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Correspondence: Address correspondence to Jiska Cohen-Mansfield, PhD, Research Institute on Aging, 6121 Montrose Rd., Rockville, MD 20852. E-mail: cohen-mansfield{at}hebrew-home.org
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Abstract |
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Key Words: Dementia • Dressing ADL • Staff–resident interaction • Nursing home residents • Nursing home policy
Assistance with dressing requires a balance between aiding residents and allowing them to try to complete a task. Though many residents are dependent, they may be able to independently, or with minimal help, accomplish subtasks within the activity of dressing. This independent accomplishment promotes overall independence in the resident's life (Vogelpohl, Beck, Heacock, & Mercer, 1996).
We found only one study that describes the dressing process as it is currently performed in the nursing home. Rogers and colleagues (1999) observed morning care routines of 84 nursing home residents with dementia and reported that morning care took an average of 11 min per resident, with dressing tasks accounting for 38% of that time. During dressing, on average, 0.9 min involved physical assists, 0.103 min included verbal directive assists, and 0.098 min included verbal nondirective assists.
The purpose of the current study is to describe the process of dressing persons with dementia in the nursing home and to elucidate areas where the process can be improved by alteration of environmental and staff–resident interactive processes. The article describes the communication between nursing staff and residents who are being dressed, environmental factors (location, equipment), and the level of involvement of residents in the process.
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Methods |
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Procedures
The IRB of one of the nursing homes approved the study. The family member responsible for the care of the resident provided consent. Consent was given for videotaping the resident during the dressing process, from after the resident was in underwear until the resident was dressed (i.e., videotaping always started after the resident was wearing undergarments). After receiving consent for the resident, the research assistant spoke with the nursing assistant prior to videotaping, received nursing assistant consent, and inquired about the usual dressing time for the resident. The research assistant then came to the unit with the video camera on a different day and videotaped the resident. Visits to the unit on multiple days and at different times were needed to complete the videotaping.
Videotapes
A research assistant conducted the videotaping at the location of the dressing process during usual dressing time. The research assistant videotaped each resident in one session as part of usual dressing. Half of the tapes included a record of the time of taping. Of these, 6 occurred around 7:00 a.m. (7:10 a.m.–7:41 a.m.), 2 occurred around 8:00 a.m. (7:59 a.m. and 8:26 a.m.), and 2 occurred very early in the morning (5:10 a.m. and 5:16 a.m.).
Focus Group
After the completion of the videotapes, staff members from the special care unit at one of the nursing homes met with two of the authors at the end of their work shift in the afternoon. They were briefed about the project and queried about their experiences in the dressing process in an effort to clarify the findings from the videotapes.
Coding Assessment
We developed an assessment instrument for this study to code the dressing process from the videotapes. We convened a meeting of experts, all of whom viewed the videos, in order to determine the domains of the dressing process that should be examined. We based the coding system (developed by J. Cohen-Mansfield, A. Parpura-Gill, and M. Dakheel-Ali) on analysis of the literature and on information provided by experts and the staff focus group for the study. We included the following categories: background information, dressing process, and staff–resident interaction (see Table 2). It included objective items, such as time from start of tape (when resident was in undergarments to the end of dressing or location of dressing), as well as scales requiring judgment rating the efficiency of staff members (on a 4-point scale from inefficient to very efficient), difficulty of the dressing process for staff members and residents (on a 4-point scale from easy to very difficult), and the appropriateness and level of interaction (appropriate, inappropriate, or both; sufficient or insufficient). We developed instructions to operationalize the coding system. For example, we rated time to respond after a prompt as sufficient if either the resident responded verbally or by following the prompt physically, if the prompt was repeated, or if there was a pause that allowed for a verbal or physical response. We coded the response as insufficient if the staff member continued the prompt immediately by a physical action (e.g., asking, "Would you like this shirt?" and immediately putting it on) or by a continued verbal discourse by the staff member. We considered communication appropriate when the manner of communicating with the resident was kind or respectful or when it had a positive attitude and tone of voice. We considered communication insufficient based on criteria concerning the amount of talk. We trained two research assistants to use the coding assessment.
