J Clin Nurs. 2019;1–10. wileyonlinelibrary.com/journal/jocn  | 1© 2019 John Wiley & Sons Ltd

Received:4July2018  |  Revised:23January2019  |  Accepted:9February2019DOI: 10.1111/jocn.14825

O R I G I N A L A R T I C L E

Bed bath with soap and water or disposable wet wipes: Patients’ experiences and preferences

Pia L. Veje1,2  | Ming Chen1,3 | Christian S. Jensen4 | Jan Sørensen5,6 | Jette Primdahl1,7,8

1DepartmentofRegionalHealthResearch,UniversityofSouthernDenmark,Odense,Denmark2UniversityCollegeSouthDenmark,Aabenraa,Denmark3DepartmentofClinicalMicrobiology,HospitalofSouthernJutland,Sønderborg,Denmark4NationalCenterforInfectionControl,StatensSerumInstitut,Copenhagen,Denmark5DanishCentreforHealthEconomics,DaCHE,UniversityofSouthernDenmark,Odense,Denmark6HealthcareOutcomeResearchCentre,RoyalCollegeofSurgeonsinIreland,Dublin,Ireland7KingChristianX’sHospitalforRheumaticDiseases,Gråsten,Denmark8HospitalofSouthernJutland,Sønderborg,Denmark

CorrespondencePiaL.Veje,DepartmentofRegionalHealthResearch,UniversityofSouthernDenmark,Odense,Denmark.Email:pveje@health.sdu.dk

Funding informationUnrestrictedfundingprovidedbytheUniversitySouthernDenmark,TheRegionofSouthernDenmark,UniversityCollegeSouthDenmarkandHospitalofSouthernJutland.

AbstractAims and objectives: Togainanin‐depthunderstandingofpatients’preferencesre‐gardingtwobedbathmethods:soapandwateranddisposablewetwipes.Background: Bed baths allow hospitalised, bedridden patients to stay clean andfresh.Theyserveanumberofpurposes:healthpromotion,socialproprietyandpurepleasure.Traditionally,soapandwaterhavebeenusedforpersonalhygiene,butinrecentyearssoapandwaterhaveincreasinglybeenreplacedbytheuseofdisposablewetwipes.Design: Aqualitativestudywithahermeneutical‐phenomenologicalapproachwaschosentoexploreandunderstandpatients’experiencesofbedbathmethods.Methods: Semi‐structured, individual, in‐depth interviews with 16 bedridden pa‐tientsfromthreewardswereconducted.Thesoftwareprogramnvivowasusedtostructurethetranscribedinterviewsandassistintheinitialdataanalysis.Thedatawere analysed and interpreted within a phenomenological‐hermeneutical frame‐work.COREQguidelineswereusedinthepreparationofthispaper(SeeSupportinginformationAppendixS1).Results: Four overall themes were identified: “Creating a sense of cleanliness,”“Preferencesandconcerns indifferentsituations,” “Cleanlinessofhandsandface”and“Clinicaldecision‐makingaboutbedbathmethod.”Conclusions: Overall,patients’bedbathpreferencewasforsoapandwater,butdis‐posablewetwipeswereconsideredaconvenientalternativeandpreferredincertaincircumstances,forexample,whenapatienthadpainordiarrhoea.Shareddecision‐making regardingbedbathmethod is recommended.Handsand facehadspecificrequirements.Relevance to clinical practice: Nursingstaffshouldbeawarethatbedriddenpatientshavevaryingpreferences,anditisimportanttoincorporatethepatients’preferencesinthedevelopmentofstandards,healthpoliciesandclinicalguidelinesforbedbathpractices.

K E Y W O R D S

bedridden,disposablewipes,hermeneutic,patientexperience,personalhygiene,phenomenology,qualitativeinterviews

2  |     VEJE Et al.

1  | INTRODUC TION

Nursing staff provides bed baths for hospitalised, bedridden pa‐tients tomaintainpersonalhygiene.Bedbaths serveanumberofpurposes: health promotion, social propriety and pure pleasure(Lentz,2003;Möller&Magalhães,2015;Shoonhovenetal.,2014).Furthermore, bed baths are regarded as necessary procedures toimprove patients’ quality of life, social acceptance andwell‐being(Ahluwalia,Gill,Baker,&Fried,2010;Downey&Lloyd,2008;Lentz,2003;Sheppard,2000).

Traditionalbedbathswithsoapandwater(SAW)arenowincreas‐ingly replacedwithbedbathsusingdisposablewetwipes (DWW)(Groven, Zwakhalen, Odekerken‐Schröder, Joosten, & Hamers,2017;Ogai et al., 2017; Shoonhoven et al., 2014). The prepackedandheatedDWWwasintroducedinnursingpracticein1994intheUSA(Skewes,1994).Areportshowedthat71%ofbedbathsusedSAWuseand12%DWWwithoutdisinfectants (Coyer,O´sullivan,&Cadman,2011).

TheincreaseduseofDWWforbedbathsinDenmarkduringthepast10–15yearsfollowstheinternationaltendency(Hørdametal.,2017;Nøddeskou,Hemmingsen,&Hørdam,2014).

In Danish hospital wards, bed baths are provided to approxi‐mately15%ofsomaticpatients(Nøddeskouetal.,2014).Estimatedbynumberofhospitalisedpatients’andbeddays,thiscorrespondstoapproximately600,000bedbathsperyearprovidedannuallytohospitalisedpatients(StatbankDenmark,2017).

