The Gerontologist 45:694-699 (2005)
© 2005 The Gerontological Society of America
The Potential of Wash-and-Dry Toilets to Improve the Toileting Experience for Nursing Home Residents
Jiska Cohen-Mansfield, PhD1,2 and
James R. Biddison, BA1
Correspondence: Address correspondence to Jiska Cohen-Mansfield, PhD, ABPP, Director, Research Institute on Aging, Hebrew Home of Greater Washington, 6121 Montrose Road, Rockville, MD 20852. E-mail: cohen-mansfield{at}hebrew-home.org
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Abstract
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Purpose: We investigated the feasibility of using a "wash-and-dry" toilet in the nursing home. Design and Methods: We used a controlled comparison baseline-versus-treatment design with 22 female nursing home residents aged 75 and older living in a 562-bed, not-for-profit nursing home facility in Maryland. The Luscence Luxury Lavage wash-and-dry toilet–bidet system was installed in the bathrooms of the experimental group. Measurements included staff and resident toilet experiences and toilet reaction questionnaires, utilization logs, Minimum Data Set information, Mini-Mental State Examination scores, and urine cultures. Results: About half of the residents and staff members reported the toilet to have a positive effect on toileting. We saw a positive trend in resident affect for the experimental group that was not apparent for the comparison group. Nursing staff reported that the toilet functions did clean the residents, but that cleaning was not complete. Bacterial content of urine decreased in the experimental group and increased in the comparison group during the trial. Toilet installation was more complex than anticipated. Implications: These results show that a wash-and-dry toilet shows promise for improved resident comfort in toileting and cleanliness, although further research is needed to verify the findings. Improved toilet design, design of nursing homes, and design of care activities would all improve the utility of these toilets in the nursing home population.
Key Words: Toileting care • Incontinence • Technology
Toileting care in the nursing home is complex, as it encompasses interventions for not only incontinence but also those for declining mobility, dexterity, and cognitive skills. Although many nursing home residents present high levels of need with regard to toileting care (Cohen-Mansfield, Werner, & Reisberg, 1995; Ouslander, Uman, Urman, & Rubenstein, 1987), current toileting practices are generally insufficient (Schnelle, Newman, & Fogarty, 1990), resulting in problems with cleanliness and, in turn, the risk of developing urinary tract infections (Barnett & Stephens, 1997; Garibaldi, 1999; Nicolle, 2000). Creative care plans such as prompted voiding and more frequent trips to the toilet have been shown to reduce the number of urinary tract infections (Newman & Palmer, 1999), but implementation of these methods in nursing homes is often difficult as a result of understaffing (Schnelle et al., 2002). Moreover, the physical and psychological discomforts (including the invasion of privacy) associated with toileting care in the nursing home negatively affect the well-being of both resident and staff. Yu and colleagues (1991) found that only 50% of staff reported feeling comfortable working with patients with urinary incontinence, and 63% felt frustrated. Clearly, there is a need for new ways to approach toileting in the nursing home.
Japanese technology has developed sanitary bidet–toilet combinations that clean as well as air dry the user and offer additional comfort amenities, such as a heated seat. Although these innovative toilets have been popular in Japan for many years, only a few locations in North America, such as luxury lounges in airports and some residential homes, have obtained them. As far as we know, this technology has never been used with elderly nursing home residents in the United States, and we found no literature on this topic. By introducing this technology into the nursing home, we have the potential to improve toileting by increasing the cleanliness and comfort of nursing home residents while decreasing the burden on caregivers. In addition, "wash-and-dry" toilets may reduce health problems that accompany incontinence, such as urinary tract infections.
We conducted the current study in order to initiate the investigation of the effect of wash-and-dry toilets on the toileting care of nursing home residents. Specifically, we examined the feasibility of these toilets for nursing home use as well as the effect of these toilets on residents and staff.
