Dirt,decency and the symbolic boundaries of caregiving in residential homes for older people

Abstract

This article draws upon an ethnography of two differently-priced UK residential care homes for older people. Informed by recent scholarship on the materialities of care, together with separate theoretical contributions by Mary Douglas and Émile Durkheim, I examine the spatial and material organisation of care work. I sketch out care workers’ attitudes and practices concerning hygiene and bodily waste, and how these are established and reaffirmed through the marking out of boundaries between materials, spaces and persons. Central to understanding care workers’ erecting of, or inattention to, these boundaries is an awareness of the material, temporal and cultural conditions of work. Variances in the availability of resources, the formal organisation of work and the layout of residential homes affect the care provided to residents. In examining these variances, I identify how care workers’ use of space functions to maintain or undercut not only hygiene and infection control standards but, also, more interpersonal virtues, such as dignity and respect for older people receiving care. I conclude by highlighting how the (mis)treatment of older people is a story of both a deeply inequitable market for care provision and a broader context of oppression, devaluation and dehumanisation.

Introduction

This article draws upon an ethnography of two residential care homes in Southern England. I examine the spatial and material organisation of care work in two differently-priced settings – Millstead (low-cost) and Shorefield (high-cost) ¹ – and explore how care workers navigated the buildings, objects and persons they came into contact with. I begin by summarising recent contributions on care settings and the role of materiality in shaping caregiving practices. From here, I outline the theoretical tenets which guide my analysis and, I argue, extend current shortcomings in the literature. Residential care homes are dense and complex environments; making sense of them, and their materiality, requires theoretical plurality. The contributions of Mary Douglas and Émile Durkheim can be used, I claim, to grasp the spatial dynamics of care, how care workers’ use of materials and spaces convey value, and how spatial boundaries function to uphold or undercut the symbolic expression of virtues (e.g. respect). After providing an overview of the fieldwork, I explore the boundary work of care workers at Millstead and Shorefield, relating to their attitudes and practices around hygiene and bodily waste. Values are established and reaffirmed by marking out boundaries between materials, spaces and persons; attending to, or not attending to, such boundaries is entangled in the material, temporal and cultural conditions of work. I show how, in turn, variances in the availability of resources, the formal organisation of work and the distinct architecture/layout of the homes impacted upon the care that workers were able to provide to residents.

At high-cost Shorefield, care workers’ practices took a symbolic form. Drawing upon Douglas’s (1966) work on ‘matter out of place’, I explore how care workers at the home enforced strict boundaries concerning the management of ‘dirt’. At low-cost Millstead, the lack of material, spatial and temporal resources available to care workers meant that they were able to do little to establish boundaries between ‘clean’ and ‘dirty’ matter. Employing Durkheim’s concept of ‘moral individualism’ – referring to an attitude characterised by respect for the boundary that protects and sacralises the individual – I consider how such boundary work can function to maintain not only hygiene standards, but also more interpersonal virtues including dignity, privacy and respect. In so doing, I highlight not only the enduring value of classic social theory for making sense of contemporary arrangements, but also how uniting these with a focus on materiality in healthcare/social care contexts provides the foundations for understanding how marginalised groups (older people, in this case) are denied agency, respect and dignity in their everyday lives. I conclude by highlighting how the (mis)treatment of older people is a story of both a deeply inequitable market for care provision (Johnson, 2018, 2022, in press), and a broader context of oppression, devaluation and dehumanisation (Hughes, 2019).

Materialities of care

Recent work within medical sociology has attended to the significance of materialities in care settings (Allen, 2015; Bødker et al., 2019; Lovatt, 2018; Martin et al., 2015; VanHeuvelen, 2019). Informed by science and technology studies (STS), geography and new materialist approaches, such contributions make visible the frequently mundane and invisible aspects of material culture in health and social care sites (Buse et al., 2018; Latimer, 2000, 2018). This spans settings such as hospitals (and departments such as surgical theatres, accident and emergency rooms and neonatal ICUs), GP surgeries, homecare environments and birthing rooms/family planning clinics (e.g. Bromley, 2012; Fannin, 2003; Rapport et al., 2007; White et al., 2012). Such work also sketches out the role of objects, technologies and ‘things’ in curating care relations, such as homecare pendants (López & Domènech, 2008), clothing (Buse & Twigg, 2016) and food (Ellis, 2018). This includes both established health technologies and more mundane forms, or what Pink et al. (2014) call ‘quiet’ or ‘taken for granted’ technologies such as shoes, carpets and soap.

For example, several researchers have analysed the hygienic and symbolic functions which gloves can perform in caregiving interactions (Twigg, 2000; Van Dongen, 2001). In an interview-based study on the infection-prevention behaviours of nurses, Jackson et al. (2014, p. 400) suggest that nurses were sometimes perceived by colleagues to wear gloves as an attempt to ‘protect self’ or to ‘put on a show’: that is, to give an impression of thoroughness, knowledge and taking infection seriously. For the care workers in Twigg’s (2000) study, gloves were used both as a means to avoid direct contact with bodily waste and, more symbolically, to provide protection from the intimacy of care activities and to erect a barrier of professionalism between client and ‘self’. Both Twigg (2000) and Van Dongen (2001) have, however, identified that workers can feel guilty about using protective clothing due to connotations of contamination. Similarly, Jackson et al. (2014, p. 404) found that wearing gloves was sometimes perceived by nurses as offending patients who may feel ‘dirty’ (I discuss the use of gloves at Millstead and Shorefield later in this article).