2  | BACKGROUND

The provision of hygiene care to patients is a core nursing task(Groven et al., 2017) and is offered on almost all hospital wards(Collins&Hampton,2003a,2003b;Sheppard,2000;Shoonhovenetal.,2014).Bathinghasbeenregardedasaritualisticpleasureand,inrecenttimes,anecessarytherapeuticdailyprocedure(Sheppard,2000).Inaddition,personalhygieneisconsideredoneofourbasicneeds (Orem, 2001). Bed baths allow bedridden patients to stayclean and fresh. The primary goals of bathing are tomaintain hy‐giene, and to leave patients feeling refreshed, and comfortable.Thereareotherbenefitsasbathingcanremovesweat,oil,dirtandmicrobes fromtheskin,decreasebodyodourandstimulatecircu‐lation. In addition, bathingmay also reduce the risk of infections(Lentz,2003;Sheppard,2000;Skewes,1994).Ithasbeenreportedthatupto10%ofalladmittedDanishpatientswillgetanosocomialinfection(CentralEnhedforInfektionshygiejne,2018).Nosocomialinfectionsareassociatedwithhighermortalityratesandrepresentan economic burden on the healthcare system (Stone, Braccia, &Larson,2005).Otherbenefitsincludetheabilitytoinducecomfort,relaxation and reduce pyrexia. In addition, bathing allows nursingstaff to assess the patient's skin for integrity and pressure sores(Coyeretal.,2011).

BathingwithSAWcanhaveadirect impactontheepidermis,byposinganumberofthreatstotheintegrityandbarrierfunction

of the skin. Soap can affect the resident flora and natural lipidsandcanchangeskinacidity.Furthermore,itmayinterferewiththewater‐holdingcapacityoftheskinandcanhaveathinningeffecton the outermost layers of epidermis and the stratum corneum(Collins&Hampton,2003a;Massa,2010;Voegeli,2008).TheuseofSAWandsubsequentdryingwithatowelcanhaveadisruptiveeffectontheskinbarrierandtentativeevidenceshowsthatahighfrequencyofbedbathswithSAWisassociatedwithanincreasedriskofskindamage(Voegeli,2008). It isnecessarytoremoveex‐cessbodysecretions,butpreferablywithoutdryingout theskin.Intact skin serves a vital role inmaintaining the body's first lineofdefenceagainstinvadingmicrobes(Collins&Hampton,2003a).Dryskinisalsopronetocracks,whichcouldleadtoinfectionsandpressuresores(Beeckmanetal.,2010;Hampton,2011).Basinsforwaterusedforbedbathingcanbeareservoir forbacteria, ifnotproperlycleanedafteruse,andmaybeasourceofcross‐contam‐inationbetweenpatients(Greaves,1985;Johnson,Lineweaver,&Maze,2009;Marchaimetal.,2012).Furthermore,rubbingtheskinduringbathingmayreleaseskinfloraintothebasin,whichmaybe‐comeasourceofcross‐contaminationbetweendifferentareasofthepatient'sbody.

DWWmayoffermanyadvantagesforpatients,includingalowerriskforcross‐contamination,becauseoflimitedcontactwithdiffer‐ent bodyparts, and avoidanceof having to use a basin (Collins&Hampton,2003a;Lentz,2003;Wright,1996).

DWWmayalsoleavethepatient'sskinsoftandbettermoistur‐ised (Sheppard, 2000; Skewes, 1994;Wright, 1996). Furthermore,comparedtoSAW,DWWseemtoenhancetheskinbarrierfunction,reducetheriskofskinimpairment,reducedermatitisandpressureulcers(Beeckman,Verhaeghe,Defloor,Shoonhoven,&Vanderwee,2011;Hodgkinson&Nay,2005;Kron‐Chalupa,Benda,&Williams,2006;Lentz,2003;Massa,2010;Shoonhovenetal.,2014).However,inanexperimentalsetup,nosignificantdifferencesinskinphysiol‐ogywerefoundbetweenwashingwithSAWandDWW(Ogaietal.,2017).

Additionally there are studies, which support the idea thatDWWareeasytouseandavaluablealternativetoSAW(Grovenet al.,2017;Hørdametal.,2017;Nøddeskouet al.,2014,2018;

What does this paper contribute to the wider global clinical community?• Thispaperprovidesinsightsintoanddeeperknowledgeabouthospitalised,bedriddenpatients’preferencesforbedbathmethods.

• Thegeneralpreferencewasforsoapandwater,butdis‐posable wipes were considered convenient and werepreferredincertaincircumstances.

• Theresultscanenhancenursingstaff’sfocusonthein‐clusionofpatients’experiencesandpreferencesinnurs‐ingcare

     |  3VEJE Et al.

Sheppard,2000;Shoonhovenetal.,2014;Wright,1996).ADutchstudyevenshowedthatsomepatientswouldprefertoexchangewashing with SAW for washing with DWW on a permanentbasis (Shoonhovenetal.,2014).DWWmighthelp support inde‐pendence and studies have described that patients like the factthateachwipeonlycomes incontactwithonepartof thebody(Skewes,1994;Wright,1996).

A cluster randomized study (Shoonhoven et al., 2014) of 500nursinghomesresidentsshowedthatmostoftheresidentsfeltre‐freshedandcleanafterwashingwithoutwater.SecondaryanalysisofthesamedatafoundthatpatientsalsoseemedtoreceiveamorethoroughbathingwithDWWcomparedwithSAW (Achterbergetal.,2016).

Furthermore,theuseofDWWseemstoreducestafftimeandsavecosts (Collins&Hampton,2003a; Larsonet al., 2004; Lentz,2003;Nøddeskouetal.,2014,2018).

Despite the increasing use of DWW, no in‐depth qualitativestudies that explored the patient's experiences regarding the twobed bath methods has been identified. The patients’ perspectivefrom quantitative studiesmay not nuance the patients’ individualperspective(Grovenetal.,2017;Hancock,Bowman,&Prater,2000;Hørdametal.,2017;Nøddeskouetal.,2014,2018;Sheppard,2000;Skewes,1994).