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Toilet Description
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The Luscence Luxury Lavage toilet, manufactured by the INAX Corporation of Japan, has a modified seat that can be retrofitted to an existing toilet. It includes several features to augment personal daily hygiene regimens, most importantly the cleansing and drying of sensitive body areas by use of a warm spray of water and warm airflow, both with adjustable temperatures. It features two nozzles, one to clean the perirectal area and one for the female periurethral area. The nozzles have a self-cleaning function, ensuring sanitary maintenance. This system includes a heated seat that can be preset to a resident's preferences, eliminating the need for readjustment at every use. All functions, with the exception of the heated seat, work only when the user is seated; therefore, there is no risk that the user will be inadvertently sprayed by water when he or she is not seated, even if the user touches a switch. All functions are controlled through a wireless remote control panel mounted on the wall next to the toilet. This last feature was an important consideration for us, because some models have a built-in control panel mounted on the side of the toilet that may not fit in smaller bathrooms or may interfere with wheelchair access. The remote also allows the nursing staff to intervene from a distance, providing privacy for the resident. The retail cost of the toilet is $1,200 (although Internet ads have listed it for $800, and the price can be expected to decrease as use of such toilets is becoming more common).
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Overall Design
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We instructed the primary nursing assistants of the residents who received the wash-and-dry toilets in their bathrooms (the experimental group) on how to operate the new toilets and how fill out a toilet-use logbook (after checking the resident and wiping, if necessary). When the resident was cognitively able to manipulate the remote control, she also received training on operating the toilet. A trained research assistant interviewed residents in the experimental group and their primary nursing assistants separately at baseline (before installation of the wash-and-dry toilets), immediately after the new toilets were installed, and 2 months after continuous use of the new toilets. As to the comparison group (i.e., residents who did not receive the new technology), a trained research assistant also conducted interviews with residents and their primary caregivers at times matched to each of the three phases. We examined resident affect and privacy during toileting as well as urine bacteria colony counts for all study participants. For the experimental group, we assessed utilization, effect, and reactions to the wash-and-dry toilet through interviews and through logbook entries.
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Methods
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Participants
Participants were long-term residents of a 562-bed, not-for-profit nursing home (from five units of two different buildings) in Maryland. Our recruitment focused on female residents who had been identified by nursing staff as having difficulty with cleanliness or toileting care (specifically, not being independent for toileting, not being fully clean after toileting, or having a foul odor directly related to toileting), so that we could test all functions of the new toilet, including the feminine wash. A copy of our screening sheet with inclusion criteria is presented in Table 1. We obtained informed consent from all participants, or their agents in the case of cognitive impairment (Cohen-Mansfield, Kerin, Pawlson, Lipson, & Holdridge, 1988).
Originally, 15 women received new toilets and were included in the experimental group and 13 women were included in the comparison group. One resident in the experimental group fell in the hallway and broke her leg the day after the new toilet was installed in her bathroom. This fracture had nothing to do with the new toilet installation, but she was dropped after it was determined she could not be toileted safely. (We were unable to reinstall her toilet in another resident's room as a result of budget restrictions.) As to the comparison group, two residents died after consent was obtained and three others withdrew their consent for a variety of reasons (e.g., being placed in the comparison rather than the experimental group; not wanting to answer personal questions). Thus, in this article we report on the outcomes of 14 experimental and 8 comparison participants. As our goal was to document the feasibility and effect of the wash-and-dry toilet in the nursing home, we did not initially randomize participants into experimental and comparison groups; rather, we gave the first two toilets to participants who were cognitively intact or presented with minimal cognitive impairment in order to get their initial feedback. After this, we randomized entry into experimental and comparison groups, thereby including those with more severe cognitive impairment in the experimental group. However, as can be seen in Table 2, both groups were of similar age, cognitive functioning, and toileting status, and we found (by means of t tests and chi-squares) no significant differences between the experimental and the comparison groups.