Despite a recent emergence of work attending to material cultures in social and health care contexts, an analysis of how architecture and design, objects and technologies impact upon caregiving remains in its infancy. Residential care homes are environments where people, objects, talk and technologies intersect, yet the quantity, quality and use of space in residential caregiving environments have been subjected to little empirical attention. This article sits within recent contributions on the materialities of care (Buse et al., 2018). However, such work is less theoretically focused on how matter and meaning are entangled in ways that can be damaging and harmful for particular populations (e.g. older people; learning-disabled people). If matter matters (Barad, 2003), we should also examine how the material and discursive are mutually implicated in ways that can lead to forms of neglect, devaluation and violence. To advance this work, I argue that the use of classic social theory – specifically the work of Mary Douglas and Émile Durkheim – allows me to make sense of life at Millstead and Shorefield, and, specifically, how space and things mediate the caregiving encounter in affective, together with toxic and violent, ways.

Mary Douglas and Émile Durkheim

Douglas (1966) argues that notions of purity are central to all societies, acting to reaffirm social order by drawing boundaries which give shape and unity to our experience. Attempts to eliminate dirt are part of ‘positively re-ordering our environment, making it confirm to an idea’ (1966, p. 3). Society’s ritual, symbolic marking out of what is clean, from what is dirty, acts to establish and restore social order. Dirt, as something that is relative and never absolute, is ‘matter out of place’, the ‘by-product of a systematic ordering and classification of matter, in so far as ordering involves rejecting inappropriate elements’ (1966, p. 44). Matter only becomes dirt, Douglas argues, when it confuses or negates our valued classifications. Bodily orifices, for example, can act as symbolic representations of ‘points of entry or exit to social units’ (1966, p. 4):

Any structure of ideas is vulnerable at its margins. We should expect the orifices of the body to symbolise its specially vulnerable points. Matter issuing from them is marginal stuff of the most obvious kind. Spittle, blood, milk, urine, faeces or tears simply issuing forth have traversed the boundary of the body. (1966, p. 150)

For Douglas, the materiality of the body’s boundaries can be used to symbolise community boundaries. In societies attaching a strong moral value to the integrity of the body, we would expect the boundaries of the body to play a prominent symbolic role in the maintenance of social cohesion, and vice versa. This was, in fact, an insight central to Durkheim’s theory of ‘moral individualism’. I contend that Durkheim’s insights elevate Douglas’s analysis. Douglas attends to the rules of pollution and purity which point towards a moral order, yet Durkheim’s conception of moral individualism allows for a more sustained and engaged consideration of matters of respect, compassion and dignity. In short, Durkheim offers us the theoretical thread necessary to weave a more, intricate analysis of morality within boundary-making practices.

Durkheim’s sociology is famous for its stress on the importance of social solidarity and the primacy of the ‘collective conscience’ and, for this reason, he is often thought of as a conservative thinker who is opposed to the growth of individualism. However, this reading is inaccurate and unhelpful. Durkheim (1898/1969), in fact, developed an account of a form of individualism that is not egoistic in form. This individualism concerns not the individual per se, but, rather, persons in general. Respect, compassion and care for actual persons, in other words, can only be a by-product of the collective belief in the sacredness of all individuals, the ‘individual in general’:

The sentiments which protect human dignity touch us personally. Assuredly, I do not mean that we only respect the life and property of our peers out of utilitarian calculation. . . . If we reproach acts that are deficient in this respect, it is because they violate the sentiment of sympathy which we have for man [sic] in general, and these sentiments are without self-interest precisely because they are a general object. . . . [The object of moral conduct] is humanity in general. (Durkheim, 1899/1978, p. 174)

Moral individualism makes the human person the object of its morality, and virtue arises from those thoughts, beliefs and actions taking humanity seriously. Here, the human person is deemed sacred:

It is conceived as being invested with that mysterious property which creates an empty space around holy objects, which keeps them away from profane contacts and which draws them away from ordinary life. And it is exactly this feature which induces the respect of which it is the object. (1898/1969, p. 21)

Respect for this ‘empty space’ – a respect which is not a product of the uniqueness of one’s character or personality but, rather, of the idea of a common humanity – acts to maintain the individual’s integrity (Durkheim, 1898/1969, p. 21). It protects those inviolable elements of the individual which are common to all persons. A defence of the rights of the individual – a demarcation of this empty space – is therefore, simultaneously, a defence of the vital interests of society. For individualism’s motive force is ‘not egoism but sympathy for all that is human, a wider pity for all sufferings, for all human miseries, a more ardent desire to combat and alleviate them, a greater thirst for justice’ (1898/1969, p. 24). When the sacredness of the person is not upheld – when the protective space around the individual is traversed – moral anarchy will ensue because society’s common sentiments are being violated. However, whilst Durkheim’s earlier work saw the performance of the sacred as an exceptional break with mundane reality, marked by ritualised gatherings of a community and an escalation of emotional energy (or what he called ‘collective effervescence’), I want to consider how the rules of conduct pervade everyday interaction and which, by means of their enactment, secure the honour of persons or things (e.g. Goffman 1956).

