Nursing Homes: Clothing and Incontinence

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?