In his Key Note address at 2005 WOCN annual conference, Tim Porter O'Grady emphatically announced our "arrival" into the 21st century, identifying the accomplishments and significance of our profession as healthcare experts. As Dr Porter O'Grady put it, healthcare as we used to know it no longer exists. In acute care particularly, the typical 7-day stay of the 1980s has been shortened to approximately 2 days or less. Although some still try to wedge a 21st century healthcare timeline into a 1980 schedule, attempts to accommodate such incompatibility lead to frustration, job dissatisfaction, and colleague distress, especially with the newer graduates who did not learn to provide care in a 7-day context. The challenge, as Dr Porter O'Grady presented it, was to let go of the beliefs and values that gave meaning to the workday 20 years ago but that now are unnecessary or symbolic.

Consider, for example, the bed bath. "A new generation of nurses who are 'too posh to wash' are threatening traditional nursing practices by refusing to perform basic tasks," the leader of Britain's nurses' union stated in May 2004, sparking a flurry of vocal activity from the BBC News and the Royal College of Nurses.1,2 Of note is that this statement was not based on substantive data but on the opinions of practicing nurses who may not see the whole picture but rather form an impression on an N of 1. The debate was further fueled by the motion put forward at the Royal College of Nurses annual meeting that given the shortage of registered nurses, tasks such as bed baths may be relegated to nonregistered auxiliary staff. The motion was defeated, but the debate continues.

Nurses in the United Kingdom are not alone in voicing the sentiments, substantiated or not, that today's nurses are not interested in basic care. I recently overheard colleagues in North America noting that nursing students, "don't even know how to give a bed bath anymore." Although not necessarily intended to lean in that direction, the discussion had an air of self-satisfaction about it-the new nurses just didn't know about nursing the way that the "old school" did. Can this be true? Are our universities really turning out inferior students? Is the bed bath the key marker of good nursing? What, one may ask, is good nursing? Hooper notes that the topic fuels the ongoing academic discussion of the definition of nursing-a science or an art or both?3 From a clinical practice viewpoint, nursing is competence, critical thinking, and skilled assessment. From a patient's viewpoint, the most important attributes of nursing are connected to respect and dignity, confidence and trust in providers, and courtesy and availability of staff.4

Because the average age of the nursing work force is 40 years and older, the majority graduated in the late 1970s or early 1980s at a time when nurses were still giving bed baths to acute care postsurgical patients and hospital stays were still several days. No one used computers or digital images for wound care, and there was time for ostomy or wound care teaching. Teaching nurses was didactic and memory-based rather than case-based or problem-based compared to today's education of nurses by Web, in groups, and collaboratively along with a skill set not even conceived of 20 years ago. What remained constant and comfortably unchanging was the bed bath. And yet, much has changed.

Despite 21st-century nursing graduates bearing little resemblance to their predecessors, the qualities of respect and dignity espoused by Nightingale persist as fundamental to nursing care. The bed bath symbolizes such consistency, but even Nightingale changed a previous nursing regimen, or lack thereof. Today, we expect rational and evidence-based care that is systematic, critical, collaborative, and patient focused.5 Patient-focused care does not exclude the bed bath, so why do students not give baths? The short empirical answer is that patients in acute care do not require a bed bath-they are helped out of bed the day of surgery, assisted to the sink to wash, and encouraged to do so for themselves. During this assistance, the nurse is assessing the patient's color, balance, pain level with activity, respirations, urine in the catheter or voided, and cognition. Encouraging and proactive, the nurse ensures that the patient is safe, exercised, and clean. Even during this initial foray out of bed, discharge is discussed, challenges considered, and home support considered.

Where does the bed bath fit into nursing? Certainly bathing itself is a powerful ritual associated with healthcare. Furthermore, a deeply religious connotation to cleansing and comforting asserts itself throughout cultures. Hector and Touhy provide an excellent overview of the meaning of bathing from cleanliness, self-control, and discipline to a therapeutic and healing art. Indeed, 19th-century nursing textbooks devoted several pages to sanitation and cleansing, at a time when many did not have running water or could not bathe regularly. "Don't make your sick room into a sewer," writes Nightingale in 1859.6 There is something immensely satisfying about bathing a patient thoroughly, rinsing and combing his or her hair, indeed making him or her feel better by virtue of a nurse's touch. And yet, notably, a search of the literature on bed baths revealed few articles on the topic. Dunn and colleagues compared thermal bed bath and tub baths in patients with dementia and concluded that physiologic parameters indicated a high level of stress associated with tub baths.7 Several other studies were also found that address the issues of dementia and bathing, but none were found that evaluated the qualitative aspects of bathing from the nurses' or the patients' perspectives. Related to the bed bath was cost; the newer disposable bed bath in critically ill patients was at least as effective in cleansing as the traditional basin bath and more efficient in time spent, nurses' satisfaction, and cost savings.8,9

Is it time to let the bed bath fade away along with other remnants of the 7-day routine? Virtues as powerfully symbolic as Latin learning, religious instruction-even nursing caps and uniforms-are long gone. Necessity dictates that 21st-century nurses must let go of the symbolism of the bed bath but retain the conscientious critical care that finds meaning in bed baths and other intimate contact necessary and meaningful in nursing care.

References