I contend that bringing together concerns highlighted in recent contributions on materialities of care, together with work by Douglas (on dirt and classification systems) and Durkheim (on morality and sacredness), allows us to explore how, and to what extent, the research sites (Millstead and Shorefield) yielded symbolic systems promoting respect for the self. I show how activities of caregiving can be used to demarcate or infringe on the ‘ideal sphere’ or ‘empty space’ around individuals. I will now outline the fieldwork sites.

Fieldwork

Located in a local authority area in the South of England, Millstead and Shorefield were 1.5 miles apart, but were located in different local council wards. In the 2010 indices of deprivation, Millstead’s ward was ranked among the top 5% most deprived wards in the UK, whereas Shorefield’s ward was ranked in the bottom 50%. Millstead was a single, private residential home which accommodated 33 residents. It was identified as ‘low-cost’ due to the low fees that were charged to its 24 local authority, and nine private-paying, residents (the average price paid by the local authority for a funded place was £448 per week). Shorefield was a large-scale corporate home provider. In January 2013, it offered care to 99 residents and the cost of receiving care varied depending on which room a resident occupied and their assessed care needs. The lowest priced fee – including accommodation, meals and activities, but not direct care – was £750 per week. Of the 33 homes in the local authority which formed my initial sample, the cost of care for private payers at Shorefield was the highest, even before taking direct care charges into account. Of the 99 residents at Shorefield, four received funding from the local authority, which paid an average of £540 a week for their care. Shorefield was a purpose-built home which was marketed as a luxury alternative to more traditional care homes, with advertisements often emphasising its activities, entertainment, cuisine and hotel-like facilities.

Approximately 800 hours of participant observation were carried out over two years, where I took on the role of care worker for 12 months, first, at low-cost Millstead and, second, at high-cost Shorefield (fieldwork at Shorefield included attending training sessions prior to employment; this was not offered at Millstead). Observations were supplemented with 30 interviews with care workers from other residential homes in the same local authority area. These techniques allowed for an in-depth, ethnographic examination of the ordinary practices and encounters occurring in residential homes as well as a consideration of the moral, emotional and material stresses encountered by care workers. This revealed the respective roles played by political-economic factors, working conditions, material, moral and human resources, and workplace culture, among other things, in producing types of ‘care’.

Observations were carried out in a ‘covert’ manner. The ethical concerns surrounding covert research are reported at length in the literature (Herrera, 1999; Spicker, 2011). For some, the omission of ‘informed consent’ means that it can never, or rarely, be ethically justified, though others problematise the idea of (truly) informed consent by showing that the realities and intricacies of fieldwork – overt and covert – mean that ensuring participants are fully informed is unrealistic (Calvey, 2008). Moreover, some scholars have argued that viewing overt research as inherently good, and covert research as inherently bad, is an oversimplification which risks detracting from a more nuanced examination of research ethics (Spicker, 2011).

Nonetheless, covert research must not only be justified in terms of necessity and the quality of data produced (Hammersley & Atkinson, 2007) but must also be ethically and morally defensible. Here, a covert approach was necessary for gaining access to the less visible spaces and practices of residential homes, without causing great changes in the behaviours of those whom I observed. The decision was also made with an acknowledgement that care workers and care home managers have good reason to be suspicious of inquisitive outsiders (e.g. unfavourable media coverage – see Hayes, 2016). To be clear, the approach was not employed with the intention of producing an exposé, but, rather, a detailed account of everyday life in two residential homes and the, often mundane and less visible, rituals and routines of those who worked in them. From an ethical standpoint, Spicker (2011) argues that the rights of research participants do not automatically take priority over others. In the care homes that I observed, the rights of residents were, to me, of equal importance to those of the workers, and I did not want my respect for the rights of these workers to prevent me from studying the abuse of the rights of the more vulnerable. Not researching such settings in this way may also mean that such practices remain hidden and un(der)reported.

My approach, however, raised ethical concerns beyond informed consent, such as reporting the abuse of residents by care workers. I was often deeply troubled by what I observed. Where possible, I took practical measures to address my concerns, such as informing the Care Quality Commission (CQC) of substandard care, reporting illegal underpayment of care workers to HMRC, and discussing poor work conditions and care quality with the care homes’ managers. Even when problems or concerns did not emerge, I often found the fieldwork to be mentally exhausting and emotionally draining. I became angered by practices that denied both workers and residents their dignity and respect. I was upset by the suffering and/or death of older people living in Millstead and Shorefield. I often thought or worried about residents after work, and I felt frustrated and ashamed when the constraints of the job prevented me from providing the best possible care to them. Though not always pleasant or easy, attending to my emotions in the field provided me with a valuable insight into the common pressures, tensions and anxieties experienced by care workers. I discuss my research design and the ethical issues arising from this research at length elsewhere (Johnson, 2018).

