When people enter residential or respite care, many of their personal likes, sense of dignity and privacy give way to a facility’s routines and requirements especially in bathing and toileting. Even with dementia-friendly care, a practical focus on personal needs and respect for people with dementia, privacy cannot be guaranteed.
Ageing and cognitive impairment mean help is eventually needed with bodily tasks. A goal for dementia-friendly care is personal care practices protecting privacy wherever possible, respecting a person’s wishes, and supporting independence for as long as possible.
Changes you can make now
- Soften institutional-style bathrooms by hanging pictures on walls, placing decorative towels on towel rails and using indoor plants if appropriate.
- Record people’s bathing preferences and what they can do so they are helped according to need.
- Have organisational policies valuing flexibility around personal care tasks.
- Give people plenty of time to wash and dress in a relaxed manner and encourage as much independence as possible.
- Train staff in appropriate communication during personal care and bathing to uphold dignity and privacy.
- Fix handrails and grab bars in bathrooms.
- Paint bathrooms in warm peach-coloured tones to add warmth and flatter skin tones.
- Put extra heating in bathrooms.
- Choose items from the Bathroom design checklist.
- Put in mirrors at appropriate heights and useful shelving so soaps and shampoos are in easy reach.
- Fix height-adjustable hand-held showers.
- Have a nightlight and clear pathway to the toilet.
- Put in a spa bath for relaxation and revitalising massage.
- Put in a ‘smart toilet’ with hygiene features for people who find it hard to get up and sit down.
Organisational vision and policy
An individualised problem-solving approach to bathing is best, and may need a change in facility culture. You need:
- policies focusing on the person
- commitment to empowering staff
- openness to possibilities
- shared vision among management and staff
- staff training
- changed care practice
- communication with families
- appropriate equipment.
Factors affecting bathing
Bathing is an important activity in person-centred care and can be hard for people with dementia and staff. During bathing, people with dementia can feel exposed and helpless, and often do not enjoy or understand what is happening. Poor communication, timetabling and physical design can all help make bathing a difficult experience. Noise and acoustic conditions can cause great stress. Confusing, irritating or frightening sounds include rushing water, toilet flushing, exhaust fans and whirlpools.
For enjoyable bathing experiences in your facility, think about the following issues.
Culture and religion: Check for issues relating to gender or modesty in a person’s culture.
Bathing schedule: Instead of sticking to a timetable, check what a person’s prior habits were. Did they bathe early or late, before breakfast or after?
Communication: Explain what is happening, and follow steps for good communication during personal care.
Family communication: Ask family members if there is anything you should know about a person’s bathing preferences.
Fixtures and equipment: Prepare appropriate bathing items before starting, buy suitable fixtures and make bathrooms more pleasant places to be.
Staff training: Have staff training in how best to bathe people with dementia.
Organisational issues: Give enough time for bathing and support individual problem-solving among staff to bathing issues.
Step-by-step guide to bathing
For a smooth bathing experience, plan and communicate.
- Ask about a person’s past habits, likes and cultural background.
- Prepare needed items: soap, towels, face-washers.
- Use nice smelling soap or scented bathwater to suit personal wishes.
- Learn what music the person finds soothing and play it during bathing.
- Using a bath? Fill it before the person enters.
- Using a shower? Test water temperatures first and make sure the person does not face the wall.
- Respect a person’s privacy: close doors to passages and outer areas.
- Do not hurry bathing.
- Follow steps for good communication during personal care: explain what is about to happen, use the person’s name and make encouraging non-verbal sounds and gestures.
- Talk the person through each step.
- If a person becomes frightened or distressed, stop and try again later.
- Think creatively to solve problems around personal issues in bathing.
Personal care: how to communicate
Bathrooms need to be warm and welcoming. Many bathrooms in facilities have an institutional feel and behaviours of unmet need (sometimes called challenging behaviours) often occur in these areas.
Design can change the feel of bathrooms, no-cost decorative changes and basic building principles making bathrooms more practical and easy to use. Design can create a sense of calm, reduce risk, noise, glare and odour, and meet needs of people with dementia and staff.
Decorative features include soft and colourful towels, indoor plants and home-like pictures on walls.
Design includes possible provision for fixed and portable technologies, for example:
- mobile lifting hoists
- overhead tracking
- shower chairs
- walking frames and wheelie frames
- standing lifters
- commode chairs
- mobile shower trolleys.
Hand basins come in different sizes, shapes, materials and types. Very small basins with taps and a central spout close together do not suit people with dementia.
- Basins need an overflow mechanism to reduce flooding and floor damage. A floor waste outlet near the basin is cost-effective if an overflow feature is not within budget.
- Semi-recessed basins have better access and leg room for those who want to sit and those in wheelchairs.
- Taps must be well spaced and easy to use.
- A height-adjustable hand basin is best.