We interviewed a total of 27 nursing assistants, of whom 82% were female and 80% had grown up outside the United States (either in Africa or the Caribbean). Three of the residents in the experimental group were noncommunicative and another 5 were interviewed but had some difficulty in communicating or could not always answer all the questions (all 8 had scores < 20 on the Mini-Mental State Examination, or MMSE). The other 6 experimental participants were able to answer all questions clearly. Figure 1 displays the answers of the 11 experimental residents who were able to answer at least some of the questions. In the comparison group, 7 of the 8 residents were able to answer all questions clearly.
Procedure
The baseline phase included the 3 weeks prior to the installation of the new toilet. Trained assistants conducted interviews each week with the primary nursing assistant and with the resident if she was able to respond. The initial phase consisted of the 3 weeks immediately following toilet installation and usage for the experimental group or at least 1 month after the completion of baseline interviews for the comparison group. We repeated all baseline assessments each week, and we administered an additional toilet reaction scale to the experimental group. We administered the final assessments for the 3 weeks following 2 months of new toilet use for the experimental group and after a corresponding 2 months of regular toileting for the comparison group. We obtained urine samples for the analysis of bacterial content (as a clean catch) once during baseline and once after the final phase.
Assessments
Resident Questionnaires
The Toileting Experiences Questionnaire, which was developed for the study, included one question about the resident's level of privacy in the bathroom (rated from 1 = no privacy to 5 = complete privacy), four questions tapping the resident's negative feelings when toileting (angry, frustrated, depressed, or in pain), and one item concerning whether or not the assistance received in toileting was sufficient (rated from 1 = none of the time to 5 = all of the time). Residents also were asked open-ended questions about which problems they encountered while toileting, other feelings they experienced while toileting, and how the toileting experience might be improved. A Toilet Reaction Questionnaire included questions concerning residents' reactions to the new toilet (from 1 = very negative to 5 = very positive), and about relief from mental or physical stress while toileting (i.e., pain, embarrassment, or poor hygiene; from 1 = no relief to 5 = complete relief). Open-ended questions (e.g., time to adjust to using the new toilet; toilet-related problems) were also asked.
Nursing Staff Questionnaires
We administered the Toileting Experiences Questionnaire to staff members as informants describing their perceptions of residents' reactions. Questions were the same as those asked of the residents. We also used the Toilet Reaction Questionnaire with staff, with the addition of a question about the nursing assistant's own reaction to the new toilet (rated from 1 = very negative to 5 = very positive). We asked nursing staff members to write in a logbook (kept in the bathroom) each time the resident used the new toilet, and to indicate how dirty and wet the resident was after using the wash-and-dry toilet functions (on a scale of 1 to 5, with 5 being completely clean or completely dry) and also to include comments.
Urine Test
We performed urine cultures and colony counts on urine samples obtained noninvasively by nursing staff once during baseline and once after 2 months of use of the new toilet for the experimental group or after 2 months of continued regular toileting for the comparison group.
Participants' Background Variables
We extracted demographic data and information concerning incontinence and assistance during toileting from the Minimum Data Set (MDS; Morris et al., 1991), and we obtained two measures of cognitive function. The first was the Mini-Mental State Examination (MMSE; Folstein, 1983), which was administered to each participant by a trained research assistant. The MMSE has a maximum score of 30, with scores of less than 24 considered to show cognitive deficiency. In addition, we calculated the MDS Cognition Scale (Hartmaier, Sloane, Guess, & Koch, 1994) from eight MDS components, yielding a score with a range from 0 (minimal) to 10 (very severe cognitive impairment).
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Results
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Feasibility
Although the wash-and-dry toilets consisted of toilet seats designed to fit over preexisting toilets, we still experienced delays in the installation of the toilets, as it was necessary to make modifications in residents' bathrooms to connect these new toilet models to the central piping and electrical systems in the nursing home. Moreover, following installation, four of the new piping connectors leaked, causing water to spill on the bathroom floor. Although these leaks were caused by faulty new connections in the wall and not from the new toilets themselves, this situation led some residents and nursing assistants to rate the new toilet negatively.
