Better bathing for residents with Alzheimer's: can caregivers help residents with Alzheimer's cope with bathing? A Massachusetts pilot project investigates

Nursing Homes, April, 2004 by Janet Strassman Perlmutter, Lois Camberg

Most experienced nursing staff members would have no trouble guessing a CNA's least favorite job on an Alzheimer's unit--bathing. The Commonwealth of Massachusetts recently funded a pilot project to improve working conditions for frontline staff in nursing homes and enhance quality of care for residents with Alzheimer's Disease and Related Disorders (ADRD). Bathing was chosen as the area most in need of attention.

When asked what they disliked about bathing residents with ADRD, CNAs cited examples of aggressive resistance that caused them emotional distress and concern for their physical safety. Some of the behaviors reported included kicking, scratching, grabbing, screaming and cursing at CNAs, pulling on shower hoses, and pounding the bathwater, soaking the CNA and the tub room. One CNA reported, "A soiled patient was fighting and I got scratched and had to go to the hospital for a tetanus shot." In fact, bathing can be a time of increased risk of injury to residents and caretakers caused, in part, by physical struggles.

Such resident behavior comes as little surprise when one considers the bathing experience from the perspective of a resident with ADRD. Residents who are disoriented are predictably irritated or agitated by splashing water, the multiple transfers from bed to bath, being naked in front of others, time-pressured CNAs, or simply a dislike of showers or baths.

Standard care in participating nursing homes in this pilot project entailed washing each resident on a prearranged weekly schedule in moderate-to large-sized sterile, windowless rooms often described by residents and CNAs as cold, referring to both temperature and the stark atmosphere. In some settings the tub or shower room was oppressively hot with no apparent air-circulation system. In others the tub room doubled as a warehouse for spare wheelchairs and equipment. Residents were assisted and belted into either a stiff shower chair or a tub chair and, in the case of a bath, elevated several feet in the air, swung over the deep bathtub, and mechanically lowered into the tub.

Was there a safer, more pleasant, and healthy alternative?

The Project

Two CNAs with specific training about Alzheimer's disease were selected by the staff developers at four nursing homes to participate in the project. Their goal: to apply the recommendations of Joanne Rader, who provided training to the facilities based on a publication she edited. Bathing Without a Battle: Personal Care of Individuals With Dementia. (1) The recommendations indicated that the distress associated with bathing residents with ADRD can be decreased or eliminated to make the bathing experience positive and pleasant for both resident and caregiver. The key, the authors found, is to change bathing from a task performed on a body into an activity between two people in a relationship. This involves identifying and implementing a bathing plan individualized to meet the needs and preferences of each resident. They further recommend consideration of nontraditional bathing techniques that can be managed with in nursing facility guidelines and constraints.

Each CNA chose one resident with a history of bath refusal and aggressive behaviors with whom to try an individualized bathing approach. CNAs and staff developers agreed to attend training sessions and project meetings and to document their experiences on checklist forms. CNAs were interviewed immediately after bathing trials.

Strategies for Optimal Bathing Experiences

CNAs were instructed and encouraged to experiment with several different bathing strategies during the six-month trial period.

Towel bathing. Project CNAs learned a towel-bathing techniquein which a resident is cleansed thoroughly using warm, damp, soapy towels while remaining in bed. I he resident stays under the warmth, comfort, and privacy of blankets, in the relative familiarity of his or her room, and is washed without the distracting and, for some, painful spray of a shower.

CNAs reported some initial awk wardness with the new approach, including pressure to complete the bath before the wet towels cooled. Once towel bathing is learned, however, it can be done by a CNA working alone in less than 15 minutes, often in less time than it takes to give a tub bath. Even in early experiences with this technique, staff reported positive outcomes. "It helps calm agitated people," reported one CNA. "It saves time: No time is lost transferring patients into shower or tub," added another. And staff remarked that the towel bath is good for observing skin condition.

Benefits of this new approach quickly traveled beyond the scope of the study. One CNA reported that towel bathing was a wonderful alternative to working with non-ADRD residents who didn't like bathing. "And it would be good for want-to-stay-in-bed types," added another CNA, emphasizing that towel bathing could be a matter of preference rather than need.

CNAs also liked towel bathing for working with residents with late-stage disease and those who were difficult to transfer because of hip fractures, paralysis, or recent surgery. They also thought it would be useful with residents "on precautions" for contagious conditions, such as skin infections, because they could be bathed without leaving their own rooms.