Thus,theobjectiveofthisstudywas,throughin‐depthqualita‐tive interviews, toexploreandnuancehospitalised,bedriddenpa‐tients’experiencesof, satisfactionwithandpreferences foreitherSAWorDWWbedbaths.

3  | METHOD

We conducted a qualitative interview study based on a herme‐neutical‐phenomenological approach to analyse and interpret‐ing patients’ experiences of bed baths with SAW and DWW.Hermeneuticphenomenology isaqualitativeresearchmethodol‐ogywhichcanbeusedtounderstandhowindividualsexperienceacommonphenomenon(Zahavi,2003)andissuitabletodescribean unexplored phenomenon (Kvale & Brinkmann, 2009; Patton,2002).Theapproachwasused in the formulationof the researchquestions,todevelopasemi‐structuredinterviewguide,theprob‐ingquestionsusedduringtheinterviewsandinthefirststepoftheanalysis.The interviewswere intended tocreateanunderstand‐ingofaphenomenonfromthe interviewedperson'sperspective,tounfold themeaningand importanceof their experienceswiththe intention of setting aside the interviewer's preconceptions(Kvale&Brinkmann, 2009; Patton, 2002). Semi‐structured, indi‐vidual, in‐depth interviewsallowthe interviewer todelvedeeplyintopersonalexperiencesandarewidelyusedtoco‐createmean‐ingswith interviewees, and to reconstruct theirperceptionsandexperiences related to healthcare (DiCicco‐Bloom & Crabtree,2006). COREQ guidelines were used in the preparation of thispaper(Tong,Sainsbury,&Craig,2007)(SeeSupportinginformationAppendixS1).

3.1 | Setting and data collection

The inclusion criteria were bedridden patients who were able tospeakandunderstandDanishfluently,wereabletounderstandoralandwritteninformationand,abletosignawrittenconsentform.Allparticipants should have experienced bed bathswithDWW for aminimumof2daysinahospitalandhavepreviousexperiencesofbedbathswithSAW.Inthisstudy,abedbathwasdefinedasstaffwash‐ingthepatient'sbodyinbed(Downey&Lloyd,2008;Shoonhovenetal.,2014).Eligiblepatientswereidentifiedaccordingtotheinclusioncriteriabythenursewhocaredforthemduringdayshifts.

Priortoparticipationoralacceptancefromthepatientstohearmoreabout thestudywasobtainedby theirnurse.Next, the firstauthor offered potential participants oral andwritten informationaboutthestudy.ThereadabilityofthewrittenpatientinformationandconsentdocumentswasassessedusingtheGunningfogindextoensurethatthereadabilitylevelmatchedtheaverageeducationallevel(Hamnes,vanEijk‐Hustings,&Primdahl,2016).

Toensureheterogeneityinpatientcharacteristics,theaimwastoapplyasamplingstrategywithmaximumvariation(Patton,2002).Specifiedcharacteristicsofpotentialparticipantswereusedinama‐trixforparticipant inclusion,toallowfortheselectionofavarietyofparticipants(Wacherhausen,1996).Thecharacteristicsincludedsex,age,occupationalbackground,cohabitationstatus,ward,lengthofadmission,diagnosis,bariatricinformation,skinissues,stomaandinformation regarding use of urinary catheter and diaper. In thisstudy,bariatricinformationwasnotedifthenursingstaffassessedthatthepatientrequiredbariatricequipment.

Asemi‐structuredinterviewguidewasdeveloped.Theinterviewguidecontainedthematicdimensionsrelatedtotheresearchques‐tion,forexample,bedbathwithDWW,andadynamicdimension,expressed in everyday language, for example, “Can you describehowyouwerewashed thismorning?” (Kvale&Brinkmann,2009).Theinterviewguidewasdevelopedbasedontheinterviewer'spre‐viousexperience,conceptualandtheoreticalknowledgeandfamil‐iaritywiththetopic(Larsonetal.,2004;Pedersen,Delmar,Falkmer,&Grønkjær,2015;Sheppard,2000).Thequestionswerekeptbriefandeasy tounderstand.Academicconceptswereavoided topro‐mote a positive interaction, to optimise conversation flow and toencourage the participants to talk about their experiences (Kvale&Brinkmann,2009).All interviewswereplannedtolastmaximum1hrandweredigitallyrecordedandtranscribedverbatimbythein‐terviewer.Theinterviewswereconductedinseparateconsultationroomsinthewardoratthebedsideandbythefirstauthoracrossallinterviews.Thelengthofeachinterviewwasnoted.

Participantswere included until no new information appearedinthreeconsecutiveinterviews,inordertoachievedatasaturation(Francisetal.,2010;Patton,2002).

3.2 | Data analysis

Thetranscribed interviewbecamethebasis for theanalysisandahermeneutic interpretation (Gadamer, 2004).nvivo version: 11.4.3

4  |     VEJE Et al.

wasused tostructure thedata,ensurea systematicanalysis,helpreinforcecompletenessandallowflexibilityintheanalyticalprocess(DiCicco‐Bloom&Crabtree,2006).Throughaninitialinductiveanal‐ysis, themes regarding the specific phenomenon were developed(Kvale&Brinkmann,2009).

Afive‐stepcodingmethodwasemployed (Kvale&Brinkmann,2009).

Thefirststepwastoreadall interviewtranscriptionsinordertoachieveanoverallsenseoftheinterviews.Thesecondstepwasanopeninitialcoding,wherenaturalmeaningunits,asexpressedbytheparticipants,wereidentified.Thethirdstepwasathematicdescriptionoftheinitialnaturalmeaningunits,astheywereunder‐stoodbytheinterviewer.Duringasecondreading,newunitsandconcepts,whichwerenotpreviouslycaptured,wereaddedtothethemes.