My iterative approach to data analysis required a constant conversation between theory and data, rather than an early formulation of codes which may have limited subsequent analysis. I used ongoing analysis to guide areas of later enquiry, whilst being aware of new ideas/themes. Practically, my analytical approach involved (re)reading fieldnotes and interview transcripts and creating analytical notes. For observations, analytical notes were made alongside hand-written notes in my fieldwork diary. In order to distinguish between data and analysis, a simple process of using different coloured pens was used. This analysis entailed identifying, studying and analysing patterns in the data, and noting similarities and differences between observations and interviews with care workers. I rely exclusively on observational data here, given that the intention is to explore the everyday rituals and rhythms of care work, and the importance of architecture, space and objects for these. The study received ethical approval from the Cardiff University Research Ethics Committee.

Boundary-making: Private/public spaces

I begin my analysis, in this article, by showing how care workers’ ideas about what constitutes ‘dirt’, and their treatment of boundaries, conveyed broader institutional beliefs about the value of the older people receiving care at Millstead (low-cost home) and Shorefield (high-cost home). I demonstrate how a routine commitment to the maintenance of spatial, material and human boundaries allows care workers to convey respect, dignity and compassion for those in their care, and each other.

The ways that the ‘empty space’ (Durkheim, 1898/1969) around residents was regarded at the two homes were markedly different. At Shorefield, residents had name plates outside their rooms, which were displayed alongside memory boxes enclosing photos and small mementos. These served as markers of individual identity and displayed the boundaries between ‘private’ and ‘communal’ spaces. Residents possessed a bedroom key (workers could not enter without first knocking) and no items were shared between spaces. On one occasion, a new resident, Poppy, asked for a commode for her room. Another worker and I spent over an hour finding a new commode, despite many home-owned commodes being in rooms adjacent to Poppy’s. Taking time to ensure residents had their own care equipment was commonplace:

I am helping Karina to wash and dress Mrs Penton ² ready for breakfast. After washing, drying, and applying cream to Mrs Penton’s buttocks, we are ready to put on a new incontinence pad. Karina goes into the en-suite to fetch an incontinence pad and calls out that there are not any there. I can hear Karina removing her gloves, washing her hands, and leaving the bedroom. As Karina fetches a new pad, I cover Mrs Penton’s unclothed lower half with a towel and tell her Karina should not be a minute. I know there is a pack of the required pads in Marjorie’s room next door. Ten minutes later . . . Karina returns to the room with a large pack of incontinence pads . . . I ask Karina why we cannot take pads from Marjorie’s room. Karina says ‘we can’t just take stuff in and out. They’re Marjorie’s.’

Regardless of the situation whereby an item (incontinence pads, wipes, buckets, toilet paper) was required, or the convenience of entering adjacent rooms, items were never taken from another resident’s bedroom at Shorefield. Objects were used to symbolise, and show respect for, individuals. Items removed from rooms, such as clothes, were also clearly separated. Each garment was discretely labelled with a resident’s name, laundry was washed in individual cycles, and clean clothing was folded, stacked and returned to residents’ bedrooms individually.

At Millstead, this ethos of moral individualism (showing respect to the ‘empty space’ around persons) was absent in the daily activities of care workers. Very few distinctions were made between residents. They were commonly referred to in groups based on needs rather than by names – ‘early eaters’ or ‘late eaters’ (‘early eaters’ required eating assistance), ‘doubles’ or ‘singles’ (residents needing the assistance of one worker or two workers) – and care tasks were divided accordingly. Care workers would often be responsible for ‘toileting the singles’ or ‘feeding the early eaters’; groups of residents signified ‘packages’ of work. This frequently included referring to residents not by name, but by room number – together with erecting few boundaries between bedrooms or possessions. This lack of private space was made clear during my first shift working alone:

I am washing Pat in her bedroom. Rather than giving residents baths or showers, we are told to use buckets of warm soapy water and Millstead-owned flannels. On one side of the building, there is only one room with a ready supply of hot, clean water: Pat’s bedroom. Elsewhere, the water is either cold or discoloured. The carers therefore enter Pat’s room each time they need to fill a bowl with warm water (at least twelve times a morning). As Pat is sat on her commode and I am washing her, two other carers rush in and out of Pat’s room to fill up their bowls. They do not knock on the door or acknowledge the presence of Pat or I in the room, and they both leave the bedroom door open after leaving. On my shadow shift, I was told that I must only use one hand-sized towel per resident, per day. This means that, whilst I am washing Pat, there is no means to cover up her damp body, either to keep her warm or to protect her privacy. She appears unfazed by the coming and going of the other care workers.

The use of residents’ bedrooms as communal spaces was common at Millstead. Pat’s room was freely used for its hot water; a commode in Billy’s room was used as a communal toilet due to its proximity to the lounge; Judith’s room was a storage space for large lifting equipment and spare wheelchairs. It was not just residents’ rooms that were treated as public spaces at Millstead; material items were also used collectively. Disposable items (e.g. incontinence pads) and personal possessions (e.g. clothes) were viewed as communal by care workers, made necessary owing to a lack of material, temporal and spatial resources. ³ During fieldwork, I noted that, when changing residents into their nightclothes, workers carried a large plastic laundry basket and a clinical waste bag between rooms. Soiled/dirty clothes and soiled incontinence pads would be placed in each respective container and one care worker washed the clothes together. Sometimes, washed items such as undergarments would be redistributed between residents to reduce the need to regularly do laundry. Like other practices at Millstead, this disregard for residents’ clothing and possessions broke procedural rules concerning hygiene and infection control, but also discounted the symbolic work required to respect the ‘empty space’ of individual residents and to uphold their personhood.