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Data Management and Analysis
The tapes were coded into paper forms of the coding system. Research personnel then independently entered the data twice into SPSS softward and compared the two entries for discrepancies. Research personnel checked discrepancies against the hard copy and cleaned the data. The analysis involved background variables (e.g., dressing time), dressing process (e.g., resident ability) and staff–resident interaction. We also explored correlates of length of dressing period and the relationship between physical difficulty for staff and resident cooperation and dependence.
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Results |
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Staff Members
In 19 of the dressing sessions 1 staff member was involved; 2 staff members were involved in only one session.
Location and Equipment
Eighteen of the dressing sessions took place in the bedroom, and 2 occurred in the bathroom. The more common positions for dressing were sitting on the bed (5), lying in bed (4), and sitting in a regular chair (3) or in a wheelchair (3). Additionally, 2 residents were standing in the middle of the room, 1 sat on a bench, 1 sat on the toilet, and 1 was in a shower wheelchair. The beds that could be observed for height (8 out of 9) were all low, and most of them had bed rails (7) and footboards (8). No equipment was used (e.g., foot rests, lifts, or stocking aids), and supportive bars were available and used in just one session. Staff used gloves in 15 sessions, and the remaining 5 sessions did not involve glove use.
Dressing Process
Articles of Clothing
The residents were dressed with an average of 5.4 articles of clothing (range = 2–9). The main articles of clothing used were shirt or blouse (14), pants (9), sweater (6), sweat shirt (4), sweat pants (4), skirt (4), dress (3), vest (1), and jacket (1). Of the 6 sweaters, 5 opened from the front, and 1 went over the head. In the process of wearing these, buttons were used with 12, a zipper with 4, and a belt in 2. As for shoes, 3 residents had their shoes on at the beginning of the session, 15 had shoes put on during the session, and 2 did not wear any shoes during the session. The 18 pairs of shoes included 9 sneakers, 4 slippers, 4 shoes with tongues, and 1 pair of slip-on shoes. One pair of shoes had Velcro, and 10 had tie-up shoelaces. Fourteen of the residents had socks put on during the session. In 13 sessions, clothes needed to be placed over the head.
Resident Ability
Mobility was rated as adequate for 7 residents, limited for 2, and impaired for 9. Upper extremities were rated as adequate for 13, limited for 2, and impaired for 4, and range of motion was rated as adequate for 14 and impaired for 5.
Resident Involvement
In most cases, staff members completely dressed the residents (17). In 2 sessions, residents were able to dress themselves with physical help from the staff, and in only 1 session the resident was independent most of the time and needed supervision only. The residents actively cooperated with staff in 2 of the sessions, were uncooperative in 3, and were passive in 15.
Degree of Difficulty
Most of the residents had difficulty dressing themselves, with a range of 4 to 7 and a mean of 6.5 (scale of 1–7, 1 = easy, 7 = so hard that they cannot do). The degree of difficulty for the staff ranged from 3 to 7, with a mean of 4.3. Staff members had a very difficult physical task in 3 of the sessions, medium difficulty in 7 sessions, no specific effort was needed in 7 sessions, and in 2 sessions, the staff needed extra help and were unable to do the task alone.
Safety
As can be seen from Table 3, there were substantial safety issues for staff members. These included excessive bending in 9 of the observations, lifting in 5, and major physical effort in 8. In 6 of the sessions, the staff members wore safety belts, though they were not used in care activities in any of the videotaped sessions. Safety issues were less common and different for residents. In most cases, they involved lack of support and lack of safety locks. For 3 residents, there were no supportive bars on the wall when these residents needed support. Safety locks were needed on a shower wheelchair that was moving. In addition, there was 1 case of excessive bending by a resident while working with the staff member to put on pants, and in 2 cases, residents strained themselves (one was the same as the excessive bending, and the other involved putting on a tight shoe).