Throughanaxialreadingoftheinterviews,thefourthstepwastolinktheinitialthemesbetweenthetranscripts.Thefifthandfinalstepwas to condense the initial themes intomoreoverall themes(Kvale&Brinkmann,2009).

Thehermeneuticapproach(Gadamer,2004)formedthedescrip‐tionsfromtheanalysisandaddressedtheidentifiedoverallthemesin three interpretationalcontextsdescribedas self‐understanding,criticalcommonsenseunderstandingandtheoreticalunderstanding(Kvale&Brinkmann,2009). Self‐understandingexpresses thepar‐ticipant'sexperienceinthetranscribedinterviewsasrephrasedandcondensed statements. In the critical common sense understand‐ing, the interpretationgoesbeyond the rephrasedandcondensedthemeswhileremainingwithinthecontextofcommonsense.Thiscontextprovidedawiderunderstanding, includinggeneral knowl‐edge, which amplified and enriched the condensed statements(Kvale&Brinkmann,2009).

Some of the patients’ self‐understanding and critical com‐monsenseunderstandingarepresentedasfindingsintheresultssection.

Interpretation in thethirdcontext, “theoreticalunderstanding”goesbeyondtheparticipants’experiencesofbedbaths.ThefindingsarediscussedwithrelevantliteratureintheDiscussionsection.

3.3 | Ethical considerations

ThisstudyfollowedtherecommendationsgivenintheEthicalguide‐linesfornursingresearchintheNordiccountries,publishedbytheNorthernNurses’Federation (Vård INorden,2003).Furthermore,the study followed guidelines developed by the World MedicalAssociation and implemented by the National Ethics Committee(World Medical Association, 2001). The local Scientific EthicsCommitteefoundthatformalethicalregistrationandapprovalwerenot required (The Local scientific Ethics Committee of SouthernDenmark, 2011). The head physicians in the three participatingclinicsapprovedthestudyandformalpermissiontostorethedatawasobtainedbytheDanishDataProtectionAgency(DanishDataProtectionAgency,2015)(J.No.18/35356).Writtenconsenttopar‐ticipatewasobtained.

4  | RESULTS

Sixteen in‐depth, individual, semi‐structured interviewswerecon‐ducted,fromOctober2016–May2017,withbedriddenpatients inthreedifferentwardsatoneDanishhospital.Fivemenandelevenwomen,withameanageof67(rangefrom43–81)were included.ParticipantscharacteristicsaresummarisedinTable1.Twopartici‐pantswhomettheinclusioncriteriadeclinedparticipation.

The interviews were conducted during admission. The meanlength of stay before participationwas 8days (range: 2–35days).Theinterviewslastedbetween17–41min(mean:23min).Sevenoftheparticipantshadacohabitantstatusandnineweresingle.Tenwereretired,butfiveofthesestillhadalinktotheirwork.Threeofthepatientswereassessedasbariatricpatients’bythenursingstaff.

In general, the participants reported that when they were athome, taking a showerwas the overall preferredmethod for per‐sonalhygiene,andtheparticipantsnormallytookashoweralmostevery day. This informationwas expressed in an unsolicitedman‐nerbythepatients.Cleanlinesswasconsideredabsolutenecessaryandpersonalhygienewasessentialforwell‐beingandself‐esteem.Furthermore,manywereconcernedaboutodourandexpressedthatitwasextremelyimportanttosmellnice.Otherwise,theywouldfeeldisgustingandbeashamed.

Theanalysisderivedatfouressentialthemes:“Creatingasenseofcleanliness,”“Preferencesindifferentsituations,”“Cleanlinessofhandsandface”and“Clinicaldecision‐makingaboutbedbath.”Theparticipantsarereferredtobyanumbering(P1–P16).

4.1 | Creating a sense of cleanliness

TheparticipantsstronglyexpressedageneralpreferencefortheuseofSAWforpersonalhygiene,ifgivenachoice.TheyhighlightedandreaffirmedabeliefthattheuseofSAWmadethemfeelcleanerandfresherthantheuseofDWW,buttheydidnotknowifthiswasactu‐allytruethatSAWdidcleanbetter.SAWwasdescribedasthetypeofbath that removesbacteria,dirt and sweat from the skinmuch

TA B L E 1  Characteristicsoftheparticipants

Patient characteristic matrix

Ward Surgical8

Medical 4

Emergency4

Occupationalbackground Healthprofes‐sional5

Communication2

Vocational9

Diagnosis Infection4

Chronicdiseases7

Elucidation5

Othervariables Stoma5

Diaper10

Urinarycatheter9

     |  5VEJE Et al.

moreeffectivelythanDWW.TheycharacterisedtheeffectofSAWasbeing“reallywashed,”andoneparticipantnotedthatifSAWwereleftout, itwouldbeunhygienic.SAWhelpsyoufeel “really”cleanand some participants believed that SAW removedmore dirt andwasmorethoroughandhygienicthanDWW.Thefollowingpartici‐pantsdiscussedreasonsfortheirpreferencesforSAW.

ThenIwouldtakesoapandwater…Ijustthinkthatit’sthebest,butwhy,Idon’tknow…againIthinkthatIamcleaner. (P7)

IfeelthatIamcleanerthatway(withSAW),Imean,bacteriahave tobe removedasmuchaspossible…because, in any case, you cannot go around beingcrusty. (P12)

TheparticipantsalsodiscussedsocialreasonsfortheirbeliefsandthatbathingwithSAWwasapartofgrowingup,traditions inchild‐hoodandhabits.Becauseofthat,theydidnotquestiontheassumptionthatbathingwithSAWremoveddirt,bacteriaandprovideafeelingofcleanliness.However,itwasdifficultfortheparticipantstoexplainandfindtherightwordsfortheirbeliefs.