Bodily waste

Care workers routinely deal with ‘the negatives of the body’ – dirt, decay, decline and death – yet these aspects of the job are often overlooked in sanitised, and oddly upbeat, understandings of care work (Twigg, 2000, p. 393). For care workers at both high-cost Shorefield and low-cost Millstead, dealing with unbounded, leaking bodies (faeces, urine, saliva, vomit, blood) was part of the job. The way that tasks involving bodily matter were organised and conducted, however, varied markedly between them. Care workers at Shorefield enforced and upheld strict spatial boundaries concerning bodily waste, and there were numerous physical boundaries (doors, corridors, walls) between communal areas and spaces where the care of residents’ bodies took place. When these boundaries were crossed, care workers performed rituals to mark the transition from ‘unclean’ to ‘clean’ spaces, and vice versa. Some of these techniques followed national guidelines on infection control, but others were more obviously symbolic. These symbolic techniques were often passed on between care workers in shadow shifts and reaffirmed in daily practices.

For example, waste resulting from personal caregiving (such as soiled incontinence pads, used gloves, wipes and aprons) were temporarily disposed of in sanitary waste bins, before being discarded in an outdoor waste disposal area. No area in which personal caregiving took place was devoid of a sanitary waste bin. In practice, this prevented bodily waste products from crossing the boundaries (marked by doors) separating private areas from communal areas after each act of personal caregiving.

This clear architectural and material separation of spaces was indicative of Shorefield’s strong institutionally-embedded beliefs about a form of matter that constituted dirt: bodily waste. For example, before passing from a private (e.g. bedrooms) into a communal area (e.g. leaving a bedroom), gloves were removed, hands were washed, and materials were ordered, concealed and/or disposed of. Bedroom doors marked the boundary between areas for ‘dirty’work and ‘clean’ communal spaces, and crossing this boundary involved performing rituals. Before leaving bedrooms, items used in personal care would be disposed of in an order (incontinence pads, plastic aprons, then disposable gloves) before care workers washed their hands. This series of tasks did not solely concern the spread of pathogens; it entailed the symbolic treatment of the temporary spatial boundary between ‘dirty’ bedroom and ‘clean’ communal space. Julie, for example, touched the handles of Gwyneth’s wheelchair, first, with (unhygienic) gloved hands and then with washed, un-gloved hands without notice, yet she was careful not to pass into the communal corridor without carefully completing the series of hygiene rituals documented above. Outside of en-suites, there was little indication that activities undertaken by care workers at Shorefield involved dealing with residents’ bodies; there were no wall-mounted glove/apron dispensers and, even in communal toilets, gloves were kept hidden in cupboards. Moreover, there was little visible movement of clean or dirty incontinence pads.

At Millstead, in contrast, bodily waste (as ‘dirt’) spilt out from the confines of lavatories and residents’ bedrooms into all communal areas. Few attempts were made for spatial boundaries concerning bodily waste to abide by deference rituals, and to respect the empty space marking out the dignity of the person. After my first shift at Millstead, I wrote:

Personal care seems to be a complete free-for-all. There is no peace, no retreat from the chaos. There is no attempt to conceal what is happening. Residents are left sitting naked and soiled on commodes in the middle of cold rooms with their doors open for all to see. Care workers walk in and out of residents’ bedrooms as they are being changed or bathed without acknowledgement. Yellow bags full of faeces and stale, urine-soaked pads are left on the floors of the corridor and are lugged in and out of bedrooms and up and down the stairs. Residents shout out for assistance but are often ignored. The care workers appear unmoved by the sights, sounds, and smells which I find overwhelming.

Millstead’s lack of spatial boundaries regarding residents’ bodily wastes undermined the symbolic system which care workers were taught to express. Given the working conditions of the care workers at Millstead, their acceptance of dirt should not be simply read as indicative of wickedness or moral failure. Instead, the lack of spatial boundaries concerning bodily waste can be best understood as a product of insufficient training and, moreover, of the spatial, material and temporal structuring of care work (but also a broader dehumanisation of non-normate bodies, as discussed later). For example, to avoid the repeated moving back and forth between sites of direct/personal care and waste disposal areas, many care workers opted to carry clinical waste bags with them. In order to save money, Millstead’s manager restricted the allocation of these bags to two per shift and, as such, they would regularly be left in the corridors for several hours until they were completely full before being disposed of in the external bin. The internal organisation of space at Millstead made it difficult to contain dirt. The minimal toilets and waste disposal facilities, small private living spaces and long corridors made the discreet movement of soiled incontinence pads, garments, bedpans or ‘unclean’ residents almost impossible. Physically, the materiality of the home meant that completing a journey from where human waste was primarily dealt with, to where such waste could be disposed of, could not be completed without entering a communal space.

