Findings

Bathing Dependence

Bathing dependence varies greatly between people and their physical conditions. Ability to bathe independently did not depend on any one factor. For example, a 63 year old female with left sided paralysis, hip replacement and arthritis in the sacroiliac was dependent upon being bathed, while an 85-year-old woman with arthritis, impaired vision and shortness of breath bathed independently. Several persons, in spite of as many as seven disabling conditions bathed independently. All three mobility-impaired persons bathed independently. An 80-year-old who lived independently in her own home was dependent on being bathed. While another person who had difficulties living independently, bathed on her own.

Bathing dependence generally resulted from illness and/or injury. For example, a 90-year-old mother's dependence was due to falls in the home, and an 80-year-old woman's dependence resulted from a physical injury. No individual was completely dependent on being bathed. They all offered various levels of assistance. For example, one person who required help with soaping, rinsing and drying, transferred on her own. Another person who only needed help in transferring in and out, bathed mostly on her own. Bathing dependence was both physiological and psychological. For example, one person phoned her daughter before and after her bath. Another person has her care-provider remain present in the bath area at all time. A 90-year old mother made sure that her daughter stood outside the closed bathroom door. People's ability to bathe on their own depended on age, severity of disabling condition(s) and their willingness to do so.

Mechanical and Physical Difficulties

Bathing difficulties vary significantly. The most common problem was maintaining balance when bathing and making transfers. Those unable to make safe transfers had abandoned tub-oriented bathing. Other problems were largely due to inadequate reach, poor grasp and low level of thermal sensitivity. Many individuals indicated that because of their inability to "reach low," using controls from the outside of the tub was impossible. Opening faucets and adjusting water temperature are troublesome for many. Those who lack sensation in the hands frequently misjudged the water temperature and got scalded. Low level of illumination made it difficult for bathers to see controls and accessories. In the absence of auxiliary heating, people felt cold while bathing. Inadequate storage caused laying around of articles. This made it impossible to keep the bath space organized. The size of the bathing space presented diametrically opposite problems. Small size restricts movement of wheelchair users and those providing care. Excessively large space makes controls and accessories inaccessible, and wheelchair users become fatigued from wheeling around in an attempt to reach for accessories.

Accessible showers, specially built to provide a greater degree of convenience, are not free of problems. Several users of accessible showers indicated that they have trouble using controls and bathing accessories while sitting on built-in seats. Consequently, many of them were either forced to stand up with water running to reach for accessories, or store them on the seat. One individual had installed a transfer bench and a flexible hose to combat the reaching difficulty. Another individual who has a paralyzed right side, had no use of the grab-bar (since it was located only on the right side). In the absence of a bar on the left side, getting out of the shower safely was difficult. A third person, a lower limb amputee, found it impossible to make transfers to and from the builtinseat. She used a transfer seat to get in and out of the accessible shower, and used the built-in seat to hold accessories.

A majority of persons have difficulty using integrated level type controls. Even though they felt it was easier using such a control, the difficulties were due to: 1) the problems of understanding the color-coded signage for water temperature and flow, 2) the complex operational demands of the faucets requiring two simultaneous actions,push and turn, or pull and rotate, 3) the non-standard nature of these operations. Those with tremor of the hand or arthritis in the hand were unable to fine-tune the temperature and flow adjustments.

Practically all care-providers indicated that bathing people is the hardest task for them, and getting people out of tub is the most difficult part of the task. They reported that narrow passages and awkward layout of bathrooms make it difficult to handle clients with side-by-side movements. They also obstruct the movement of persons with mobility aids. Inadequate space in the bathroom makes it difficult to roll-in wheelchairs. According to homecare-providers, most clients have great difficulty accepting bathing-oriented assistance from other people. They felt that gaining clients' trust and cooperate in the bathing process are the most difficult part of their job. They complained about sliding glass doors and how they pose great difficulty in transferring people in and out of the tub.

Some of the other difficulties they mentioned included:

lack of space between tub and adjoining fixtures,
inadequate space around the tub,
unavailability of a proper transferring device,
slippery floor conditions,
inadequate lighting,
excessive postural stress resulting from bending over,
client's unwillingness to be bathed,
client's ability to assist, and
fatigue of bather.

Care-providers find it difficult to shower clients in a shower stall because they themselves become completely drenched.

Unsafe Practice

Both individuals and care-providers frequently practiced unsafe methods while bathing or assisting with the task. This was due to not understanding the associated risk level. Standing while bathing in the absence of adequate grab-bars was the most common of all unsafe practices. Some people stood up to soap their underside knowing full well that they had a balance problem. Others reached out to grasp objects fearing they would fall. Some people had stored accessories on the bathseat, thereby decreasing the seating area and increasing the chances of sliding off. An individual who walks with the help of a walker adopted a series of very dangerous methods to make transfers and regulate water temperature. While transferring, he did several complex tasks simultaneously while holding on to the walker with one hand and grasping the wall-mounted grab-bar with the other. He then lifted, dragged and bumped his legs up against the tub. While his hands tremble from the excessive force, he transferred one leg at a time into the tub. The method he adopted for adjusting the water temperature is equally dangerous. He operated it by kneeling down on the narrow floor space between the tub and the toilet, grasping the walker with one hand, extending himself over the rim of the tub to reach the controls. The lighting level in the tub was also very low.