It’sacleaningprocess–Imean,yougetoiloffyourskin.Maybe it’smostly inyourmind, Idon’tknow–it’sjustthatyou’vealwaysdoneitlikethat.It’satradi‐tionyoucouldsay. (P5)

4.2 | Preferences and concerns in different situations

SeveraladvantagesofusingDWWwereexpressed,whichincludedindependenceandself‐careforbedriddenordisabled.Participantsdescribedthequalityofthewipesandhowfastandeasytheyweretouse.Thewipeswerecharacterisedasbig,soft,moistandpleasant,comparedtoawashingclothusedwithSAW.

Ithinkthey(DWW)aresoftandtheyaremoistandthey are not so big, you can do it yourself, I’m soplaguedwithrheumatismallover,soIcan,like,Icanhardlymovethisarmanymore–butIjustthinktheyaresogood–theyworksowellforme.ThefirsttimetheyopenedoneupandIhadtouseitmyself…thenIthought,noit’smoist,andit’snotthatbigandsosoft,and that, I could sort of notice that I feltwashed. IthinkIcouldreallyfeelthat. (P15)

Itwasconvenientandfastertousethewipesiftheyhadpainordiarrhoea,becauseitwouldtakea longertimetobathewithSAWand itrequiredmultipleactions.Onehadtowashwithsoap,rinsewithwateranddryallpartsofthebodywithatowel.Incontrasttothis,DWWrequiredonlyoneaction.

Yes,yesterdayIwaswashedwithsoapandwater,andIthinkthatitwasactuallyveryuncomfortable.IhadsomuchpainandshekeepsayingthatIshoulddoitmyselfandIjustcouldn’tandthenshecameupwiththesolutionsoapandwater–yousimplycannotdryoff likeyoucanwiththe (DWW)–and itshouldbedriedanditshould…thereyouwouldwanthertouseDWW. (P4)

WashingwithDWWwasdescribedasawaytofreshenup,butiftheparticipantswerevisiblydirtywithsweat,dirtandemanatedanodour,theydidnotfeeltheywerecleanorsmelledcleanafterusingthewipes.SomeparticipantsevenexpressedveryclearlythattheydidnotliketobewashedwithDWW.

I think they (DWW) are great for freshening up –like now, for example, let’s say you have just comefrom surgery and youwake up and you need to berefreshed a little before bedtime on your forearms–Ithinktheyarequitegood–but Idon’t liketobewashedwiththem. (P10)

Otherparticipantsdiscussedthedifferencebetween“freshen‐ingup”andbeing“reallywashed.”Theydescribedtheirconcernsanddoubtsaboutcleanliness.BeingwashedwithDWWwasdefinitelypreferred tonobathing, butwas judged tobe the second choice,afterSAW.

Yesthat’sit,andifyoujusthavetofreshenuporthat,they’refine.Well,it(soap)doesn’twashyouanybet‐ter, but I think it’s like I haven’t beenwashed (withDWW), I don’t think so – I don’t feel thatwith thewipes.It’sbetterthannothing,ofcourse–soyouarefreshenedup. (P8)

Incontrast,otherparticipants feltcleanandappreciatedthead‐vantagesbyusingDWWasanalternativewashingmethod.

No, I actually think I feelpretty clean (withDWW). (P9)

Youfeelyou’recleanand,really,Idon’thaveanythingagainstit. (P12)

OtherconcernsaboutDWWwereexpressed.Someofthepar‐ticipants described that itwas as if theDWW left a layer on theskin,whichtheyexpressedas“oilyorafilm.”AfterusingDWWforseveralconsecutivedays, theyalsodescribed that theskin turneddryandscaly.Inaddition,otherparticipantsdescribedredness,skinirritationanditchinessoftheskin,whichwerelinkedtorecentskinproblems,suchaseczemaorflakingskin.

It’sasiftheskincan’treallygetair,or…But,Ijustthinkthere’sjust,like,afilm,overit. (P11)

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Bed bathswithDWWdid not necessarily include subsequentdryingoffwithatowel.ParticipantsdescribedthemoistfeelingleftontheskinafterabathwithDWW.Ittooktimetodryandtheyex‐pressedhavingthesensationofmoistskinforalongtime,comparedtotheuseofSAW.Somedidnotliketohavewetskinforlongtime,andinaddition,thiswasassociatedwithfeelingsofnotbeingclean.

Ithink,likethosewipes,(theskin)isnotdrystraightaway,butwithsoapandwater,ifyouuseatowel,youknow...(theskin)it’slikeit’sdamp. (P16)

However, other participants expressed great satisfaction withDWW,includingbenefitstoskinintegrity,softnessandthefactthattheydidnotneedtoapplylotionafterwashing.

The skin is alsodry (after using soap) and then youhavetousebodylotion…andIdon’tthinkyoufeelthatwith thewipes, it’snotatall thesame, it’s (theskin)softer. (P4)

BothpreheatedandcoldDWWhadsomeadvantagesforthosewhohadexperienced them.PreheatedDWWwere considered tobeverynice,especially iftheparticipantswerecold inbed.Otherparticipantsappreciatedthecoolnessbecauseitwascomfortableontheirwarmskin,ifitwashotfromfeveroriftheyfeltsweaty.

Itwasreallylovely.Idon’tknowiftheyheattheminthemicrowave…Itwasgreat–Ididn’trealizethatitcouldbedone… (P3)

4.3 | Cleanliness of hands and face

Allparticipantswhomentionedthefaceandhandspointedoutthattheirneedsandpreferencesforthesetwobodypartsweredifferentfromtherestofthebody.TheydescribedtheneedtouseSAWasex‐tremelyimportantwhenitcametothehands.Theywantedtheirhandstobe “reallyclean,”becausehands toucheverything in theenviron‐mentandareusedtoputfoodintothemouth.Furthermore,thepar‐ticipantsexpressedthattheuseofSAWhelpedthemfeel“really”clean.