Categorising, containing and dismissing dirt

At Shorefield, as well as a clear spatial marking out of ‘dirty’ areas from ‘clean’ areas, there was an ordering and categorisation of different kinds of ‘dirt’. For example, Sarah (care worker) categorised not only bodily and domestic waste but, also, the activities and materials associated with each:

Sarah and I are changing Barbara (resident) into her nightclothes and assisting her into bed. We remove Barbara’s soiled incontinence pad and I go to take a spare bin bag from Barbara’s household waste bin to put the soiled pad into before disposing of it in her sanitary waste bin. I push down the foot-pedal of the bin and reach to pick up the bin bag. Sarah immediately stops me, exclaiming ‘don’t do that . . . that’s crossover!’ She explains I should not touch the household waste bin or the bin bags whilst carrying out personal care because this will contaminate the household waste bin.

For care workers at Shorefield, dirt was relative (Douglas, 1966). There were numerous types of dirt, each of which required distinct boundary maintenance. Care workers also treated ‘food’ waste differently to bodily waste, and had different responses to both. For example, care workers were unfazed by faeces and urine during personal care (when such matter was in place), but were unnerved and disgusted when, for example, food waste was ‘played with’ by kitchen staff ⁴ (when food waste was out of place). Of all categories of dirty matter, bodily waste called for the most symbolic work. As Sarah’s exclamation about ‘crossover’ indicated, other dirty matter was polluted by bodily waste. Bodily waste, on the other hand, could not be polluted by anything: it was the most impure of all matter.

At Shorefield, building design and care workers’ practices promoted a spatial categorising of dirt. At Millstead, in contrast, there was little attempt to enforce or reinstate spatial boundaries between different matter and the activities associated with them, even where the home’s physical layout did not present an observable barrier to categorising work. Consider how Mahesh (care worker) reacted to Billy (resident with an intellectual disability) defecating in a communal space:

Billy is being encouraged to stand from his seat in the dining room . . . As Billy rises from his chair, there is a loud rumble and squelch, and a strong faecal smell disperses into the room. Mahesh, who is holding Billy by his belt, says bluntly ‘he shit himself’. Though the smell is pungent and sounds continue to emanate from Billy as he walks, Mahesh guides him out into the corridor, past his bedroom (where another resident is using the commode) and into the lounge (where other residents are gathered for their afternoon tea). Mahesh tells me that Billy is not ‘due’ to be toileted for another thirty minutes and, so long as Billy is toileted at his designated time, Mrs G, the home’s proprietor, will be happy.

The fitting of personal care activities into Millstead’s strict routine was commonplace. Though these activities took up a great deal of care workers’ time, they did not happen as and when the boundary from clean to dirty was broken and needed mending but, rather, when time was scheduled for it. The ‘toileting’ of residents was scheduled after each mealtime and would happen in a set order based on how long each resident was expected to spend on the commode/toilet. This routine meant that residents who took the greatest length of time to ‘toilet’ could be assisted first and left alone whilst other residents were assisted. Lawton (1998) argues that unbounded bodies experience a loss of selfhood; bounded, sealed bodies are key to notions of personhood in the Global North, whilst unbounded bodies fall out of personhood by virtue of lacking capacity for self-containment. Yet, whilst Lawton (1998, p. 128) describes moments where bodies are ‘re-bounded’ (e.g. through medical treatment), no such attempts are immediately made at Millstead. Unlike personal care activities at Shorefield, the cleaning up of human waste at Millstead did not express a symbolic system. It did not take place when a resident’s ability to project a viable, sacred self was threatened by their body’s ‘unboundedness’, but was ordered by practical concerns about time and efficiency; there was no hurry to reinstate a boundary between clean and dirty matter. This was made clear when a resident, Joan, vomited whilst sat amongst other residents:

I am helping Joan to eat a yoghurt, when she unexpectedly begins to vomit. The vomit falls upon the table cloth and placemat in front of Joan. I call out to the other care workers to ask for help. They do not approach the table to assist me nor recoil in disgust. Nobody leaves to gather cleaning products, approaches to reassure Joan, to move other residents away from the table, or to stop them from eating. Everybody carries on as though nothing out of the ordinary has happened. I leave the table to get cleaning products . . . When I return to the dining room, Joan remains in her chair, salivating on the table. She does not appear to have been moved, spoken to, or washed and vomit is dripping from the edges of the tablecloth onto the floor. Agata, another care worker, continues to spoon dessert into other residents’ mouths.

This lack of care worker response not only points towards minimal devotion to procedural rules regarding infection control, but also shows a lack of symbolic boundary work at Millstead. Boundaries at Millstead were too unclear to invite or justify protection. Matter considered ‘unclean’ or ‘out of place’ at Shorefield was quite acceptable in communal areas at Millstead. Millstead’s care workers were not compelled by a need to undertake symbolic work – to clean, re-order and eliminate dirt – when a resident’s ‘empty space’ was breached. This suggests, constrained by Millstead’s strict routine, care workers did not have the time or materials required for adhering to the principles of moral individualism and upholding the dignity of residents like Joan.