Numerous individuals observed unsafe bathing practices and jeopardized their safety and well being. For example, by placing throw rugs outside the tub, many individuals encouraged tripping and catching their walker/cane. Objects scattered around the bathroom constituted hazards for everyone, especially those with visual impairments. One individual admitted hanging on to the bathroom door and the sink to make transfers. Another person who had difficulty reaching the controls from outside the tub, regulated the water temperature from the inside and often got scalded. A care-provider bathed her 90-year-old mother in a tub that had no grab-bars. The tub was equipped with sliding glass doors. When stepping in and out of the tub, the mother leaned on the glass doors.

Common Accidents

Bathing-related accidents are due to the physical and mental stress that both care-providers and clients experience. These problems are compounded by medication and fatigue from heat. Several individuals had either fallen or come close to falling in the bathroom. An individual who has hip problems and arthritic knees, was unable to get up after a tub bath. She sat on the tub floor for thirty minutes, rolled over the tub edge to grab the sink, and dragged herself out of the tub. Many people have reported falling into the tub while arising from the toilet seat. One of these people used her emergency beeper for assistance and was rescued by her family. Although none of the participants were ever severely scalded, many have been and continue to be mildly scalded because of poor sensation of the hands.

The risk of falling along with clients is a well known fear among care-providers. Yet, only one among those interviewed admitted having done so. According to the care-providers, if a bathing accident will usually occur under the following conditions: 1) toward the end of the bathing procedure since clients are both tired and relaxed at that time, 2) after a care-provider as been on a case for some time, because a client's ability to assist diminishes as his/her condition worsens, and 3) when transferring a client out of the tub, because the client's body is damp, the tub inside and the floor outside are wet and slippery, and the client and the provider are fatigued.

Unsafe Bathing Conditions

Even though a concern for safety is on the rise, a large majority of the elderly who live in older homes continue to bathe in unsafe conditions. In spite of all their difficulties, they make no modifications to their outdated bathroom, and expose themselves to unnecessary risk. There are several reasons why they make no environmental changes. During their early phase of functional decline, they simply make behavioral changes in the way they bathe, hoping that this will compensate for the lack of safety. Because a majority of them live on fixed incomes, retrofitting the bathroom is an economic burden they are unable to bear. Even if many individuals are willing to make modifications, the condition and layout of the buildings they live in do not lend themselv es to make bathroom modifications. Older residents are generally uninformed about the type of technical assistance they need andwhere to look for it. They see modifications as an acknowledgment of their own disabilities and they are embarrassed by it. They think modifications will effect the value of the property and/or burden the successor with undoing them.

Present Safety Measures

Both individuals and care-providers do take precautionary measures to ensure safe bathing conditions. For example, most bathers and care-providers place slip-resistant bath mats inside and outside the tub to prevent skidding and falling. Those with grab-bars in the tub area hold on to these bars when bathing. Many people make sure that hotel bathrooms have grab-bars before reservations are made. Most people ensure safety by being very careful about every activity. Careproviders ensure safety by remaining vigilant and remaining with the person all the time. Home care-providers wear sneakers in the bathroom and ensure good illumination in the bath area.

Constant Stresses and Fears

Falling and colliding with hard, pointed fixtures was the most common of all fears. People were afraid of falling while standing in the shower, during transferring in and out of the tub, and while holding on to a grab-bar. Some were afraid of getting scalded because of misjudging the water temperature. One person had abandoned tub-oriented bathing because of her fear about not being able to exit.

Both care-providers and clients experience physical and emotional stress due to bathing. The most common stress is physical. People get tired during and after showering, and they experience shortness of breath. Non-ambulatory clients tire themselves easily from movement and from the level of activity that is demanded by being bathed. Most home care-providers get fatigued by bathing clients, assisting them during transfer, and from bending over. Many experience serious emotional stress. This is because they develop a family-like bonding with their clients. The emotional stress results from the personal nature of the service they perform and it is further heightened by the long hours of client contact and proximity they maintain.

Many family care-providers experience very high levels of mental stress from providing care to their relatives. Emotional stress is the most difficult part of being a family care-provider, who sometimes are themselves older and have other family responsibilities. In addition to looking after other family members, many work outside their homes as well. Consequently, they feel pressured to meet their obligations. Most of them are exhausted from providing constant attention and are burdened from having to contend continually with family care. Often, lack of acknowledgment from the one receiving care greatly escalates the level of emotional stress.

Client-related stress varies with:

size, shape and physical condition of the client, and
the level of nervousness, cooperation, and willingness the client may display during bathing.

Environment-related stress is dependent on:

the availability of transferring devices, and
physical features of the bathroom such as the tub height, presence of sliding glass doors,

bathroom layout, narrow width of clearances, floor conditions and low lighting level.

Care-provider related stress is a function of height, weight and physical condition of the careprovider, and the time pressure resulting from trying to complete all tasks quickly.