Bathing and Carer Posture

Bathing

Do people ever step back and ask themselves what bathing is and why do we do it?

Early in my career as an Occupational Therapist when working in an acute setting the focus of bathing was often on access and transfers, can the client get in and out of the bath safely, and if not what other method can be provided to enable them to do this or attend to their hygiene needs, a bath lift, shower, washing from a bowl or sink. This prompted me to raise the question of whether this is actually bathing, and does it satisfy the internal demands that clients place upon themselves as individuals to maintain that occupational balance in their lives and achieve good health and well-being outcomes.

According to Wright (1960) and Koren (1996) personal cleansing is integral to life and bathing is a subjective experience, having such qualities as health, wellbeing, pleasure, safety, thermal stimulation, cleanliness or purity, body-mind reconciliation, and relaxation. Should bathing therefore be viewed as a complex activity, which is only partly functional and is different and unique to each individual? As such we should consider these aspects within our assessments as practitioners, or as those supporting people to access bathing. It may not be the hygiene element only that is valued and beneficial to people but also other elements of the activity such as engagement, relaxation, or family time. Why then do we lean towards showering as the less risky activity in relation to handling?

Bathing and posture

As part of a clinical intervention to enable access to bathing clients are often prescribed physical support via carers. This can take many forms from verbal cues and prompts, physical moving and handling, to complex manual/moving and handling involving specialist equipment.  The purpose and main focus of the intervention is to support access to bathing via a safe method for the client, but there is an important element that can often be overlooked, the posture of the caregiver throughout the process.

Often in the care industry if people think of posture, they may relate this to manual/moving handling (MH) and applying a good posture to activities involved with it.

Anyone that has been on a MH course may have been taught about adopting a good posture throughout the MH process. This is a good starting point and also vitally important to maintain good back care and decrease the risk of work-related musculoskeletal disorders WRMSDs during moving and handling tasks.

The HSE (2021) outline that manual handling causes over a third of all workplace injuries. These include WRMSDs such as pain and injuries to arms, legs and joints, and repetitive strain injuries of various sorts.

‘The term manual handling covers a wide variety of activities including lifting, lowering, pushing, pulling and carrying. If any of these tasks are not carried out appropriately there is a risk of injury.’ (HSE, 2021)

So it is clear there is a risk with MH and transfer aspects of supporting a client to access the bath, and it is vital that good posture is maintained by the caregiver to reduce the associated risks of injury; but what about the caregiver’s posture when supporting the hygiene aspects of bathing, is this important? The Manual Handling Operations Regulations (1992) report that it is not only the movement of a load that is classed as manual handling, but also supporting a load in a static posture.

How many people have seen or heard of caregivers sat on the side of the bath, stooped, or leaning and twisted, trying to support a client’s position in the bath or assist someone to carry out the hygiene aspects of bathing?

After all the guidance and advice that is put in place to safeguard the welfare of caregivers from WRMSD injury how is it that the posture of the caregiver during this part of the process can be overlooked?

From the guidance discussed we can see that it is therefore vital the caregiver’s posture is considered during the risk assessment process, and control measures are put in place to sufficiently reduce the risk of WRMSDs when caregivers are supporting clients with bathing, but how can we do this?

Ergonomics are an important factor for consideration when looking at back care and good posture, simple environmental adjustments and adaptations can often be the answer to protecting our caregivers from the risk of unnecessary injury and time off work, which stops them providing much needed support for individuals.

In 2019/20 musculoskeletal disorders accounted for 30% of all work-related ill health cases and 27% of all working days lost due to work-related ill health. The main work factors cited by respondents as causing WRMSDs were manual handling, working in awkward or tiring positions, and repetitive work (HSE, 2021).

WRMSDs are associated with work patterns that include:

  • Fixed or constrained body positions
  • Continual repetition of movements
  • Force concentrated on small parts of the body such as the hand or wrist
  • A pace of work that does not allow sufficient recovery between movements

How many of us can relate the above risk factors with elements or the role of the caregiver, bathing in particular. Of all WRMSDs working days lost, conditions affecting the back account for 22% of these with an estimated 11.2 days lost per case. This compares with conditions affecting the upper limbs and neck that accounts for 50% of these working days lost, (20.8 days lost per case). Bearing this in mind as employers this is a significant impact upon the workforce and service provision, which will also have an impact from a financial viewpoint when attempting to plug the workforce gaps, often with more expensive agency staff. But whilst doing this it is the clients that miss out on the necessary care to support their health and well-being, and keep them from entering our already stretched acute health care system; care professions record the third highest prevalence of WRMSDs out of all occupations. This information highlights the critical need for us all to act now to protect our clients, caregivers, and health-care system.

