The Minister for Health and Ageing, Mark Butler has announced a new aged-care workforce compact which will result in 350,000 workers receiving supplementary payments of 1% over and above award increases. This amounts to $1/hour more for each worker the lowest paid workers in the health care industry. Why is intimate nursing care, for the purposes of distinguishing it from technical nursing care, identified as not needing qualified nursing staff and relegated to care workers? Furthermore these care workers, the mainstay of our nursing homes and residential aged care facilities, may only have the support of a single registered or enrolled nurse to care for as many as 60+ patients.

Yet today the people we see in our nursing homes would have filled a medical ward in the 70s. There will be increasing numbers of elderly people to look after, with chronic and complex care needs, so surely there is a need to rethink and recognise the complexity of intimate nursing care and have it performed by appropriately qualified nurses? For proper remuneration? I cant remember who said it, but the elderly are the only group against whom we discriminate to which we will eventually belong.

This intimate nursing work, described usually as basic nursing care is, in reality, far from basic and you need skilled nurses to perform it well. When they do, its value and necessity transcends its physical messiness. Despite what those who dont do this work might think, it is not basicit is extremely psychologically complex. Cleaning patients who are soiled with excreta, blood, or vomitus, who feel ashamed of themselves for being dirty or for losing control, and restoring both their hygiene and their sense of self worth in the process, requires the highest order of skill. Nurses know its worth, yet understand societys abhorrence of its reality.

But the paradox is to recognise that other people simply dont want to acknowledge the worth and complexity of the work. Better to imagine its basic. It is also a given that nurses who do this work dont discuss it. Nurses do things to other people which have the potential to strip them of their dignity. One of the reasons why, most of the time, nurses dont do so is because what transpires behind the screens will never be discussed in public. Good nursing care is eminently forgettable. Nurses manage to be almost invisible as they perform the most private of functions for the patient. Listen to this description as a nurse washes a patients genitalia.

Jane is looking intently at the scrotum, lifting carefully the folds to ensure a thorough wash, and painting lotion gently on the grazed area. The penis is washed with equal care and their conversation continues throughout. They could have been having this conversation in a sitting room, it is so unselfconscious[1].

Nurses, for entirely professional reasons, dont discuss these aspects of their work. If we did, how could the next patient feel comfortable? The view that any nice person can deliver this kind of care diminishes the sensitivity and skill required to manage such situations. Maybe this is partly because nurses have always done this intimate work, and usually only changes to practice are considered to deserve increased pay. But this provides an unsatisfactory model for re-assessing work value when this work was never valued originally. Furthermore the nursing management of sensitive issues of the body is not granted the same status as - say a psychiatrist handling sensitive issues of the mind. Because it involves manual work, getting your hands dirty, it is considered to be menial or domestic. Yet to practise such work without intellectual engagement would be crass, and could cause psychological damage. If the courts and tribunals were to value this work similarly, the entire award system would need to be revisited.

Can we finally acknowledge how complex and difficult this work is? Let us not just admire (oh theyre wonderful I dont know how they do it) but also reward the people who do it with more than $1/hour. Let us recognise that intimate care of people who are old and sick (and it might be us one day) is actually extraordinarily skilful and requires a great deal of sensitivity.

Professor Mary Chiarella

[1] Taylor B, Being Human: Ordinariness in Nursing Churchill Livingstone: Melbourne (1994).