Staff perspectives on paperwork in group homes for people with intellectual disability

ABSTRACT

Background: Paperwork can transform organisational aims into action in group homes, but it can also be problematic for staff. The aim of this study was to explore frontline staff perspectives on paperwork in group homes for people with intellectual disability.

Methods: Constructivist grounded theory methodology guided the study. Data were collected from 29 participants through semi-structured interviews, participant observations and journaling. Coding and sorting methods were used to analyse participants’ perspectives.

Results: Staff have nuanced paperwork perspectives. They described and evaluated paperwork in terms of its value and fit with resident-focused practice. They identified gaps in paperwork and reimagined its design and use.

Conclusions: Frontline staffs’ reflection suggests some paperwork hinders them from supporting residents well. This suggests organisations could consult better with staff to design paperwork that has a goodness of fit to their practice. Further research could explore how staff manage the limiting characteristics of paperwork.

KEYWORDS:

• Group homes
• intellectual disability
• paperwork
• frontline perspective
• support workers
• critical reflection

Paperwork is a large part of daily service provision in group homes for people with intellectual disability because it is a technology that can transform organisational intentions including policy into daily service action (Levinson, 2010; Mansell & Beadle-Brown, 2012). We refer to pieces of paperwork as paper tools and to the process of using these tools as paperwork. Paper tools include written tools such as paper-based medication forms or electronic tools like emails, as well as the systems that help organise paperwork, for example, the resident folders and electronic information systems. Over recent years, the number of paper tools used in group homes appears to have increased markedly as shown by an 80% increase from 1988 to 2009 (Quilliam, Bigby, & Douglas, 2015). This increase in paperwork possibly reflects its growing use for achieving organisational aims beyond transforming policy intentions into practice, for example, to aid employee surveillance (Lyon, 2001) and meet the increasing contemporary focus of minimising risk (Beck, 2001).

The small amount of literature on group home paperwork emphasises a number of problems with frontline staffs’ paperwork, particularly practices that are unexpected by the organisation or that negatively impact residents’ lives (see Clement & Bigby, 2010; Hamilton, 2014; Nunkoosing & Haydon-Laurelut, 2011; Poppes, Van der Putten, & Vlaskamp, 2014). The potential for incongruence between organisational expectations and the way staff actually use paperwork raises questions about the conventional practice of using group home paperwork to evidence quality of support (McEwan, Bigby, & Douglas, 2014). Given the possible increase in paper tools and emerging problems around their use, there is a need to better understand how staff think about and use paperwork as a service tool in group homes for people with intellectual disability.

The theoretical lens researchers use to explore the way staff use paperwork influences how they perceive these frontline practices and therefore their findings and recommendations. Group home and disability services researchers (e.g., Poppes et al., 2014) typically frame paperwork use that deviates from expected practices as problematic. However, Garfinkel (1967) adopted a functional theoretical lens for his research on paperwork in psychiatric services where he found staffs’ use of paperwork previously labelled as problematic or acts of resistance to organisational power were actually incidences of staff demonstrating agency by adapting paperwork to enable them to work more effectively. Accordingly he suggested researchers avoid labelling paperwork practices as problematic without first understanding how they meet the requirements of the stakeholders using them. Building on Garfinkel’s suggestion, bureaucracy theorist Lipsky (1980) proposed frontline human services staff consider some paperwork as more important for meeting organisational goals than benefiting service users. Adopting this lens to group home paperwork research changes the focus of enquiry from exploring why staff engage in poor paperwork practices to one that seeks to understand how staff experience or perceive paperwork. Exploring this line of enquiry must be done from the perspective of frontline staff because paperwork is integral to their practice – they refer to it, create it, and share it with other stakeholders (Levinson, 2010).

An understanding of frontline staffs’ perspective of paperwork could help disability service organisations adapt paper tools to better fit workplace requirements and daily service practices. The development of more suitable service tools could help staff better transform organisational values and policy approaches into daily practice (Bigby, Knox, Beadle-Brown, & Clement, 2015). In a rare study that canvassed staffs’ own perceptions of paperwork, Davis et al. (2015) found that staff considered asthma plans, devised by health professionals for people with intellectual disability living in group homes, did not fit well with their day-to-day practice. This study along with our earlier research (Quilliam, Bigby, & Douglas, 2017) suggests that staff can provide an expert’s perspective around paperwork because their workplace experiences provide them with contextual knowledge. Thus, in this study, our aim was to explore frontline staffs’ perspectives of paperwork in group homes for people with intellectual disability using the question – how do staff perceive paperwork?

