The boundaries of care
The boundaries of care

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The boundaries of care

6 Developing agreed ways of working

Although it may be undesirable to cut across the informality of care relationships by making unnecessary rules or regulations, intimate care is clearly one site where things can go wrong. There is a narrow margin of error. The usual social rules and inhibitions have already been broken and it is not always easy to arrive at new ones which are appropriate to the particular context within which you are caring or being cared for. Moreover, receiving or giving care arouses strong feelings which people rarely put into words.

Activity 3 Help with going to the toilet

0 hours 10 minutes

Imagine that you need help to go to the toilet. Perhaps you do receive this kind of assistance, or have done in the past. If so, you will have first-hand knowledge to draw on. Write down three things which your helper could do to ease any embarrassment or discomfort you might feel, and three things which would make the whole situation even worse. Think about who would be helping you in this situation, their gender, their relationship to you, their manner, what they say, their facial expression, and so on.

Discussion

You might have included things like:

  • what tone you would like them to take with you

  • whether you would want them to talk while they were helping you

  • whether you would like them to pretend they haven't really noticed what is going on.

Lawler's research identified the following ‘scene-defining’ strategies employed by doctors and nurses when undertaking intimate care:

  • They set up the caring task by making clear that the context is'medical’ rather than social or sexual.

  • They use their uniform as ‘a barrier’.

  • They put on a deliberately matter-of-fact manner.

  • They protect the person's privacy by sending other people away or drawing curtains.

  • They say things which minimise the awkwardness like ‘Oh, it isn't much’, ‘It isn't that bad’, or ‘It could have happened to anyone’.

  • They change the style, volume and tone of their conversation tocreate a private atmosphere.

‘Intimate’ care?
Figure 4

But still nurses have to deal with their own natural reactions especially around smell, which can be particularly difficult to ‘stomach’. Here they will develop ways of concentrating on the mechanics of the task, or they may take breaks by going out of the room. One of the nurses Lawler interviewed said she ‘hides the horribleness from the patient’ (p. 176). It is as if the worker becomes more formal to compensate for the very personal and potentially intrusive nature of the help they are giving. But this might not be appropriate if this help is being given at home or in a homelike setting.

So what can be done to help carers or people being cared for in these situations? One approach is to bring the subject of intimate care ‘out of the bathroom’, so to speak, and on to the job description. This has benefits for workers and management: it allows this part of the work, its difficulty and delicacy, to be acknowledged, but it also makes managers take back responsibility for how it should be done. Some services have begun to explore just what good practice would mean in these areas as an alternative to waiting until things go wrong and then saying something. For example Eric, who is a colleague of Marie's, always leaves the door open a bit when he takes service users to the toilet: anyone passing by can see that he is in there with someone. The staff are now having a discussion about whether it should be shut and, if so, locked or not. Eric says he is ‘covering his back’ but some people were saying that Eric is not doing his job properly. He can reasonably say that he does not know what ‘properly’ means until the staff group make up their minds.

Activity 4 Guidelines for intimate care

0 hours 10 minutes

Imagine you are the head of care at Marie's unit and you are asked to draw up some rules on how to give intimate care which would act as a safeguard for the residents and also for the staff. See if you can sketch out the section on bathing residents.

Discussion

Did you think about the following issues in drawing up your ‘practice guidance'?

  • Who should give baths, what gender, and should there be oneperson only or two?

  • Should doors be shut and locked?

  • What exactly does ‘bathing’ involve? What needs to be washed andhow?

  • How will help be given? Should staff do the bathing or try to help theresidents do it for themselves?

  • What don't you expect to happen?

Key points

  • Workers providing intimate care emphasise the formality of their roles to compensate for the crossing of boundaries.

  • It is difficult to hold workers to account for intimate care tasks when no one has spelt out how they want these to be done.

  • Agreed procedures provide one ‘benchmark’ for good practice which can protect service users, staff and workers.

K100_8

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