Nursing home bathing transformed
Draped in a thin, white sheet, Mrs. Williams tried to look dignified as she was paraded past her peers on the shower chair, her bare feet dangling in the air. As her aide turned around the corner, I caught the rear view-and it was a rear view; the sheet covered only her front, leaving her back and behind exposed. My shocked expression didn’t escape the notice of 83-year-old Ms. Johnson, who was sitting across from the nursing station watching the passersby. She nodded toward Mrs. Williams and raised her eyebrows at me. This was exactly what she’d described with outrage in her psychotherapy session earlier in the week.
There are many aspects of life in a nursing home that could be improved by a customer service approach, but the bathing experience is high on the list for an overdue transformation. Showers, for most of us throughout our lives, are pleasant and revitalizing. Showers in nursing homes, however, often start with a humiliating transfer and lead to a cold room for an all-too-brief cleansing. The gap between what is and what could be provides the perfect opportunity to distinguish your nursing home for its customer service and to provide a positive experience that improves, rather than challenges, the mental health of the residents.
In their 2009 study, “Satisfied residents won’t recommend your community, but very satisfied residents will,”1 Margaret Ann Wylde, PhD, and her colleagues found that very satisfied residents are four times more likely to recommend an independent living community than residents who were merely satisfied. Nonphysical factors were more likely than physical factors to influence satisfaction, and among the top nonphysical factors were feeling that the residence is home, feeling safe and secure, having a sense of control over what they do and maintaining privacy. Nursing home showers incorporate all of these elements, and each was raised by the residents I spoke with about their bathing experiences.
A MENTAL HEALTH ISSUE
The MDS 3.0 has put an increased emphasis on residents’ perceptions of depression. According to Erickson’s Psychosocial Stages of Development, the last phase of life focuses on “Ego Integrity vs Despair,” with the hope that we look back on life with a sense of fulfillment and the belief we have lived wisely. Despite the fact that it can happen to anybody, most residents feel that if they’d lived life wisely, they wouldn’t be in a nursing home. The most frequent comment I’ve heard over the years is, “I never thought this would happen to me.” Unpleasant, dehumanizing showers increase feelings of regret, bitterness, and despair-an unsuccessful resolution of this developmental phase.
By contrast, when showers are pleasurable, rejuvenating experiences, they can reduce depression. A recent Yale University study even suggests that the physical warmth of a shower can act as a substitute for emotional warmth, reducing loneliness.2
FOUR RESIDENT/STAFF CONCERNS
I spoke to residents and staff at various facilities around the country-not a representative sample, but illuminating-and combined this feedback with my 15 years of nursing home work and my training as a psychologist. I’ve identified four main areas of concern about the shower procedure: scheduling, equipment, technique and privacy. Recommendations for addressing these concerns, which correspond to top customer service factors, are provided.
1. Scheduling issues (control over what we do/residence as home). At home, we’re able to choose when we take a shower. To create a more homelike experience while working within the realities of long-term care, residents benefit from increased control over the timing of their showers.
Allow residents to choose their bath schedule (day versus evening).
Remind them about their shower early in the shift, and, if possible for residents with a strong need to be in control, give them the option of choosing a time within that shift (for example, before or after lunch).
If the facility has a policy of allowing more frequent showers upon request, residents should be made aware of this, because residents assume they can only get the scheduled number of showers.
Training regarding the shower frequency policy will help the line staff respond warmly to requests for increased showers. If the policy is in place but the residents sense staff resistance, then only the boldest, most assured residents will actually pursue something that can make them a very satisfied customer.
Residents may want increased showers temporarily, such as one active lady who only wanted to shower more often in the summer months (but was afraid to ask).
2. Equipment issues (control/residence as home). We try to make our own homes as comfortable and efficient as possible, but in most cases the staff and residents are unable to make changes to the shower room without administrative approval, creating a loss of control. The improvements they suggested to me did not involve costly renovation, but minor adjustments with a big impact.
There was universal agreement that the shower rooms are too cold. Consider devices such as floor warmers or towel warmers to address this problem, and train staff members to be sure their residents are well covered immediately after bathing.
Residents and staff also felt much could be done to improve the institutional look of the shower rooms: “I remember one resident referred to getting a shower as ‘going to the car wash.’ Soon after, one of the aides went to the dollar store and, out of her own funds, bought some decorations and pretty curtains and made it look more inviting.” Follow her lead.
Providing a shelf for resident belongings can improve the manageability of the process.
Keeping bathtubs in proper working order allows the certified nursing assistants (CNAs) to offer that option to their residents.
3. Technique issues (control/safety and security). The residents offered a long list of suggestions here, while the CNAs, not surprisingly, tended to focus not so much on their own bathing techniques but on the procedures they’re required to follow.
Consider employing shower aides with the main role of giving showers to residents. Residents and staff report these designated aides tend to give better, faster and more individualized showers because they know the residents’ bathing preferences.
Allow bed baths, which can be as effective as showers. At times they can be more so, such as when staff members can’t completely shower residents because they’re in a mechanical lift that covers their backs. Some residents report pain during the transfer to the shower room and prefer bed baths because of this.
Unless it could harm the residents, try to do things their way to increase their sense of control and security.
Residents appreciate being bathed by staff members who are organized, thorough in cleaning and drying, and respectful rather than wasteful of their personal shampoo and other supplies.
4. Privacy issues (maintaining privacy/control/safety and security). During most other aspects of care, residents can be partially clothed, but showers necessitate nudity. Residents react differently to this: from embarrassment, to reawakening the trauma of past sexual abuse, to sexualizing, to acceptance. (As one male resident put it, “When in Rome…”) Some adjustments in technique can provide greater privacy, increasing residents’ sense of control and feelings of being safe and secure.
If it’s not possible to undress and clothe residents in the bathing area, train staff to fully cover residents during the transfer from their beds to the shower room. I’ve seen so many half-naked residents roll through the halls that I wondered if it was feasible, but a CNA I respect told me, “If the aide does it properly, the resident isn’t exposed. It isn’t difficult and it doesn’t take much time.”
Close curtains and protect residents’ privacy when others are in the shower area. Hold essential staff conversations through the shower curtain rather than in the bathing area.
If a resident is making sexual overtures when bathing, consider changing to an aide of that resident’s gender or having two aides give the shower. One aide advises, “If it’s a situation where the resident just becomes aroused during a shower, I’ve had the most luck with just ignoring it and finishing the shower.”
Allow the residents to complete as much of the washing as possible.
Discuss difficult shower interactions with team members, including social workers, psychologists and family members.
Resident bathing is an opportunity to provide a mood-enhancing and revitalizing experience. As one element of your good customer service, this can result in very satisfied residents who recommend your home to others.
Eleanor Feldman Barbera, PhD, is an author, speaker and consultant on psychological issues in long-term care. For more information, visit Dr. Barbera’s website
- Wylde MA, Smith E, Schless D, Bernstecker R. Satisfied residents won’t recommend your community, but very satisfied residents will. Seniors Housing & Care Journal 2009; 17 (1): 3-13.
- Bargh JA, Shalev I. The substitutability of physical and social warmth in daily life. Emotion, May 2011.
Long-Term Living 2011 October;60(10):41-43
Topics: Articles , Rehabilitation