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Staff–Resident Interaction
Interaction between Staff and Resident
The most common interaction by staff members was giving command instructions, used in 18 of the cases, followed by announcing tasks (11), and chatting or personal and supportive communication (8). Staff rarely announced each stage of dressing to the resident or named the item of clothing to be donned (no announcements in 45% of the sessions, and in the rest, clear announcements were provided in an average of 23% of the opportunities to do so; see Table 4). In the majority of cases, staff members did not encourage or express thanks to residents who had cooperated during the dressing process. Pauses to allow the resident the opportunity to undertake or complete a subtask independently were rare. There were no occurrences of modeling, asking permission (however, this category does not include asking if the person would like a specific item of clothing, which was rated under "offering clothes," and did take place in a minority of the sessions), arguing, or reasoning. In the cases where communication by staff occurred, it was most often appropriate (with the exception of teasing), but was insufficient, that is, communication did not occur at least half the time, or when communication occurred, it was insufficient in that essential elements of communication were missing, such as providing only part of a sentence, not naming the clothing article, or when timing of the sentence was too late for the action described (see Table 4). The total amount of communication between staff and resident was considered insufficient in 15 observations and was sufficient for 5 of the residents. For example, 1 staff member did not have any communication with the resident, and 5 staff members only communicated either by announcing a task or giving commands and instructions.
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Time Provided by Staff
Of the 9 occasions of verbal prompts, 5 were considered to be followed by sufficient time to respond, while 4 were considered insufficient. When allowing the residents to try to dress by themselves, on most occasions (5 out of 6) the staff members waited appropriately. Similarly, on most, but not all (4 out of 5), occasions when staff members asked residents questions, staff waited for a response for a sufficiently long enough time.
Manner of Physical Handling of Residents
Level of gentleness was rated as gentle in 3 cases, normal in 13, slightly rough in 2, and rough in 2 of the observations. Staff members were hurried in 1 of the 20 tapes.
Correlates of Length of Dressing Period
Length of the dressing period correlated significantly with the number of articles of clothes used (r =.82, n = 20, p <.001). Dressing took significantly longer when a zipper (t18 = 2.0, p =.03, one-tailed) and shoe laces (t18 = 2.84, p <.01, one-tailed) were involved.
The Relationship between Physical Difficulty for Staff and Resident Cooperation and Dependence
Physical difficulty for the staff members was highly correlated with resident dependence (Spearman's 
=.49, n = 20, p =.027) and lack of resident cooperation (Spearman's =.53, n = 20, p =.017).
Focus Group
Following the videotaping, investigators met with the focus group, which consisted of 6 CNAs, 1 charge nurse, 1 physiotherapist, and 1 social worker from one facility. The investigators explained that the purpose of the meeting was to review selected video segments of the dressing process in that facility and to get the group members' observations regarding staff–resident interaction, safety concerns, environmental factors, apparel and shoes, and organizational and workload issues (the residents' relatives had given permission for the videotaping, as had the staff in the reviewed segments). The participants alerted the investigators to an important organizational policy issue, that is, whether dressing is required before or after breakfast, thus adding time pressure to both staff and residents. Other topics discussed included staff safety, bed-height impacts, wheelchair care, the importance of knowing the resident over time, variation in dressing routines, staff–resident ratio, and assignment to difficult residents. The participants noted that the residents who were able to sit on the edge of the bed were easiest to assist, while residents using wheelchairs were difficult to help. Participants also noted that the bathroom might be the best place for residents to dress, given that bathrooms are outfitted with special, appropriate devices (e.g., rails) designed to assist with daily tasks.