What is clear here, too, is that care workers are not simply dealing with bodily waste, but with types of bodily waste as produced by (devalued/impure) bodies. These are bodies, Hughes (2009) tells us, viewed through a lens not just of pity, tragedy and vulnerability, but of abjection, disgust and inferiority. He claims that this is central to the ‘ontological and moral invalidation’ of, in this case, disabled people, whereby they are perceived in the non-disabled imaginary as ‘good to mistreat’ (2019, p. 830). Although care workers at Shorefield seemingly avoid casting older people in this way (though Hughes may contend that they are configured as ‘good to be good to’), the practices of care workers at Millstead ‘provide a window on the distribution of human worth; the relative validity of groups or persons; the qualities that come to be admired or demeaned; who belongs and who does not’ (2019, p. 842).

Dirty discourse

At Shorefield, dirt was not only contained, categorised, and made the responsibility of groups of workers in its material forms, discussing bodily waste was also confined to particular spaces. Consider care workers’ silent response to an incident when Shorefield’s valued classifications were temporarily negated by dirt (i.e. when bodily waste traversed the boundary between private and communal spaces):

Maude urinates whilst at a cheese and wine event in the Café and she is not wearing an incontinence pad. The situation is handled so discreetly that no residents or visiting family members appear to notice. As soon as Maude stands up from her chair to ask for a second glass of wine, and Helena notices the wet mark on her skirt, she approaches Maude saying ‘do you mind coming to help me with some paperwork for a minute?’ Meanwhile, Helena nods towards the chair that Maude has been sitting on and James approaches the chair mumbling about how it is ‘due for housekeeping’. James wheels the entire chair away from the Café and out of the coded door into the laundry room in the staff area. Within a minute of the incident, there is no visible trace of what has happened. Fifteen minutes later, Helena returns with Maude, dressed in a clean outfit, ready for her second helping of wine, and with a new chair to sit on.

Throughout this incident, there had been no use of the words ‘unclean’, ‘wet’, ‘soiled’, or even any spoken acknowledgement that an incident had occurred. Contaminating persons (Maude) and props (chair) were quietly removed into the (non-communal) staff area and Maude’s bedroom. This was the usual approach when dealing with instances where matter was ‘out of place’ at Shorefield. When care workers were questioned by (soiled) residents, who did not understand why they were being moved away from communal areas, they would not discuss what had happened until reaching the resident’s room. Even within residents’ bedrooms, dirt would rarely be explicitly cited; they were told that they had had an ‘accident’, or that they simply required a change of clothes. This practice of avoiding the discussion of dirt in communal areas was also observed in the communication between Shorefield’s care workers. Each used subtle body language and facial expression to indicate, without publicity, when an incident had taken place. The silent ways of informing other care workers that matter had fallen out of place allowed care workers to reinstate the boundary between clean and dirty without further polluting the communal space.

In a Durkheimian sense, care workers’ silence on bodily waste in communal spaces can be understood to secure the honour of residents, particularly when in front of other residents and visitors. Similarly, personal caregiving acts were not discussed among care workers. One exception to this spatial separation of ‘clean’ and ‘dirty’ dialogue was the care office (e.g. a Bristol Stool Chart ⁵ on the wall was often used to debate the stool ranking of a resident’s faecal matter). This discussion of ‘dirt’ commonly took a pragmatic form (e.g. bowel leakages), and with a sympathetic tone, as a matter of ‘caring well’ and assigning residents a kind of sacredness through presentation rituals (e.g. ‘bless her’, ‘poor thing’). The materiality of the care office equipped the home’s care workers with the appropriate material and discursive resources to talk about bodily waste, without rendering themselves or residents undeserving of deference and respect.

In contrast, at Millstead, discussing faeces, urine and leaky bodies in communal areas, and in front of other residents, was common. Care workers would often shout across the lounge to ask residents if they needed the toilet. Likewise, in communal spaces, residents would sometimes be ‘reassured’ that they were wearing an incontinence pad and, therefore, that receiving assistance to a private space was not a prerequisite for relieving themselves. Residents’ speech and behaviour were also rarely policed in communal areas. Billy frequently masturbated without interruption in the lounge whilst catcalling the care workers, and Eileen would often take off and display her soiled incontinence pad in corridors. Millstead displayed many of the degrading characteristics that Goffman (1956, p. 483) found typical of psychiatric wards which were preoccupied with the ‘substantive and instrumental requirements of the situation’, but indifferent to the symbolic and the ceremonial. This discussion of intimacies in others’ presence, as if the resident was not there, constitutes a ‘classic form of non-person treatment’ (1956, p. 483).

The temporal, material and spatial constraints of care work at Millstead made it nearly impossible to confine or eliminate dirt in a ritualised way. Care workers’ solution appeared to be a trivialisation of the dirty aspects of care, either through disregarding dirt or subjecting it to humour. On one occasion, Pamela (care worker) referred to Helga’s (resident) dried stools as ‘truffles’. Other care workers asked her, and I, to recount this story during the shift, and they subsequently giggled and teased us. Making bodily waste the subject of humour and anecdotes was perhaps how Millstead’s workers prevented the dirty aspects of the job from polluting or spoiling their self in the presence of unbounded, leaking bodies. Yet, making residents’ bodies the subject of their humour did little to un-soil and show respect to them.

