Improving the Bathing Experience.

Our collaborative bathing studies program, combining researchers from the Oregon Health Sciences University and the University of North Carolina at Chapel Hill, has been studying the long-term care bathing experience for several years. Recently I contributed a chapter based on these studies to a forthcoming book tided Bathing Without a Battle (Springer Publishing, to be published in November). We've encountered several reasons that bathing can be a "battle" (and they're probably familiar to most direct-care providers), but more importantly, we've developed suggestions for using equipment to optimize the resident's bathing experience. This article will summarize a few of the more important ones.

The central fact is that bathing is a highly individualized process for facility residents. Not all residents use the same modalities or, even within a modality, the same equipment. The equipment and its particular uses must be matched to the individual resident's needs and circumstances.

There are three principal modalities: showers, tubs and in-room bathing. In our study, we found that two-thirds of residents use showers, approximately 25% use tubs, and the remainder require in-room bathing. Each of these modalities has important considerations for the individual resident.

Showers. This modality is indicated for residents who are independent and want to shower; for those who need to rinse with running water to "feel clean"; for those who are unable to use a tub but still want the traditional soap-and-water bath and for those with injuries or wounds that should not be submerged.

Perhaps the most important consideration is simply keeping residents warm. Showers are notorious for chilling people before and after the hot water flows. One might consider focusing a heat lamp just in front of the shower, but not so close that the caregiver, if there is one, gets overheated. Large, warm towels should be available to wrap the resident in before and after the shower, and bathing supplies should be at hand, so that there are no delays while the caregiver runs off to find something.

Shower chairs are necessary for some residents, but comfort has been an issue with some of them. There's no need for shower chairs to be uncomfortable these days; there are options available that are soft and have good-size openings for cleansing personal areas. Meanwhile, the shower stalls themselves should be large enough for comfortable caregiving, but not cavernous.

An important consideration for residents with dementia is the severe discomfort some feel when water from the shower hits their faces or hair. For these residents, hair washing can be done with a handheld shower device, or perhaps should be reserved for the beauty parlor.

Tubs. One should realize that no matter how much effort one puts into product selection or how good the product, many residents will never use a particular tub, because no one tub will work for everyone. Nevertheless, the specialized tub is important, because the traditional "homelike" tub presents problems in this setting. Often the tub is located too close to the wall and, wherever it is positioned, it is always too low for practical caregiving. It also requires that residents be capable of getting in and out.

In selecting the larger, specialized tub, it's important to make sure that the bathing room is large enough to accommodate its convenient use and that it is easily accessible for both caregiver and resident. The lifts that raise residents high off the ground into a tub are never good; they're simply too frightening for them. It's better to have a transfer board or slide. Some tubs have side entries, which solve the accessibility problem, but require the resident to wait in the tub as it fills. This can be a soothing time for agitated residents if they are kept warm, but the filling process can be noisy and disturbing to some residents.

The cleaning of the tub between baths can be quite time consuming, particularly if the disinfectant has to be run through various jets. Ultraviolet technology can solve the time problem but is quite expensive.

Some observers have noted that the physical appearance of these specialized tubs can put some residents off. In my view, the appearance of the tub is not nearly as crucial as how staff approach and treat the resident. If they can make him or her feel comfortable, the tub's appearance is not likely to be an issue.

In-Room Bathing. This is indicated for residents who are anxious about being transferred, who get cold easily or who experience severe pain with movement. There are some useful techniques one can use for this modality--for example, the "towel bath." One puts a large bath blanket and a smaller towel into a plastic bag with no-rinse soap and warm water. The resident has all clothing removed and lies in bed covered with a sheet. The sheet is folded down from the specific areas of the body to be cleaned and the moistened bath blanket rolled over these areas, using a gentle massaging technique. The smaller towel is used for cleansing personal areas. Afterwards the sheet is pulled back over the resident. The procedure is both comforting and cleansing, and we have seen it have a profoundly calming effect on residents who are agitated.

Using a basin to bathe residents in their rooms might seem primitive, but it should be remembered that some residents are comfortable with the idea, having used this technique to bathe themselves during their childhood or even later.

Finally, for all bathing modalities there are several accessories that, while not essential, are nice to have--e.g., no-rinse soaps, personalized shampoos and body washes, and perfumed soaps. Also useful are the small, inflatable tubs that are positioned behind the head and used for washing the resident's hair.

In sum, it is important to make sure that the bathing experience is as personalized as possible. Efforts toward this end will pay off in fewer "battles" and bad marks for quality of care.

Philip D. Sloane, MD, MPH, is the Elizabeth and Oscar Goodwin Distinguished Professor of Family Medicine and codirector of the Program on Aging, Disablement and Long-Term Care, the Cecil G. Sheps Center for Health Services Research, at the University of North Carolina.