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Discussion |
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We were surprised to learn how quickly the dressing process was completed with persons with dementia, yet this finding is congruent with the result of Rogers and colleagues (1999). Despite residents' need for significant assistance, dressing took an average of 4 min (as compared to an average of 4.2 min of dressing during usual care in the Rogers study), with the longest process taking 9 min. This was probably partly due to the nursing assistants' attempts to be as efficient as possible. In one of the nursing homes, nursing assistants were aiming to dress all residents before breakfast (around 8:30 a.m.). This efficiency came at the price of quality; it may have contributed to nursing assistants' failure to allow sufficient time for residents to complete tasks, answer questions, be offered choices, and receive sufficient communication concerning subtasks. Organizational policy regarding dressing-task completion (before breakfast for all residents or a later hour) is a very important factor in time pressure on nursing assistants, resulting in early awakening of residents and limited willingness to allow time for the resident to undertake dressing tasks. Although we did not record how many residents were actually awoken for the dressing procedure, at least 2 of them appeared to be very sleepy while a few others were agitated throughout the session.
The location and equipment used in dressing can affect resident comfort in the process. In 2 cases, residents were dressed in the bathroom possibly in order to use the bathroom support bars. Dressing in the bathroom required that 1 resident sit on the toilet for dressing. Dressing in the toilet area may not enhance resident dignity or ensure privacy, though that determination requires a comparison to the level of privacy available in the bedroom. Also, the bathroom can be a high-risk environment because of slippery surfaces, and because the bath tub, washbasin, and other hard surfaces, can cause significant injury if a resident falls. Another concern for comfort exists when residents are dressed while sitting in wheelchairs, which was the case in 4 of the residents observed. However, wheelchairs are often too narrow to allow comfortable space for dressing.
Resident comfort during dressing can also be enhanced by the choice of clothing articles because some articles of clothing place less demand on resident abilities, such as use of Velcro rather than buttons or shoelaces and clothes that do not have to be put over the head. However, shoes with properly tied shoelaces were reported to be less likely to be taken off by residents than shoes with Velcro. Thus, the decision regarding specific clothing items needs to weigh the pros and cons on an individual basis. There does not seem to be an appropriate guide or manual for families that discuss resident accoutrements. Such materials could offer needed guidance regarding choices or designs of particular items and would enhance resident capacity for this important ADL.
Staff comfort is another crucial factor in designing a better dressing process. Dressing residents who cannot participate in the process, or who are totally dependent, can be a very difficult and risky undertaking for staff members. Staff members who are assigned to such residents need to know proper body mechanics, and sometimes, more than one staff member needs to be assigned to the task. One of the factors contributing to staff comfort is bed height, which was low in all observed videos. With the exception of one adjustable-height bed, we were not able to determine if other beds had adjustable height. Adjustable-height beds can do much to reduce staff exposure to risk by reducing excessive bending and the resulting back strain, particularly in the case of bed-dressed residents. Similarly, staff members were observed undertaking a wide range of lifting tasks, for example, physically lifting a resident from a chair to a wheelchair, bending over and lifting a bedridden, nonresponsive person into bed to get pants on, or moving a person to another position. Lifts were available in both nursing homes, but often unused by staff. Reasons for nonuse may include time pressures, the recognition that lifts often are uncomfortable for and induce fear in the residents, or unavailability of lifts on a floor.
Communication of staff members with residents was minimal and insufficient. This is similar to Rogers and colleagues' (1999) finding that the most common assists were physical, with minimal verbal direct assists or verbal nondirective assists. There is a need to increase the CNAs' understanding of the importance of encouragement and positive reinforcement for each effort by a resident. Furthermore, the dressing time can be an opportunity to provide one-on-one social interaction that is crucial for alleviating a resident's isolation and loneliness. In several cases the CNA asked if a particular article of clothing was acceptable, but a choice of clothing items was never offered. In addition to verbal communication, touch is an important vehicle for communication, yet most of the staff members used gloves when dressing residents. Such practice is at odds with both research findings and documentaries that attest to the vital importance of touch for maintaining a sense of well-being (Butts, 2001; Rundqvist & Severinsson, 1999; Verrees, 1996). The dressing activity can be viewed as an opportunity to provide residents suffering from dementia with the one-on-one verbal and physical communication that is essential for well-being (See Cohen-Mansfield & Werner [1997] on the importance of one-on-one interactions). This opportunity is currently missed on both fronts.
