The boundaries of care
The boundaries of care

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The boundaries of care

1.1 The strains of intimate care

Intimate care involves stepping over people's usual boundaries. It takes us out of familiar territory in terms of how we relate to each other. It necessitates breaking the usual rules about how to behave in order to attend to bodily functions which we normally take a lot of trouble to keep private, and this ‘secrecy’ extends to the work itself. A key issue in Marie's story is the assumption that this area of the work does not need to be mentioned.

Activity 1 A better induction for Marie?

0 hours 15 minutes

Consider the information you have about how Marie was introduced to the work. Then make your own notes on the following questions.

  1. What could have been done differently in the interview or during Marie's first few days?

  2. How could the subject have been brought up in a way which would have made Marie's introduction to the work easier and would have acknowledged that it was a difficult position to be in?

  3. How do you imagine Marie's inexperience and the way in which she had been introduced to care work affected Richard's experience of being cared for?

Discussion

I have written a short statement which the head of care could have made at the end of the interview to prepare Marie for this aspect of the work. First I asked myself: What needs to be said? How can the subject be broached in a way which leaves it open for Marie to come back if she has any problems?

You will find that the work requires you to undertake some very intimate tasks, like taking a young man to the toilet, washing parts of the body – his penis, his testicles – which most people keep private. It may worry you at first. If we appoint you, I'll make sure I'm on hand when you start work, and at the end of your shift for the first week, so that you can raise any questions you might have, and ask for advice. Managing feelings about intimate care is an important part of the job. You need to feel comfortable with it, and so do the residents, who may also feel quite sensitive about it. These young people may have disabilities, but they are also men and women, and their feelings about their bodies need to be respected.

Revisit Marie's story

Now look back over Marie's story and over what you have scripted for the head of care to say to her.

Did you imagine that the head of care was a woman or a man?

Think about how this affected the way he or she spoke to Marie and what it was appropriate for him or her to say. Would it have made a difference if Marie had been an older woman do you think?

Answer

Personally, I found it easier to imagine a female head of care making the statement I scripted than a male.

It might also have been different if Marie had been a young man. It is possible that if she was a he, he would not have been expected to dress or toilet a woman. Women are expected to know how to do care work because of their previous experience in the private sphere of the family, whereas there tends to be a different set of beliefs about men doing caring work. Sometimes this includes fears that they might be less sensitive, or even abusive. In establishments like this one, men tend to do less of the actual caring work and more administration or management. These concerns help to justify this division of labour. The ‘taboo’ around male carers also means that service users themselves might choose not to be cared for in intimate ways by a man.

So we can see a number of factors at work in Marie's story:

  • First, there is the issue that an important part of the work she is being expected to do has been left unspoken. It is ‘taken for granted’, silent and invisible. In turn this has the effect that Marie oes not feel able to ask for help and actively colludes in keeping the ilence around it by not telling her boyfriend or family, and by not assing on her experience to her friend who later joins her in the ork. Marie learns that what is expected of her is to do the work ithout commenting on it.

  • Second, Marie doesn't know how to do this aspect of the work in a sensitive way, without embarrassing Richard or making him feel wkward. She has to manage this part of the work so that she can lso relate to Richard as his key worker – and she hardly knows him!

  • Third, we can see that this aspect of the work has something to do ith gender because the rules are different according to whether the people concerned are male or female. Because Marie is a woman it is s if she is expected to know how to do these tasks without being told: because it is ‘women's work’.

  • Lastly, we can see that the issue of intimate care cuts across the formal culture of the workplace. Marie is given information about what her job entails in a formal interview. This may have been conducted according to agreed rules designed, for example, to ensure equal opportunities. There is a job description which sets out the main requirements of the job (but which doesn't include taking people to the toilet) and a person specification (which doesn't say anything about it either). The personnel officer has not deliberately missed out these aspects of the work, but consigned them to a different space. They are part of a private sphere even within the workplace, not part of the publicly acknowledged aspects of the job. Marie does not get induction, instruction or supervision in how to do them, and they are not part of the management relationship. Especially if her manager is a man, Marie will not expect him to go into detail about how this part of her work should be performed, whereas for other parts of her job, such as how to fill in a care plan or draw up a teaching programme, he may show her what to do or assess her competence and give her feedback on how well she is doing.

The normally private space of the bathroom becomes one in which the intimate work of caring takes place
Figure 2

It is almost as if Marie has taken on two jobs, one which is publicly acknowledged and accounted for (her professional role) and the other which takes place behind the scenes, which she has to manage privately. This sometimes causes problems as it did, for example, in Marie's third week in the job when she was told off by her manager because she was late for a meeting with Richard's social worker and speech therapist. The reason for her delay was that she was helping to clean someone up after an ‘accident’ in the toilet. Marie's workload is often discussed as if these private elements of it do not take up any space or time. Actually they have to take priority over the written and administrative functions but that is not openly acknowledged. J. Lawler in his book Behind the Screens: Nursing Somology and the Problem of the Body comments that:

Nursing involves not only doing things which are traditionally assigned to females, and learning to do them by experience and practice, but also crossing social boundaries, breaking taboos and doing things for people which they would normally do for themselves in private if they were able.

(Lawler, 1991, p. 30)

Key points

  • Intimate care is not ‘ordinary’. It presents a very unusual set of dilemmas for both the carer and the person cared for.

  • Despite how ‘extra-ordinary’ such tasks are, care workers are often expected to be able to do this side of the work ‘naturally’.

  • Expectations about intimate care and caring are different for men and women staff and service users.

  • Although care establishments are largely organised around the need to provide intimate care, this may not be acknowledged in the public face of the service, or reflected in its training, guidance or supervision.

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