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ince the earliest reports, bathing has been a ritual bringing pleasure to the individual. From the days of Florence Nightingale, nursing has considered this ritual to be a valued part of their responsibility. Nurses feel they are neglecting their duty if they do not complete traditional daily baths for their patients.
       The business definition of a sacred cow is “an outmoded belief, assumption, practice, policy, system, or strategy, generally invisible, that inhibits change and prevents responsiveness to new opportunities.”1 Is the traditional bath a sacred cow of nursing?
       What is the traditional bath? It begins with a wash basin, soap, water, towel, washcloth, and bath blanket. The individual is dutifully scrubbed with a soapy lather from face to feet. Frequently, due to interruptions, the final parts of the bath are completed with cool soapy water guaranteed to leave a soap residue on the skin surface leading to skin breakdown and defeating one of the primary purposes for bathing.
       Bathing serves three purposes: for health protection and therapy, to enhance socialization, and to derive pleasure. The skin is the first line of defense for infection. Washing body parts removes dirt and oils that harbor germs, thereby protecting the individuals from harmful organisms. Bathing injured areas creates a soothing, therapeutic value to facilitate healing of damaged tissue. Having a clean, fresh smelling body enhances social encounters and interactions. Offensive body odors interfere with interpersonal relationships. Taking a long tub bath or shower after a hard day at work can relax even the most stressed individual resulting in pure pleasure.
       As we age, our skin surfaces become thin, dry, and fragile. The skin integrity is compromised by the loss of elasticity, the loss of subcutaneous fat, and decreased sweat and oils from aging sebaceous glands. Excessive bathing, soap residue, and skin friction from towel drying are additional risk factors for creating portals of entry for infectious organisms. Skin breakdown leads to further tissue damage and increased discomfort in the debilitated patient.
       Are there other ways to accomplish the need to cleanse the skin surfaces daily without causing additional risks to the patient? My experience answers this question with a resounding yes.
       Beginning in 1995, I had the good fortune of working in a hospital facility that valued quality improvement. This often required some changes in our processes particularly when an outcome improvement could be accomplished. As the leader of a team of nursing caregivers, I presented the evidence-based data describing the benefits of a new method of bathing. Several articles have demonstrated the increasing value of this new method called bag baths.2–4 Improved skin integrity, decreased skin irritation, increased patient satisfaction, and decreased anxiety in the Alzheimer’s patient were among the many demonstrated improvements.
       With the support of the caregivers on our quality improvement team, we initiated the bag bath process despite the resistance of the registered nurses. Within one week, the obvious patient satisfaction supported the claims made by Skewes and Rader, et al.2,3 Having initiated the process only in the intensive care unit, when the patient was transferred to a medical-surgical unit and the traditional bath was offered, the patient would object and beg to have “one of those bag baths that they used in the intensive care unit.” What a driver for success! Patient satisfaction, a priority in our hospital system, drove the new process changes forcing the nursing staff to bury their sacred cow.

Bag Baths
       This innovative bathing process was first described in the early 1990s by Skewes2 and consisted of these basic principles:
• Using one ounce of a no-rinse surfactant and emollient of choice (there are several available commercially, e.g., Septi-Soft® Concentrate, ConvaTec, A Bristol-Myers Squibb Co., Princeton, New Jersey) mixed with 500cc of warm water
• Using eight washcloths in a zip lock bag that measures 5" x 3" x 13"
• Mixing the surfactant with the water and pouring it over the washcloths in the zip lock bag (this bag can be prepared immediately before use or prepared earlier and warmed in a microwave for about 30 seconds checking the temperature carefully to prevent burning aging skin surfaces)
• Using one washcloth to wash each of these eight assigned areas: Face, back, chest, right arm, left arm, right leg, left leg, perineum
• Do not towel dry—allow the skin surface to dry by evaporation.
       After preparing the bag bath and assuring the temperature of the saturated wash cloths would meet the needs of the patient, the caregiver would prepare the patient to receive the daily “bath.” The process begins with applying the first cloth to the face. By gently wiping the area and then allowing the area to air dry, the skin surface was cleansed and allowed to dry without the friction of towel drying. The used washcloth was then discarded to be laundered and reused in the future. Then take the remaining washcloths and repeat the procedure on each of the eight body areas. Patient satisfaction results from a fresh cloth for each area, a warm cloth for each area, and no resulting skin itchiness due to soap residue. The emollient leaves the skin surface feeling smooth and soft. Have you ever been on an intercontinental flight where the flight attendants offer hot cloths at the end of your trip? The bag bath cloths replicate the pleasurable feeling that the tired passenger experiences. What a wonderful way to begin a day!
       Some companies offer the bag bath prepackaged, for example, Aloe Vesta® Bathing Cloths from ConvaTec, A Bristol-Myers Squibb Co., Princeton, New Jersey. Although this is another variation of the process, it is a more costly option. In some healthcare settings, the prepackaged bag bath is more convenient and therefore remains a viable option. In other settings where cost is critical, preparing the bag baths on site would be the preferred method.

Case Study
       Mrs. L. was a 100-year-old resident of a long-term care setting. During the days when she could independently bathe, she appreciated the regular whirlpool baths augmented by the daily sponge baths in the privacy of her bathroom. However, in the final two weeks of her life, Mrs. L. was comatose and bedridden and therefore unable to care for herself. Daily, her caretakers would enter her room, prepare the traditional bath, and scrub her skin surfaces dutifully fulfilling their nursing obligations. Mrs. L. was unable to communicate the level of discomfort this created for her. Mrs. L. had experienced eczema all of her life and had been cautioned by her dermatologist to avoid soaps and soapy residue, which exacerbated the pruritus caused by her eczema. How sad that during the final days of this individual’s life the very process she avoided for years was thrust upon her “out of duty.” The restlessness observed in Mrs. L. probably had many causes but one would have to believe that soap residue causing skin itchiness was one of those causes.
       The bag bath process is the perfect solution for bedridden and demented patients, especially those living in nursing facilities. The joy of the whirlpool can be replicated by the comfort of the bag bath in those residents who can no longer physically manage their own care or have insurmountable fears about the traditional bathing process. Not only will the resident benefit from the comfort this bath procedure provides but also the nursing caregivers will find the bag bath process less time consuming and therefore more cost effective for the nursing home. When implementing the process in the 225-bed hospital in which I worked, we realized an annual savings of $21,000. Savings occur with time efficiencies, decreased costs of laundry supplies and laundry labor, decreased cost of products needed to perform the bathing process, and most importantly an immeasurable increase in patient satisfaction.

It is Time for Nursing to Bury this Sacred Cow!
       It has been more than 13 years since the bag bath process was identified, yet nursing continues to resist the change. As a professional dedicated to improving end-of-life care, I have made it my personal goal to educate caregivers about the value of using the bag bath for patients confined to bed due to recent surgery or debilitating disease as well as for Alzheimer’s patients who are frightened by the daily bath. This should occur in every nursing care setting: hospitals, private homes, and nursing homes. If quality of life is what we espouse, how can we ignore the obvious improvements offered by this bathing option? Evidence-based outcomes have proven the merits of the bag bath. Is nursing ready to bury this sacred cow?