Some problems seem absolutely intractable. Two such closely related problems in nursing homes are incontinence and care of patient clothing.
Appearance is, for many of us, closely associated with our sense of personal dignity. Some control over how we look and what we wear seems vital to maintaining a sense of identity, of personhood, particularly in American culture. Situations in which people are forced to wear clothing they have not chosen (e.g., prisons, hospitals) make them feel objectified and de-humanized.
My mother-in-law was a fastidious person. Over the years, as she aged, she cultivated a tailored, simple, neat and soft style in her dress, both at home and in public. She had few clothes, but they were of moderately good quality, always clean and well pressed. Her attire expressed her identity and her sense of self-worth. Before she died at the age of 92 she spent two years in a nursing home. I believe that part of her rapid deterioration there was due to her inability to take pride in or have control over her appearance.
While patients are encouraged to bring and wear their personal clothing (each piece labeled with their name) to the nursing facility, this attempt to make them feel more “at home” breaks down very quickly. Nursing home laundries are notorious for losing or destroying clothing, partly due to the pervasive problem of patient incontinence.
For various reasons, many nursing home patients are incontinent. Those who do not suffer from lack of control physically, may do so psychologically. Some have lost sensation and are unable to determine when they need to eliminate. Many are completely dependent upon nursing assistants (NAs) to help them with toileting. Since the NAs are burdened with heavy patient care loads, the patient may have to wait for very long periods of time between trips to the bathroom. After numerous frustrating attempts to maintain continence, many simply give up, relinquish this relic of their dignity and succumb to incontinence. At the end of the day, or perhaps several times during the day, patients’ soiled clothing is removed and tossed in a laundry hamper, where it may sit for hours or even days before being collected for laundering. No matter how hot the water, how strong the detergent, the odor never really washes out. Inevitably, clothing breaks down quickly and the patient’s wardrobe becomes gradually smaller. [An aside: some families, like mine, frustrated with inadequate clothing care in the nursing home, resolve to collect their loved one’s soiled clothing several times a week and launder it at home. Smaller, less powerful washers and dryers are even less effective in removing offending odors and many families give up after just a few attempts.]
Dwindling patient wardrobes are also due to lack of care in returning clothing to the proper rooms. When I visited my mother-in-law, she was often dressed in ill-fitting clothing that was not her own. A peek into her closet would show that perhaps half of the items there had someone else’s name on them, and many of her favorite pieces had disappeared permanently. The clothing was poorly hung or stuffed, unfolded, in drawers. Though I have been able to understand the nature of many operational problems in nursing homes, I have not been able to figure out why clearly labeled clothing does not make it into the correct patient’s closet. I speculate that lack of care or concern, low job performance standards, and a failure to understand the importance of appearance for one’s physical and psychological well-being might be some causes of the problem. There is so much work to do in a nursing home. Caring for the appearance of a patient may be quite low on the priority scale.
Is the problem really intractable? With a different mindset – one of honoring dignity and expressing respect – would it be possible to recognize the importance of answering call bells quickly, taking patients promptly to the bathroom, soaking soiled laundry immediately, hanging clean clothing neatly on appropriate hangers, folding items carefully, reading name tags and returning clothes to their owners. Would it be possible, with such a mindset, to dress patients in their own clothing, comb their hair, and wheel them out into their world as their best and most respectable selves?
With All Due Respect 
Last evening I talked with a friend who has a great deal of experience with health care for he elderly and dying. She has, kindly, been following my blog posts over the last few months but has not, to date, commented publicly. Since she works within the eldercare system she is familiar with many of the problems that I have written about, but she expressed concern that I may not have given the fullest possible picture or the fairest evaluation of the causes of these problems. I have encouraged her to add her knowledge and wisdom on the subject.
However, I want clarify that my goal in discussing healthcare for the elderly and those near the end of life is to share my own observations and to speculate on the possible causes of problems, not to criticize or judge those who are providing the care. I am well aware how limited are their resources for doing an extremely difficult job. Many of them do it very well. Others, disheartened, tired and under-appreciated do not do so well. Why are the resources so limited? Why do we, as a society, invest so little in the care of our elderly?