Yes,Idon’tknow,itcouldbethatit’sthehabit,again–Idon’tknow,IfeelI’mcleanerwhenIstandandrubmyselfwithsoap,and…It’s important,becauseyouare putting things in yourmouth, aren’t you, and it(thehands)hastobeclean,so,yesthat’sanimportantfactor. (P12)

Soap andwater is numberone, yes…you can’t ex‐plain it…Idon’tknow, it (SAW)mightbecleaner– Idon’t know ...morecomesoff, and it’s cleaner thanwithwipes,togetthem(myhands)cleanandit’smorehygienictoo… (P13)

Furthermore,theparticipantspointedouttheneedtowashtheirhandswithSAWatleastonceadayandalwaysafterusingthetoilet.

No,Iwanttogoandwashmyhandsatthesinkonceaday. (P8)

Inaddition,otherparticipantsexpressedconcernsabouttheuseofDWWforhandwashing.Theexpressedfilmwasalsoleftonthehandsanddescribedbyoneparticipantas“clammy.”

Yes,andIfeelaswellthatthereisasortofafilmafter(usingtheDWW)…alayer–onthefingers,againit’sthat soap, that doesn’t get washed off, you know… (P10)

Someoftheparticipantsdidnot liketheirfacetobewashedwithDWWbecausetheskinfeltstrangeafterwards.Thefeelinginthefacewasdescribedas“tight”andthatitfeltlikeitneededtobemoisturisedafterwashing.Theyalsopointedoutthatfacialskinisdifferenttotherestofthebody.Theydidnotwantsoapintheirface,either,andpreferredwateronlyorotherpersonalcleaningagents,suchasoilorcleansingfluid.

Yes,Ialsotriedthem(DWW)…Idon’tlikethemonmyface. (P3)

ButI’vebeenwashedwiththem(DWW).Ifeelitonmyfacetoday ... It’sas iftheskinneedstoget, like,moisture. (P4)

Idon’tusesoaponmyface…Iusecleansingcream. (P5)

Incontrast,otherparticipantsdidnotmindusingDWWontheirfaceandsaiditwasgoodenoughandthatyoufeltfreshenedup.Theystatedthattheyfeltthatsomethingwasdonetofeelfreshandwashed.

It’s fine–theonlything is,whenwashingyourface… just like, you know, when you’re on a plane yougetthosewipes ... they’rerefreshing…buttheyen‐sureyou’reatleast,youfeelatleastthatyou’vedonesomething. (P4)

4.4 | Clinical decision‐making about bed bath method

Some participants expressed that the opportunity to have a bedbathandtomaintainpersonalhygienewasmoreimportanttothemthanwhetheritwasperformedwithSAWorDWW.

Idon’treallyhaveanopiniononthat–whenyouaresickitdoesn’tmatteradamn,soit’sallthesame–justaslongasyouarewashed. (P1)

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In contrast, other participants discussed concerns about theclinicaldecisionregardingthetypeofbath,inrelationtotheactualsituationandconditionoftheindividualpatient.Theyexpressedtheimportance and complexity in the choice of bathing method, de‐pendingonwhether theywerebedridden,hadpain, the lengthofstayandhowitfittedthesituation.Someoftheparticipantsevendiscussed economic issues, and whichmethod they believed wasmost cost‐effective. The participants also pointed out that itwasfasterforthestafftouseDWW.

So,itwasthewetwipes–theotheristoohardtouse.Ithinkifthey(thepatients)areoutinthebathroom,it’sgoingtobesoapandwater.Itdependsonthesit‐uation,ofcourse. (P12)

Participantsexpressed that thedecision regarding typeofbathshould be taken by the nursing staff and should be related to theworkload and clustering of other care activities on theward. Theyexpressedstrongacceptanceofthenursingstaff'sdecisionsandthatthenursingstaffdiditintheirownwayanddecidedwhattheyfoundsuitableinthesituation.Theparticipantswerenotalwaysofferedachoice.Someparticipantsdidnotwanttobeaskedatall,becausetheydidnotthinkitwaspossibletochooseSAWwhiletheywerebedrid‐den.Otherparticipantsdiscussedwhether thenursingstaff shouldaskatall,becausethepatientsexperiencedbustleontheward,whileotherparticipantswouldlikethenursingstafftoaskfortheirbedbathpreferencesbeforetheirdailyhygieneroutine,ifpossible.

No(Idon’twanttobeasked)and it’salsoeasierforthe staff (pointing to theDWW). So, I assume theyuse(SAW)whenIcansitup…andwhenI’minbed,theyuseawetwipe. (P4)

When you are lying in bed, you can’t use soap andwater. (P9)

Yes,Ithinkso–youshouldbeallowedtochooseforyourself. (P10)

Notheyjustwashme…no,it’sallthesame,Itakeitasitcomes...I’mverysatisfiedwiththat. (P7)

Itdoesn’tmatter,theyhavetheirownways–theyjustdowhateverworksforthem. (P1)

5  | DISCUSSION

Thisstudyaimedtogainanin‐depthunderstandingaboutpatients’preferencesregardingtwotypesofbedbath,theuseofSAWandDWW. The participants strongly preferred SAW for personal hy‐giene, a preference that they statedwas linked to traditions held

sincechildhood.However,thisfindingcannotbetakeninisolation,becausemanyofthesameparticipantsalsodescribedwashingwithDWWasachancetofreshenupandthatthistypeofwashingwasconvenient and preferred in specific situations. They expressedthat the faceandhandsneededspecialattentionandthatneithersoapnorDWWbelongedontheface.Whilesomethought itwasacceptable touseDWWon the face, andhandwashingwasover‐whelminglinkedtoSAW.Despitethesefindings,manyparticipantsalsopointedoutthatthetypeofbathwaslessimportantthantheoverallneedtobewashed.Furthermore,theparticipantsexpresseddifferentattitudesregardingtheirbedbathpreferences,whichre‐flectedtheindividualvaluetheyplacedonpersonalhygieneduringadmission.

