showers, it is important for them to have stable grab bars to hold onto for balance. For many years, we have relied on stainless-steel grab bars, which are aesthetically unappealing and often cold and hard to the touch. Today, there are a variety of powder-coated grab bars available that come in decorative colors, have a nonslip grip, and are much more appealing.

Room temperature is critically important to the comfort of the person being bathed. Older people are highly sensitive to drafts and are easily chilled. Anyone taking a shower is likely to have a significant amount of exposed, wet skin that can quickly feel cold. Also, many of the tubs available on the market only cover the bather from the waist down, leaving the upper portion of the body wet and exposed to drafts and chills. Therefore, every bathing room should be equipped with an extra heat source. If the caregiver is overly warm, almost to the point of sweating, the temperature is probably about right for the older person being bathed. Common heat sources include heat lamps or radiant heat panels. Be sure that the heat source is not a potential fire hazard.

Conclusions

In long-term care settings, the bathing room is one of the most persistent remnants of the old institutional model, where the goals of staff efficiency and utility still reign supreme over the psychological and emotional comfort of the person being bathed. But this can, and indeed must, change to reflect our changing cultural values about long-term care. If the priorities in long-term care are to recognize and support the cognitive, emotional, psychological, and spiritual needs of individuals, as well as their physical needs, then all spaces need to reflect these goals. This is especially true for spaces where the most personal care--such as bathing--is provided. How a facility manages the minutiae of life, such as the bathing process, including how bathing rooms are designed and decorated, can speak volumes about the quality of a care setting.

Margaret P. Calkins, PhD, explains how using a sensory approach can help to create an elder-friendly bathing environment

Margaret P. Calkins, PhD, is President of I.D.E.A.S., Inc., an environmental research and consulting organization specializing in settings for elders, based in Kirtland, Ohio. For further information, phone [phone] or visit www.ideasconsultinginc.com. To send your comments to the author and editors, e-mail [e-mail]. To order reprints in quantities of 100 or more, call [phone].

This article is adapted and condensed from "The Physical Environment of the Bathing Room," by Margaret P. Calkins, in Barrick AL, Rader J. Hoeffer B, Sloane PD, eds. Bathing Without a Battle: Personal Care of Individuals With Dementia. New York: Springer Publishing Co., 2001 With permission.