Example - hand basin
The photo shows a bathroom with the view of the hand basin. Design features include:
- contrasting colours of basin, bench surround, floor and walls make the basin more visible and easier to recognise
- overflow drain in floor to prevent flooding and damage from taps being left on
- overflow outlet in the basin
- semi-recessed basin for easier access
- easy-to-use taps
- cupboard on the wall close to the basin for storing toiletries
- bench space beside the basin for easy visibility of soap.
- mirror above a bathroom basin is large and low enough for people either sitting or standing.
Baths come in different sizes, shapes, materials and types. Size of bathing areas and the level of help needed affect what bath to choose.
- People need to be comfortable sitting and lying down.
- At least one bath needs to have seat lowering or have room for the sling of a lifting machine for those with a disability or who are semi-ambulant.
- Think about using a spa bath. Choose a suitable airstream to give a gentle massaging action, with minimal noise.
- Support in a spa bath may be needed, mostly for people with low body weight.
Many people with dementia need help with bathing, mainly getting in and out of a bath. Filling the bath before a person gets into it, or before they enter the room, lessens their anxiety.
Lighting fixtures must be designed and approved for wet areas. Showering areas should be well lit for good visibility.
Mirrors make some people agitated. Others enjoy speaking to their reflection. Mirrors need to be large enough and in positions for people seated or standing.
- Places for soap, shampoo and toiletries should not create a hazard.
- Recess shelves into walls.
- Fit shelves for shampoo, soap and other toiletries in easy reach.
- Do not put taps and fixtures directly under shelves as they can become slippery if covered with soap and other residues.
- Showers should be step-free and have enough room for a person and one or more assistants.
- Floor space in showers should permit wheelchair movement and moving a person between wheelchair and shower seat.
- The shower floor should have a non-slip finish.
Hand-held showers on flexible hoses adjustable to any height are better for people with dementia and staff. Hand-held showers let people stand or sit when showering.
- Fix the hose of the hand-held shower to the wall at a height so the handset will not hit the floor if dropped.
- The mechanism attaching the handset to the rail that slides it up and down should be easy to operate.
- The handset must be easy to grip.
Showers suit people unable to stand for long periods and who prefer to sit, those with a disability and those who are semi-ambulant. Shower seats need to have strong back and arm support and a strong locking mechanism. Ideally, seat height should be adjustable.
Shower screens stop water from spreading, important if showers are next to toilets. Shower curtains are better than fixed or rigid screens, but are harder to clean.
People value privacy. Half-height shower curtains have privacy for those seated and keep staff members drier.
Grab rails in showers should be effectively colour-contrasted against walls for good visibility.
- People more quickly know and are less confused by hot and cold taps with a central spout. Lever and mixer taps are not good for people with dementia.
- Taps and spouts should be far enough apart from each other and the wall so hands are not bumped or trapped.
- Taps must have a comfortable grip and good leverage.
- Capstan head taps are preferable to taps with round or square handles.
- Hot and cold taps should have red and blue colour signs to help people tell them apart.
- Put in a tap aid for extra leverage for people with limited strength or manual agility.
Toilets need to be appropriately positioned in relation to doors. The toilet user’s line of sight has to be thought about carefully to balance the need for privacy and visibility. When people with dementia can easily see a toilet they are more likely to use it.
The photo shows a view from a resident’s bed to an open ensuite bathroom door. The following features of the bathroom aid continence, recognition and way finding:
- the toilet is very clearly visible from the bed and only 1.5 meters away
- there is a night light in the bathroom
- the wall and floor are in contrasting colours
- a contrasting toilet seat would aid visibility and recognition.
WorkSafe Victoria lists key design features for toilets. These include:
- enough space on both sides of the toilet: 950mm on one side and 550 to 950mm on the other
- drop-down support arms on both sides of the toilet
- built-in staff call button and toilet-roll holder
- toilet position opposite the door
- 1500mm clear space in front of the toilet
- door-opening giving 900mm of clear space.
Grab rails help people get to, sit on and use the toilet. Standards Australia has guidelines on positioning grab rails around toilets. They should be:
- colour contrasted against the wall
- fixed or fold-down rails
- height-adjustable where possible.
Toilet seats must be easy to see. Colour contrast the toilet seat against the toilet bowl, floor and walls to help visibility. Brightly coloured or black toilet seats have good visibility.
Toilets should have durable seats and hinges to reduce movement and damage.
The photo is of a white toilet with a blue seat and lid. The contrast between the white and blue helps people to see and recognise the toilet.
There is a blue grab rail beside the toilet to support the user getting on and off the toilet, and while standing.
The bathroom floor is dark blue, which makes the white toilet bowl clearly show up.
The wall at the back of the toilet is pale blue, which enables the darker blue grab rail, toilet seat and lid to show up clearly.
Note that the white toilet flush button is not sufficiently differentiated from the wall colour, and may not be recognised.
Towel rails should be colour-contrasted against walls for good visibility and be strong enough to act as grab rails. They must be able to withstand a downwards force of 110kg.
Toilet-roll holders in bathrooms and shower areas need to be waterproof.
Bathroom design checklist
New residential facilities