Another important advantage related to DWWwas that theypromoteindependence,aspatientscouldwashthemselvesdespitetheirdisabilities,andthustheywereconvenientandcouldbeusedindependentlyofthenursingstaff'sprioritiesontheward.

Nearly,alltheparticipantsshoweredalmosteverydayathomeandthefindingsinthisstudyilluminatedthattakingashowerwastheoverallpreferredmethodofmaintainingpersonalhygiene.Thisisinthelinewithanotherstudy,whichshowedthat90%ofadultstakeashowerminimumtwiceaweek(Sheppard,2000).Allpartic‐ipants compared their experiences of the two types of bedbathswith taking a shower, and theywould definitely choose a showerduringadmission,ifitwaspossible.

Otherstudiesalsoreportedthatpatientsweremoresignificantlypositiveandsatisfiedaftershowers,comparedwithafterbedbaths,andthatabedbathisnotexperiencedasbeingequaltoashower(Hancocketal.,2000;Lopes,Nogueira‐Martins,&deBarros,2013).

Theparticipantsdescribedwashingasamandatorydailyneces‐sity,whichhad an impact on integrity, self‐image, personality andwell‐being. This is consistentwith other studies, inwhich bathingisdescribedasan importantandmeaningfulactivity. It isameanstobecomingclean, it isrelatedtonotionsofwell‐beingandvirtue(Ahluwaliaetal.,2010;Downey&Lloyd,2008)anditisconsideredimportantfortheself‐image(Massa,2010).Theimportanceofbath‐ing is instilledduring childhood, and sociocultural factors, suchasculturalbeliefsandfamilypractices,influencehygieniccare(Collins&Hampton,2003b).Furthermore,itseemsthat,inWesternsociet‐ies,thereisastigmaattachedtouncleanlinessandodourandthereisasocialexpectationthatonebathe(Ahluwaliaetal.,2010).Thiscouldexplainwhytheparticipantsexpressedthattheyfeltashamedand disgusting because of odour, if they did not wash every dayduringadmission.

Overall, theparticipantsdidnot alwaysexperience cleanlinessafterwashingwithDWW, and they describedDWWas leaving alayer on the skin. The consequences for the patients could be anuncomfortable feelingofnotbeingclean in thesamewayas theywereused to, andespecially if theyusedDWWseveral days in arow.This has alsobeenelaboratedbyothers, including thatmostpeoplecanbecomedistressediftheycannotkeepascleanastheyareusedto,andrunningwaterisgenerallybelievedtobethemosteffectivecleansingagent (Collins&Hampton,2003a).Contraryto

8  |     VEJE Et al.

our findings,other studieshave found that thepatients felt cleanusingDWW(Kron‐Chalupaetal.,2006;Sheppard,2000)andwouldtradeSAWforDWW(Grovenetal.,2017;Shoonhovenetal.,2014).

Participants in our study preferred SAW, and in general, theyconsidered that thismethodreally leavesoneclean.This is in linewitha recentstudy,whichalso foundthatpatients tendtopreferSAW(Nøddeskouetal.,2018).Inaddition,participantsinourstudyspecificallywantedSAWforhandwashing.Thishasnotbeenidenti‐fiedinotherstudies.

Contrarytothesefindings,somequantitativestudiesconcludedthat DWW was predominantly preferred by the patients (Kron‐Chalupa et al., 2006; Nøddeskou et al., 2014; Sheppard, 2000;Shoonhovenetal.,2014).

SomeparticipantsinthecurrentstudydiscussedDWWasafastandeasytypeofbath,whichcanbelessburdensomeiftheyhadpainordiarrhoeaandwasconsideredtobeaconvenientwaytofreshenup.Other studies support thatDWWforbedbath is time‐saving,easyand lessdistressing for thepatients, compared to theuseofSAW(Hørdametal.,2017;Kron‐Chalupaetal.,2006;Lentz,2003;Nøddeskouetal.,2014;Sheppard,2000).

The nursing staff did not always ask for patients’ preferencesregarding bed bath method and the majority of the participantsfeltthatthenursingstaffshouldmakethedecisionaboutthetypeofbath.Thedecisionshould followtheirworkloadandothercareactivities.

Thisisinaccordancewithareview,whichconcludedthattheim‐portantstakeholderwithregardtotheclinicaldecisionisthenursingstaff, and that theyoftendecide the typeofbathwithout shareddecision‐makingwiththepatients(Grovenetal.,2017).

Thefindingsinourstudyindicatethatmanypatientsacceptthis,astheyseethatthenursingstaffarebusy,andthatitisfastertouseDWW.

There may be different values and preferences according tothe typeofbathbetween thepatients and thenursing staff. In adescriptive study of bed bath practices, nurses report that otherfactors such as nopolicy, lackof knowledge andworkload affecttheirdecisions(El‐Soussi&Asfour,2016).Becauseofthis,thepa‐tientswhowanttohaveinfluenceonthechoiceofbedbathmethodshould be given the opportunity to choose bed bath as a shareddecision,wherespecialconcernssuchaspain(Möller&Magalhães,2015),andrequirementsforhandsandfacecanbetakenintocon‐sideration.ThisissupportedbytheDanishhomecarestudy,whichfoundthatpatientswanttohavethechoiceoftypeofbath(Hørdametal.,2017).