Conclusion

Examining how care workers at Millstead and Shorefield carried out tasks concerning human waste reveals a startling contrast in the way that residents were treated in the two homes. Able to carry out their work in a manner which preserved and reaffirmed symbolic boundaries, Shorefield’s care workers maintained both hygiene standards and more immeasurable qualities (dignity, respect, privacy) which upheld the sacredness of residents. Their beliefs about what constituted dirt, in turn, ensured that boundaries were routinely established, maintained and reinstated. Rituals concerning bodily waste, imparted in formal training and policed in everyday interactions, functioned to protect the residents’ ‘empty space’ from being traversed. At Millstead, little was done to establish boundaries between different areas, activities or persons. This promoted not only an unsanitary working and living environment, but a disregard, intentional or not, for the sacredness of residents. Millstead’s managers and staff’s disregard for symbolic boundaries can be viewed as indicative of a community in a state of anomie. Explaining the differences between Millstead and Shorefield must refer both to the material and temporal resources available to the care workers to do a humane and respectful job, and to the culture – the symbolic resources – of each community, which is transmitted both through formal training and on-the-job learning, and which outlasts the particular individuals who live and work there at any particular time.

This article makes two major contributions. First, it highlights the enduring value classic social theory – citing contributions by Douglas and Durkheim – can make for sharpening our understanding of the care industry. Second, it captures how the availability of material resources, by facilitating or impeding care workers’ symbolic work, shaped care workers’ ability to show respect and moral regard towards older people. Architecture, space and objects have frequently been disregarded in accounts of what constitutes ‘quality care’. Walls, doors, furniture and other material items create and order space and, in so doing, they shape how residential care, and care work, is experienced. Routine acts – knocking on doors before entering them, drawing curtains and bringing our talk in to line with our location – help to mark out and reaffirm sacralising boundaries. Adding to a growing yet nascent literature on the materiality of care, I show how the provision of space and materials has implications not just for residents’ measurable health outcomes (e.g. pressure sores, falls, mobility), but for more symbolic elements of quality care.

It may be reasonable to conclude from my claims that poor quality care is symptomatic of an ethically-void workforce who are not committed to the principles of moral individualism. It is not a story of irresponsible monsters (Foner, 1994), as frequently described in scathing media exposés. It is a tale of an inequitable care market perpetuated by the increasing privatisation, commodification and market polarisation of care provision. Those operating at the high-end of the residential care market know the importance of space and materials. Large-scale corporate providers, like Shorefield, employ architects and interior design teams to plan and arrange the layout, style, furnishings and decorations of homes. Shorefield’s market positioning and income ensured the spatial and material resources needed to erect boundaries concerning bodily waste: a purposefully designed building with large private spaces, en-suites and staff areas; a plentiful supply of gloves, aprons and sanitary waste bins; a well-equipped care office where care workers could professionally and privately discuss the dirty aspects of their work. That the materialities of care were so different at low-cost Millstead and high-cost Shorefield reflects how care workers need access to adequate space and material resources if care work is to be underpinned by a concern for the dignity of older peoples and care workers.

Yet, it is too simplistic to say that the boundaries of dirt and neglect exist purely in economic terms. Indeed, we must recognise the broader social context in which caregiving is delivered. ⁶ My observations at Millstead exposed moments of harm, neglect and devaluation, which sit within ongoing violence and neglect perpetuated against marginalised populations, such as older people and disabled people (and older disabled people). The scandals at Winterbourne View in 2011 and Whorlton Hall in 2019 in the UK uncovered a pattern of serious abuse at homes for adults with learning disabilities. Despite a wealth of social care policies designed to improve the lives and wellbeing of certain populations, such as older people and disabled people, they continue to face repeated failures of health and social care systems where they are stripped of ‘personhood, care, dignity, and respect’ (Ryan, 2020, p. 15). Inhuman treatment, everyday indignities and persistent abuse plague the lives of such individuals. Much more needs to be done, Sara Ryan tells us, outside of governmental lip service and empty rhetoric of rights, choice and independence.

In the context of my study, the disregard of older persons (particularly at Millstead) is arguably located within oppressive cultures and structures in which they are consistently mistreated, disrespected and configured as polluting and inferior. Irrespective of poor resourcing, the practices of care workers at Millstead dehumanised the older people in their care, which was reflective of a wider culture of invalidation and everyday harms within social care settings that render certain individuals as non-persons. Yet, whilst we should not discuss the data extracts outside of individual and ethical responsibility (the extract involving Billy is particularly unnerving and jarring in this regard), such (mis)treatment exists in a context where social care is in crisis, and where the funding of care is directly linked to the quality of the service provided. Nonetheless, providing economic resources to rectify such shortcomings is simply not enough. My research, particularly at Shorefield, shows how good quality care is rooted in symbolic systems. Developing and sustaining a ‘well suited’ (Goffman, 1956) culture of care, which allows and encourages care workers to convey moral regard for individual residents and each other, requires the presence of certain resources outside of market relations. Language, time, collegiality, a sense of community and (as I show at length in this article) space/materiality play a key role in the provision of good quality care. We must develop a cultural and material architecture of care that is sensitive to our need for moral and symbolic treatment, especially within a context that operates on ableist and disablist imperatives. It is only by taking the normative and symbolic culture of work in residential homes seriously that we can recognise and work towards establishing a care sector which is equitable, both for older people and for those who provide their care.