Legal requirements

As outlined by the HSE (2021) it is a legal requirement for each employer to:

(a) so far as is reasonably practicable, avoid the need for his employees to undertake any manual handling operations at work which involve a risk of their being injured

(b) where it is not reasonably practicable to avoid the need for his employees to undertake any manual handling operations at work which involve a risk of their being injured

(i) make a suitable and sufficient assessment of all such manual handling operations to be undertaken by them

(ii) take appropriate steps to reduce the risk of injury to those employees arising out of their undertaking any such manual handling operations to the lowest level reasonably practicable

(iii) take appropriate steps to provide any of those employees who are undertaking any such manual handling operations with general indications and, where it is reasonably practicable to do so, precise information

If this is the guidance, as employers we should be looking at safer alternatives for caregiver posture when supporting with the washing and hygiene elements of bathing, in addition to the transfer aspects.  Don’t forget that clients employing their caregivers through direct paymenthave these same legal employer responsibilities.

Employees also have duties placed on them by the Health and Safety at Work Act (2015), they must take reasonable care for their own health and safety and that of others who may be affected by their activities, and co-operate to comply with health and safety duties, such as following correct procedures and using the correct equipment.

Solutions

Carrying out an assessment of proposed interventions is integral to supporting caregivers to maintain good back care, MH plans should therefore include guidance on positioning for caregivers whilst supporting with the full task of bathing and not just the transfer elements.

For those clients not able to support themselves in the bath due to limitations with gross motor control and posture, then supportive interventions such as supportive seating with the necessary postural support elements can remove the need for the caregiver to stabilise the client in the bath, therefore removing the need for any prolonged static postures by the caregiver.

To provide a safer working height for the caregiver and reduce the risk of adopting poor body postures, stooping or bending, an adjustable height bath such as the Abacus Gemini 2000 can be beneficial. The adjustable height function raises the height of the bath so that the caregiver can stand to attend to personal care and hygiene elements of bathing, reducing the risk of WRMSKDs. The Gemini 2000 also has an in built changing bed integral to the bath, this function allows a seamless transition onto the changing bed without any need for additional hoisting or transfers for the individual thereby reducing the need for moving and handling; this supports The Manual Handling Operations Regulations (1992) guidance of removing MH where possible.

As there is no need to transfer onto a changing bed as the bath has an integrated platform the task can be done potentially with reduced carer support (a moving and handling risk assessment specific to the individual’s needs, environment and equipment would be required as part of any recommendations around this), or reduced risk to the caregiver if there was already insufficient support in place.

It is important we all work together to protect our caregivers through providing the right equipment that will reduce the risk of WRMSDs, and in doing so ensure that the supply of our care services to those that need it is impacted as least as possible by WRMSDs. Taking on board the recommendations from our Occupational Therapists and providing the financial outlay upfront to provide the right equipment for clients and caregivers, and sacrificing short term financial savings is key to this.

Stuart Brown
Occupational Therapist, Moving and handling trainer
Associate – The OT Service

References

  • Health and Safety Executive (2021) https://www.hse.gov.uk/toolbox/manual.htm (accessed 24/09/21).
  • Health and Safety at Work Act (2015) https://www.legislation.gov.uk/ukpga/1974/37/contents (accessed 25/09/2021).
  • Koren L (1996) Undesigning the bath. Berkeley: Stone Bridge Press.
  • Manual Handling Regulations 1992 (2016) 4th ed, p10. Health and Safety Executive.
  • Townsend E (1997) Occupation: potential for personal and social transformation.Journal of Occupational Science: Australia, 4(1), 18-26.
  • Wilcock A (2006) An occupational perspective of health. 2nd ed. Thorofare, NJ: Slack.
  • Wright L (1960) Clean and decent. London: Butler and Tanner.