Overcoming objections

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Instead of an in-and-out assembly line, pamper residents, experts say.
Instead of an in-and-out assembly line, pamper residents, experts say.

When it comes to bathing residents with special needs, many long-term care facilities find themselves in a slippery situation.

Practices designed to ensure safety and efficiency can undermine a resident's sense of independence, leading to sometimes violent shows of resistance or less-then-stellar hygiene compliance.

But simplifying the process with the right equipment — and employees and procedures that promote flexibility — can restore the comfort often associated with bathing earlier in life.

“Anytime someone has to have assistance with something they've spent a lifetime doing themselves, we can run into difficulties,” says Ruth Drew, director of family and information services for the Alzheimer's Association. “That includes bathing. Think about how you would feel if someone you'd never seen before were asking you to get undressed for a bath, and you don't even think you need a bath.”

For years, interior designers have worked on making patient rooms and community spaces more “homelike.” Bathrooms have often been overlooked in this conversion.

Today, options abound and skilled nursing and assisted living communities are taking note, says Megan Multanen, national sales manager for Best Bath Systems.

“We see a real interest growing there,” says Multanen, who recently helped set up 12 baths incorporating universal design in spa-like suites at a private facility.

The best baths, showers and spa products offer more than sleek looks. Quieter motors, better seating and options that let residents choose between bathing or showering can be the difference between bathing bliss or bathing battles.

MTI Baths, maker of customizable whirlpool tubs, puts stock in the power of water to purify and potentially heal. The company points to research by the National Arthritis Foundation that says water's gravity-reducing effect reduces pressure on joints, muscles and bones. Warm water therapy — even just a restorative soak — can be a plus for patients with fibromyalgia, arthritis or low back pain. MTI reps say hydrotherapy is also indicated for patients with diabetes, insomnia, stress and poor circulation.

“The combination of warm water and water movement below the surface enhances circulation to extremities through massage and by dilating blood vessels,” says David Anderson, national sales manager for Apollo Bath. He adds that baths also trigger the release of endorphins, the body's natural pain relievers.

But what about residents with more severe needs, such as multiple sclerosis, severe obesity or dementia? Showering also can deliver a relaxing experience, especially if the process provides a measure of privacy and allows a resident to control some variables.

One factor that can't be overlooked, says Fran Spidare, Invacare's product development manager for safe patient handling, is the speed at which bathing or showering is completed. Having enough tubs and showers per facility is a critical element in a successful hygiene program.

“You want it not to become like a car wash,” says Spidare. “It's a human being in there, and you have to allow time for that.”

For maximum safety, adds Lee Penner, president of Penner Patient Care, there should be consideration given to “a transfer system that is an integral part of the bathing unit.”

This could include things like a swivel seat; whatever it comprises, the transferring materials should be able to go into the water with the resident, he adds.


Spidare says investing in new bath equipment is a twofold scenario: Administrators want something that is comfortable for the resident yet helps make the caregiver's job easier. Many modern products are designed to deliver on both counts.

Invacare's Therapure line, for example, capitalizes on removable jets to give facilities an easy-to-clean bath. Such tubs can work well in large bathing rooms or any area where multiple residents might be sharing the same equipment.

More importantly, Spidare says, the jets operate below the surface without creating a torrent of bubbles on the surface. That's key for dementia patients who might be upset by the noise and motion of high-velocity jets. Drew also notes that bubbles can add to depth-perception issues experienced by many Alzheimer's patients.

Equipment that's easy to disinfect is more prevalent than ever. Apollo offers a UV water purification system on its whirlpool baths, which kills bacteria while the patient bathes to reduce the chances of transmission through open areas such as diabetic foot lesions.

MasterCare's BathAire technology blows only heated air out of self-sealing aerators with check valves, ensuring that used water doesn't stagnate in supply lines. The company has also invested in equipment that provides support for incontinent patients. The company's FlushCare feature allows residents to void in a tub or shower cabinet fitted with a special compartment and sealed lid.

“It is a sanitary and more dignified way to eliminate accidents for staff and embarrassing moments for residents,” says Marketing Manager Rachelle Congdon.

Lifts also can ease the process, with some designed specifically to move patients from the toilet to a tub or shower stall bench.


Other companies are looking at options that require less movement but allow more access.

Best Bath's roll-in shower can move from one private room to another. At 29 inches by 29 inches, it fits in most standard-size showers. And unlike a traditional seated shower that restricts access to a patient's underside, the Oasis model features four pads that drop down independently to make sure private areas get cleaned.

The Oasis promotes safety for both the patient and caregiver because there's no lifting or awkward repositioning required, says Multanen. Either a caregiver or a patient uses a remote control to deliver a complete head-to-shower experience, or aim sprayer jets or a handheld head to avoid specific areas (such as a broken bone or recently styled hair).

As Anderson notes, it's critical that bathing protocols adhere to doctor's orders to avoid surgical sites or casts, even if one staff member is typically enough to help a given resident shower, temporary needs may require a second employee to help secure waterproof coverings or implement other precautions. Active wounds with drains always should be kept dry, though Anderson says bathing can help prevent pressure wounds by lessening the weight pushing down on the gluteal and coccyx areas.

Recumbent baths also cater to patients with physical and cognitive limitations. Apollo's Pacific Shower Bathing Trolley works well with dementia residents who may feel more secure in a recumbent position, Anderson says. An optional wedge pillow helps elevate the upper body so residents feel less threatened by the water level when used as a tub, and the sides rise to block the view and reduce fears of rolling out of the tub.


Whether they're showering or bathing, patients often appreciate the same basic courtesies. Drew says that begins with being given choices. Bath or shower? Morning or evening? She tells the story of an Alzheimer's patient who always bathed the night before church when growing up. His daughter often gets him to the tub willingly by claiming it's Saturday.

“It's so worth it to know the person (being cared for) and cater to their needs,” explains Drew. To develop that kind of knowledge about a resident, facilities could assign the same staff to a resident routinely. Even offering a scented soap reminiscent of home can help, says Spidare.


Many Alzheimer's patients, in particular, act out in response to bathing. Drew says they could be acting out of confusion, feel unsafe or simply be unable to communicate that they're cold. Simple strategies such as allowing them to shower with a towel over their lap, using heat lamps, running a warm showerhead over the back while a tub drains or having warm towels on hand can all make the process feel better.

Much like dementia patients, elderly vets may act out at bath time if they associate water or the intimate act of bathing with a suppressed trauma. They may hit, pinch, curse or throw objects, says Yvette M. Rose, MSN, RN, who presented evidence-based guidelines for helping such residents during the 2015 Aging in America Conference.

Rose says the mental health of elderly males with delayed-onset post-traumatic stress disorder is a growing concern in long-term care facilities. Her guidelines are adapted from principles used with Alzheimer's and other dementia patients, and intended to provide a bathing experience that reduces agitation, aggression and discomfort.

Tapping into positive associations can help some patients as well.

The Adjust-a-Sink is built on that concept. The product is typically used in long-term care salons, making hair washing more comfortable for those who can no longer lean back or those who use wheelchairs.

“It allows a more pleasant, dignified experience for the resident,” says President Arden Olson. “There's also no need for a transfer, so there's less potential for a fall with wet floors and less risk with lifting.” “When patients feel good about their appearance, they feel better overall,” Olson says.


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