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Nursing home bathing transformed

October 12, 2011
by Eleanor Feldman Barbera, PhD
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From endurable to enjoyable

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.

Recommendations:

  • 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.

Recommendations:

  • 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.

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