5.1 | Methodological strengths and limitations

Sixteenparticipantswereincludedinthisstudy.Therecommendedsample size in qualitative research is between 6–12 interviews(Onwuegbuzie & Leech, 2007; Patton, 2002), but according toPatton,therearenorulesforsamplesizeinaqualitativeenquiry.

Weaimedtoachievedatasaturation(Francisetal.,2010),indi‐catedby threeconsecutive interviews inwhichnonewadditional

informationappeared.Thiswasevidentafter16interviewsandcon‐tributedtovalidationofthefinalsamplesize.

In small studies, heterogeneity can be a problem. Maximumvariationwas aimed for, because it can turn thatweakness into astrength,bycapturingin‐depth,detailedinformationsimultaneouslywithemergingpatternsacross cases (Patton,2002).The inclusionfromthreedifferentwardscontributedtotheheterogeneity,asdidtheotherchosenvariables.FluentDanishasinclusioncriteriamightexcludeethnicminoritieswhoseopinionscouldbevastlydifferent.

Although the interviews were conducted during the patients’present admission, their experiencesmight bemixedwith experi‐ences from other admissions and private use of SAW andDWW.ThisstudywasrelatedtoaspecificbrandofDWW,whichwasusedon all thewards at the hospital.Other brandsmay feel different,becauseofdifferentingredientsandtexturesofthewipes.Thein‐cludedpatientscouldhaveexperienceofdifferentbrandsofDWWandmaynotbeabletoseparatetheirexperiences.

Inaddition,nursingstaffwillprobablyhavedifferentexperiencesof,attitudestowards,andpreferencesrelatingtoDWW,whichcaninfluencehowtheyperformthetwotypesofbedbathandthushaveanimpactonthepatients’experiences.

Apatient'splanneddischargeandlengthofstaycouldalsoinflu‐encetheirexperiences.Onemightbemoreindifferenttothetypeofbathandwhetheroneisinvolvedinthedecision,ifdischargedwasplannedthedayaftertheinterview,orifthepatientwashospitalisedforalongtime.Ontheotherhand,thepatientscouldbemoreneg‐ativetowardsDWWiftheydidnotknowtheirdischargedateandtherebydidnotknowhowsoontheywouldbeabletotakeashowerorbathathomewithSAW.

Giventhattheinterviewswereconductedonthewardsandthattheinterviewer'suniformwassimilartothosewornbythenursingstaff, the participantsmight have been reluctant to express all oftheiropinions.Thepatientscouldfeelcaughtinaloyaltydilemma,togetherwiththefactthattheywereaskedaboutnursingcareonwhichtheyweredependent.Thiscouldhaveinfluencedthepartic‐ipants’opinions—althoughtheinterviewer'sindependentstatusonthewardwaspointedoutatthebeginningofalltheinterviews.Theinterviewer's female nursing background and previous work withintimatehygiene fromaphilosophicalperspectivemayhave influ‐encedthefindings,andotherresearchersmayanalyseandinterpretthedatadifferently.

6  | CONCLUSION

Personal hygiene was an unavoidable task during admission,and maintaining personal hygiene was linked to traditions heldsince childhood. Showerwould be thepatients’ first choice if notbedridden.

In general, the preference for bed bath type was the use ofSAW,butDWWwasconsideredtobeaconvenientandpreferredmethodinspecificsituations,forexamplewhenthepatientwasinpain,sufferingfromdiarrhoeaorifthepatientswantedtofreshen

     |  9VEJE Et al.

uporgetwashedquicklyandeasily.Washingthefacewasspecialandpurewaterwaspreferred.Contrarytothis,thepatientsfeltthatthehandsneededtobewashedbytheuseofSAWandatleastoncea day.

Nursingstaffshouldincorporatepatients’preferencesofshareddecisionregardingchoiceofbedbathmethodwhenpossibleandifthepatientswantthis.

The findings addresses some of the patients’ experiencesbutindicateaneedforadditionalresearchaboutnurses’prefer‐ences,whichcouldalsoincludestudiesofotherbedbathmeth‐odsandacost‐effectivenesscomparisonofthetwotypesofbedbath.

7  | RELE VANCE TO CLINIC AL PR AC TICE

Thefindingsshouldremindnursingstafftoacknowledgeandincludepatients’experiencesandpreferencesinshareddecisionsabouttheappropriate typeofbedbath forhospitalised,bedriddenpatients.Thefindingsarerelevantforthefuturedevelopmentofguidelinesforclinicalnursing.

ACKNOWLEDG EMENTS

Thankstoallparticipatingpatients,staffandwardsfortheirpartici‐pationandcontributiontothestudy.ThankstoLornaCampbellforlanguageedition.

CONFLIC TS OF INTERE S T

None.

AUTHOR CONTRIBUTION

PLVgatheredallthedatainthestudyandtakesfullresponsibilityfortheintegrityofthedataandtheaccuracyoftheinitialdataanalysis.PLV,CSJ,JS,MCandJPcontributedtothestudydesign,analysis,interpretationanddraftingthemanuscript,revision,reviewandfinalapprovalofthemanuscript.

ORCID

Pia L. Veje https://orcid.org/0000‐0002‐9074‐1552

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SUPPORTING INFORMATION

Additional supporting information may be found online in theSupportingInformationsectionattheendofthearticle.

How to cite this article:VejePL,ChenM,JensenCS,SørensenJ,PrimdahlJ.Bedbathwithsoapandwaterordisposablewetwipes:Patients’experiencesandpreferences.J Clin Nurs. 2019;00:1–10. https://doi.org/10.1111/jocn.14825