I have close family members whose life’s work has been caring for the elderly. They work in nursing homes, hospitals and home care services. I respect their work immensely and hope that in my declining years I will encounter some like them who will offer such sensitive, quality care to me.
Thank you to all the caregivers whose gentle, attentive respectfulness makes daily life with dignity possible for us seniors.
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Thank you again Moriah for this thoughtful post. This comment is one of many things that comes to mind.
When I am with a patient in a skilled nursing facility, I am always struck with how long it takes to care for the needs of each person. Aides are tending to someone and are physically not able to respond promptly to another call bell. When they are providing compassionate, respect-ful care, they must be patient with each person and that takes time. I love to see it when this happening! But I also feel the pressure of someone else needing their attention too. As you have commented earlier, lack of adequate staff to serve all patient needs is a persistent and pervasive problem.
I am a hospice chaplain, and when a patient has a hospice team that includes an aide, and I always strongly encourage our aide to be scheduled often–maybe even every day if we feel our patient is not getting enough attention. Some facilities are not used to hospice coming in–or even resent it: We can take care of our patient! We don’t need you! But we can really make a difference. Not only can our aide do everything theirs can do (and maybe more–nails and a bit of massage to top off a nice bath and clean hair and lotion on dry skin), but we generally are consistent with the same aide every time (barring vacation or sick days.). That is wonderful (and respectful too)–for the elder to know, like, and trust the person providing intimate care is yet another important component of maintaining dignity and respect.
I will also mention that palliative care as well as hospice patients have an aide on their team (but rarely does insurance include spiritual care I am sorry to report.) Why more elders are not served by hospice and palliative care is a mystery to me. In fact this was the complaint of one of our adult care home owners/caregivers: Why does Elwood get all this special attention and care? He’s no “worse off” than my other residents who do not have it! My only response was: their doctors have not referred them and maybe they should! Doctors are the gatekeepers and the most powerful voice for good and appropriate care in any setting. Each of us needs a doc as an advocate whenever we are part of the system of care. Families/friends can also advocate to doctors for their loved ones to get all the care they are entitled to including hospice and palliative care when active curative medicine is no longer appropriate. That’s my own personal plan!
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I had the privilege of working as a social worker in nursing homes for a number of years. I truly loved most of the residents and, at least, empathized with those I didn’t. There are many reasons why clothing is not sorted properly, handled well (i.e. someone’s hand crocheted coverlet thrown in the washer & dryer; someone’s Perry Ellis sweater having the same fate….both coming out looking like doll clothes), returning to their rightful owners or missing. Reasons include theft (nice clothing is taken home by staff members), inability to read English, no time to care about appearance (too many residents per aide), appearance not being a top priority unless the State is about to review a facility or a family member complains repeatedly, etc., etc.
I agree that appearance means a great, great deal to many of the residents but after awhile resignation sets in……after the indignities of incontinence and being wheeled into showers on a toilet seat looking transport……after being wheeled into inane activities….after food that tastes like cardboard….after administrations pressure the staff unrealistically to take care of more and more residents with poor remuneration, residents only solace seems to be the few caring staff members, a facility pet, their families and some beauty outside the windows.
Yet some maintain their dignity, their optimism, their spirit anyway…….and those are the great teachers to imperfect people like me.
– Julianna
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Thank you Diana and Julianna for adding your well-informed and wise input on this subject. Discussing it with both of you has been enlightening and heartening. It’s good to know people who work or have worked within the system, and who have supported the elderly with compassion and respect throughout their careers.
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My mother is in a nursing home, and they place the soil clothing in a bag. They place the bag in the closet where the clean clothes are in. That clothes get picked up once week. I brought her a hamper and advised them not to do that again. The father went to see her and again they put the soiled clothing in the closet. I spoke with the Social Worker and she CC the administrator. He said that he would order her a hamper. Only one hamper, how about all the other patients. I know that nursing homes are under staff. Our congress has to help our elderly pass with dignity and provide more well trained staff.
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Thanks for your comment, Nidia. The best thing you can do for your mother is to be the kind of advocate that you are right now. Those who don’t have family members to look out for them will get even poorer care.
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