One resident had to stop using the new toilet functions after a blister developed on the medial aspect of her left buttock, about halfway down from the top of the gluteal region. Her physician reported that this was not caused by the new toilet but by a pressure sore from sitting in her wheelchair.
Other issues revolved around staff and resident willingness to toilet. Several of the nursing assistants told us they found it easier to change the adult diapers of residents with incontinence and to wipe them dry rather than to take them to the toilet. In addition, 7 of the residents were reported to be physically or mentally disabled and consequently difficult to either verbally persuade or physically lift onto the toilet. Whereas six staff members were willing to consistently use the wash-and-dry functions with their residents, another six needed constant reminders to use these new features and to sign the logbook. Three of the residents reported being apprehensive about trying the new toilet and said they did not use the new toilet functions all the time because of a lack of motivation or fear of leaks. Eight residents said they were either okay with the new toilet or enthusiastic about using it.
Two residents were able to operate the new toilet independently as well as get themselves into the bathroom. Three residents were able to operate the remote control independently but needed physical assistance in order to transfer in and out of the bathroom. The other 9 residents were not able to operate the remote control and therefore required staff assistance.
Effect
Data obtained through the resident reaction questionnaire during the first 3 weeks after toilet installation showed that roughly half of the staff and residents responded positively to the wash-and-dry toilet (see Figure 1). The negative responses from residents (approximately 10%) arose primarily from leaks and other operational problems. We compared initial-versus-final phase data pertaining to the degree to which the wash-and-dry toilets had provided residents with relief from mental or physical stress associated with toileting (rated on a scale of 1 to 5, with 1 being no relief and 5 being complete relief), and we found that the residents as well as the nursing assistants felt the new toilets had offered some relief to residents during both phases (Ms = 3.0 and 2.8 for the residents; Ms = 2.6 and 2.9 for nursing assistants at the first and final phases, respectively).
Examination of data from the logbook entries revealed that residents were rated as clean 49% of the time, as slightly dirty 34% of the time, and in the range from somewhat to very dirty for the remaining 17% of the times that they used the wash-and-dry toilets. As to the ability of the hot air to dry residents after toileting, residents were found to be dry 53% of the time, slightly wet 30% of the time, and from somewhat to very wet 17% of the time. Out of the 284 logbook entries, seven comments by nursing staff were about the water or dryer temperature (e.g., "the water is ice cold, and resident can't take it"). In general, the most common problems reported by nursing staff were related to the physical and mental disabilities of the residents, such as lifting a heavy resident or when residents could not follow instructions, rather than to specifics about the wash-and-dry toilet.
As to comments from residents, problems with leaks were brought up (as mentioned earlier) as well as comments from 3 other residents, who stated that "the toilet did not clean completely," "the spray did not hit the right spot," and "the water was sometimes too cold or hot."
As to changes in residents' level of privacy or negative affect during toileting as a result of using the wash-and-dry toilet, our analyses of the toileting experience questionnaire revealed a trend toward a decrease in negative affect over time in the experimental group relative to the comparison group, according to resident data (baseline and end of the study, Ms = 1.41 and 1.07, respectively, for the experimental group; 1.15 and 1.17, respectively, for the comparison group). Staff members' responses did not show any trend.
We analyzed urine samples from each participant for quantitative prestudy versus poststudy bacterial growth. Almost the same percentage of participants in the two groups was found to have significant bacterial growth (> 20,000 colonies/ml) in their urine prestudy (43% of comparison group vs 50% of experimental group). Following the study, 86% of participants in the comparison group versus only 36% in the experimental group had significant bacterial growth in their urine. Specifically, on the basis of bacterial counts, 21% of the experimental group members showed improvement during the study versus no one (0%) in the comparison group, 72% of the experimental group remained at the same level as baseline versus 57% of the comparison group, and 7% got worse or displayed more bacteria in their urine in the experimental group compared with 43% of the comparisons (Mann-Whitney U = 25.5, p <.05). We are not sure how to explain the unexpected increase in bacteria in the comparison group, and therefore we offer this finding as preliminary and worthy of further investigation.