The results, showing a high level of dependence among residents and a very low level of reinforcement by staff members, fit with the findings of Baltes and colleagues (Baltes, Honn, Barton, Orzech, & Lago, 1983; Baltes, Kindermann, Reisenzein, & Schmid, 1987; Baltes & Wahl, 1992) that dependent self-care behaviors tend to be reinforced by caregivers while independent behaviors are not, thus supporting dependence in frail elderly persons. Similarly, Rogers and colleagues (1999) found that residents were engaged in self-dress just 15% of the dressing time (average of 38 s for the 4 min and 10 s observation) during usual care. The results also complement the dressing guidelines and staff interventions proposed in the literature. First, they suggest that system issues such as time constraints, policies concerning waking time, and timing and location of breakfast need to be addressed. Second, prior to choosing the level of required support (i.e., cueing [such as laying out the clothes], verbal prompting, modeling, etc.), staff members must change their perspective of the activity. Instead of viewing the dressing process as a race for efficiency, staff members should consider it a therapeutic encounter allowing residents to experience social contact, get a little exercise, and feel a sense of independence. In this context, additional behaviors such as social talk need to be fostered. Third, the space, equipment, and articles of clothing must be considered to maximize the experience. Finally, the issues addressed raise a basic question concerning the goal of the dressing experience. It is possible that the goal of increasing independence is appropriate for one subset of residents, whereas for others it would be better to focus on the social aspects and disregard the issue of independence. Continued thoughtful discussion is needed to clarify this issue.
The study has several important limitations, including a small sample size, use of only 2 nursing homes, and lack of an independent assessment of residents' ability to dress themselves. The small sample size allowed us to detect only relationships with a large effect size. Future studies may want to utilize an occupational therapist's evaluation of ability to dress and relate that to the level of participation in actual dressing.
This article has provided a detailed analysis of the dressing process for residents of special care units. This analysis showed the complexity of the dressing process for staff and residents alike and exemplified the impact of policies, staff behavior, resident abilities, physical environment, and articles of clothing on the dressing process. We identified many limitations inherent in the process that affect both resident and staff well-being. While dressing involves risks and difficulties for both resident and staff members, it can provide opportunities to enhance well-being through verbal and nonverbal communication and by fostering resident independence and control over the process. Optimizing the dressing process requires changes in institutional policies, staff behavior, physical environment and equipment, and articles of clothing. Changes in policies pertain to staff time, autonomy, and training, as well as policies linking dressing with other activities, such as bathing and eating. Staff members need support to enhance the physical and psychological aspects of the dressing process, including learning how to enhance communication and provide a physical environment that decreases the physical burden of dressing. Federal policies and surveyors' guidelines also need to reflect an emphasis on a higher level of communication and on the comfort of both resident and staff during the dressing process in order to promote such practices. The dressing process is one of the moments of closest contact each day between nurse aides and residents of special care units, and it has the potential to empower residents if administration and staff members so choose.
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Footnotes |
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1 Research Institute on Aging of the Hebrew Home of Greater Washington, Rockville, MD.
2 George Washington University Medical Center, Washington, DC.
3 A.T. Still University of the Health Sciences, Kirksville, MO.
4 Carlow International, Inc., Potomac Falls, VA.
5 Wallingford Associates, Fairfax, VA.
Decision Editor: Linda S. Noelker, PhD
Received for publication October 28, 2004. Accepted for publication July 18, 2005.
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This article has been cited by other articles:
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  J. Cohen-Mansfield and B. Jensen Changes in Habits Related to Self-care in Dementia: The Nursing Home Versus Adult Day Care American Journal of Alzheimer's Disease and Other Dementias, July 1, 2007; 22(3): 184 - 189. [Abstract] [PDF]
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