The boundaries of care
The boundaries of care

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The boundaries of care

1 Crossing boundaries: a case study

A number of situations put a strain on the idea that caring is just an extension of 'being ordinary'. These include times when people are giving intimate care. Since the normal rules do not apply in these circumstances, we have to develop a set of special rules to guide practice, thinking very carefully about the core question: 'How can boundaries be respected in situations where intimate care is being given?’'

This question will be explored through a fictional case study set in a residential unit for young people with learning (and some associated physical and sensory) difficulties. The story is fictional in the sense that I have made the characters up and put all the separate strands together, but the setting is based on a real establishment and each incident or situation is based on a real event or on the experience of someone known to me through my work or personal life. The fact that it is presented as a story does not make it any less real, it merely provides anonymity for the people and services involved.

In this case study you will meet Marie, a new care assistant.

Marie

Marie is a young white woman who has recently started work at a residential unit for young people with physical and learning disabilities run by a local charity. She trained as an NNEB nurse at her local college after leaving school but did one of her placements at a day nursery which included children with learning difficulties and really enjoyed it. She was very thrilled to get this job: it is local and she can easily get there on the bus even for the early morning shift. It doesn't pay very well but it is better than being a private nanny or babysitter and she really looked forward to getting her first proper pay packet. Marie lives at home: she has been going out with her boyfriend Barry for two years and is saving up to get engaged.

Figure 1

Before the interview Marie was sent a prospectus about the unit, which described how it had been set up to help young people who had left special schools to make the transition to adult living. There was also a special needs unit for people with more severe learning difficulties. The brochure said:

We have a commitment to treating the residents here like any other young people. We provide opportunities for them to reach adulthood by making their own choices and by treating them as normal young adults would expect to be treated.

Marie was at a bit of a disadvantage in the interview because her previous experience had been with younger children. The interviewers asked her about her training and said that it would be important to treat the young people as adults and not as children. They said they were looking for someone who could act ‘more like a friend than a parent’. Marie latched on to what they were saying and said she thought she could do that because she always prided herself on treating children with respect and not in a babyish way.

The head of care also asked Marie about care plans and she was able to talk about the system used at the nursery for recording what each child liked and needed during the day, such as if they had a special diet or needed a nap at a certain time, and so on. She talked about her work with Tom, a boy with Down's syndrome in whom she had taken a special interest, and how they had been working on helping him to learn new words by noticing toys he liked to play with and getting him to ask for them.

The head of care was impressed with Marie's maturity and enthusiasm and as she had a good reference from her college and from the nursery, they offered her the job. She started on the Monday after she finished college but was invited to come up for a couple of hours on Friday evening to see round the unit and to meet her ‘shift’, especially Joan, who was the senior care officer who would be showing her the ropes. Joan introduced her to Richard and Rachel as she was to be keyworker for them both and would be getting to know them better than the other residents.

For the first week she was to be on day duty, which involved getting people up and ready for breakfast and then helping them into the dining-room. Understandably, she was nervous on her first day but she got there on time and worked with another member of staff to help Rachel get dressed. Rachel needed a lot of help and Marie realised as they were having breakfast that she did not know how to feed someone who needed this amount of support. She looked round for help but there was no one near who wasn't busy so she ‘owned up’ to Rachel, who grinned. When Marie put the food in too quickly Rachel spat it out, but gradually Marie found the right speed and relaxed and they began to get on well.

The second day began in the same way except that Marie was to get Richard up first as Rachel was having a lie in. Richard had his own room and Marie knocked and went in. Joan had said Richard was a ‘total care but Marie wasn't quite sure what that meant. She had met him briefly the day before and knew he liked to play on his computer using a probe he wore around his forehead, but she felt a bit shy of barging into his room and didn't really know where to start. She had been told that he could move from the bed to his wheelchair but would otherwise need help with dressing and toileting.

When Marie went to help Richard get up it was obvious that he had an erection. She didn't know what to do: she didn't want to embarrass him but she couldn't help blushing. She wondered if she should go out of the room or go to find Joan, but if she did find her Joan would be busy and also Marie didn't know what she would say, so she decided to stay and just turn away for a bit. Eventually she took Richard to the bathroom. By this stage she was confused as well as embarrassed. She realised that Richard was going to need help to go to the loo and saw the urinal bottles on the shelf. Since he could not use his hands she had to put his penis into the bottle and keep it there while he peed. Then she took him back to his room and helped him to wash his face and get dressed.

Marie had never seen a man's penis before: although she was going steady with Barry, they had decided to wait until they were married before they had sex, which was in keeping with their religious beliefs. She felt upset that she had not realised this would be involved in the job and when she got home she thought it best not to say anything in case Barry or her parents misunderstood. She thought Barry might tell her she should leave the job so she kept it to herself. All the other women at the centre just seemed to get on with it and she didn't want to make a fuss. When her friends asked her about her new job she talked about her trouble feeding Rachel and about her time in the art room.

If Marie had got a job in a bank or a shop she would not have been expected to take a young man of her own age to the toilet, or to see him naked. Everyone acted as if it was the most ‘normal’ thing in the world, but it wasn't normal in Marie's world. Over the next few months Marie came to see it as normal too: when her friend Pebbie came to work at the unit after Christmas, Marie forgot to tell her what she was letting herself in for.

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