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Discussion
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We found that the wash-and-dry toilets provided some relief in mental or physical stress to nursing home residents and their nursing assistants. However, although this toilet offered some help with cleaning and drying residents, it was not sufficiently thorough in this regard, and it requires further development. Moreover, privacy was often not increased with the use of these toilets, because in most cases it was still necessary for nursing staff to be in the bathrooms to transfer residents or to operate the toilet. The documented reduction in bacteriuria suggests that this technology may promote health, although it is also possible that staff vigilance related to hygiene and the issue of cleanliness rather than the features of the toilet may have contributed to these results. Despite these shortcomings, we have shown the potential of this technology to improve toileting care in the nursing home. Clearly, further investigation is warranted.
Conclusions and Implications
The wash-and-dry toilet technology shows promise for nursing home use:
- The technology was perceived as beneficial for close to half of the residents in this study (Figure 1). Future research should clarify who is most likely to benefit from it.
- Despite some complaints regarding water temperature and installation difficulties, no significant adverse effects were encountered.
- The technology can be improved. Our feedback was given to the manufacturer in order to develop future products that specifically address the issues found in the nursing home setting.
In the future, nursing home facilities will have to be designed in a way that will enable use of smart toilets with minimal installation costs. The technology of toileting care is continuously improving (see Table 3), and better technology will most likely result in more satisfaction with toileting and less staff involvement with the toileting process. In view of the expected shortages in nursing home staff, such technology could be of significant use.
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Footnotes
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This study was funded by the Maryland Department of Aging and conducted by the Research Institute on Aging of the Hebrew Home of Greater Washington. We thank Dr. Steve Lipson for his help in the preparation of this article. Disclaimer: This article does not constitute an endorsement of the product by GSA, the authors, or the editors. 
1 Research Institute on Aging, Hebrew Home of Greater Washington, Rockville, MD.
2 George Washington University Medical Center, Washington, DC.
Decision Editor: Nancy Morrow-Howell, PhD
Received for publication September 20, 2004.
Accepted for publication March 28, 2005.
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References
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- Cohen-Mansfield, J., Kerin, P., Pawlson, L. G., Lipson, S., & Holdridge, K., (1988). Informed consent for research in a nursing home: Processes and issues. The Gerontologist, 28, 355-359.[Medline]
- Cohen-Mansfield, J., Werner, P., & Reisberg, B., (1995). Temporal order of cognitive and functional loss in a nursing home population. Journal of the American Geriatrics Society, 43, 974-978.[Medline]
- Folstein, M. F., (1983). The mini-mental state examination. In T. Crook, S. Ferris, & R. Bartus (Eds.), Assessment in geriatric psychopharmacology (pp. 47–51). New Canaan, CT: Mark Powley Associates.
- Garibaldi, R. A., (1999). Residential care and the elderly: The burden of infection. Journal of Hospital Infection, 43, S9-S18.
- Hartmaier, S. L., Sloane, P. D., Guess, H. A., & Koch, G. G., (1994). The MDS cognition scale: A valid instrument for identifying and staging nursing home residents with dementia using the minimum data set. Journal of the American Geriatrics Society, 42, 1173-1179.[Medline]
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- Ouslander, J. G., Uman, G. C., Urman, H. N., & Rubenstein, L. Z., (1987). Incontinence among nursing home patients: Clinical and functional correlates. Journal of the American Geriatrics Society, 35, 324-330.[Medline]
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Abstract
Toilet Description