Methods

Methodology and design

A constructivist epistemological approach and constructivist grounded theory methodology (CGT) suited the exploratory nature of the study, recognising that participants and researchers co-construct knowledge from their social positioning and previous experiences (Mills, Bonner, & Francis, 2006). CGT allows researchers to systematically collect and analyse data to guide initial exploration of social processes and identify alternative conceptual constructions, with the aim of constructing theory that explains processes within phenomena (Charmaz, 2014). This study used CGT methods to achieve the former and is part of a larger enquiry exploring the processes underpinning frontline staffs’ experiences with paperwork. The study was guided by the criteria Charmaz suggested should be used to evaluate the quality of CGT studies: credibility, originality, resonance, and usefulness.

Participants

La Trobe University human ethics committee granted clearance to recruit participants and collect data. Three non-government disability service organisations in Victoria, Australia were invited through a convenience sampling method to participate in the study; two of these agreed to participate. Data were collected at three group homes – one rural and two metropolitan. We recruited 29 participants including 14 group home residents, all of whom had intellectual disability, 3 casual support workers, 10 part-time support workers, and 2 part-time supervisors. Consent from residents was sought, and next-of-kin permission was obtained for the nine resident participants who were unable to provide informed consent. Although resident participants were not asked to actively participate because the study aimed to explore how staff perceive paperwork, data collection was conducted in their homes and information regarding their activities were included in the field notes. All participant, service and organisation names were replaced with pseudonyms and participants are not listed by their group home to maintain anonymity.

Data collection

Data were generated via individual and group interviews, participant observations, and reflective journal. The first author conducted 17 semi-structured interviews in total – 14 initial individual interviews with 14 staff, 2 follow-up group interviews with 9 staff, and 1 follow-up interview with 1 individual. The individual interviews ranged from 50 minutes to 1.5 hours and were conducted at a time and location that suited participants – either at the group home or another organisational building. The interviews were conducted outside of staffs’ work hours to reduce impacts on resident support. In line with the study’s exploratory nature, interview guides evolved throughout the collection period and included open-ended questions that aimed to generate discussion around staffs’ experiences with, and perspectives on paperwork. Interview questions included: “Could you tell me about the paperwork here [at the group home?],” and “Generally speaking, how do you feel about paperwork here at [the service]?” With participant permission interviews were audio recorded and transcribed. Eleven participants reviewed and agreed that their respective transcript(s) reflected their paperwork perspectives, while others chose not to review their transcripts. The two group interviews, the first involving three participants and the second with six participants, provided an opportunity to share initial findings with participants, gain a sense of resonance and usefulness and further understand emerging theoretical concepts (Charmaz, 2014).

Fifteen staff members participated in 50 hours of unstructured participant observations over 18 sessions, ranging from 1 hour to 3.5 hours in length. Staff interactions with paperwork were captured within everyday service events between 7:00am and 9:00pm, during the week and weekend (see Bigby, Knox, Beadle-Brown, & Bould, 2014). The first author adopted a minimally participating observer stance during the sessions to mimic the informal group home nature (see Bryman, 2012), and completed in-depth field notes after each observation session.

Finally, the first author recorded information about the research context and reflections from the collection and analysis process via reflective journal, using three prompts: “General reflections,” “What does the data say?” “What does this mean for future data collection/analysis?”

Analysis

Data were analysed via initial, focused and subcategory coding, constant comparison of data, memo writing, and theoretical sorting (Charmaz, 2014). Interview data were hand coded line-by-line and observation data incident-by-incident, by asking data questions such as: “What is this data a study of?” (Glaser, 1978, in Charmaz, 2014, p. 116). Larger chunks of data were coded and analysed through memo writing to arrive at a more conceptual understanding of the data. The codes were sorted into subcategories within an overarching conceptual category to generate meaning around staffs’ paperwork perspectives. Table 1 illustrates the overarching conceptual category, subcategories, focused codes, initial codes, and experiential consequences resulting from the grounded theory analysis. Comparison of journal notes, interview, and observation data through frequent discussion between the three authors helped refine the codes and subcategories and ensure that the processes identified in the conceptual category were credible, for instance that strong links between the data and argument existed. The study’s originality was established through various conference presentations where the findings were presented to, and challenged by, relevant stakeholders in the field (Charmaz, 2014).

Table 1 . Analysis of frontline staffs’ process for describing and evaluating paper tools in group homes for people with intellectual disability (Charmaz, 2014).

Conceptual category	Subcategories	Focused codes	Initial codes	Experiential consequences
Being critically reflective	Describing paperwork	Just for us	Finding time for quick paper-based paperwork	Finding tool gaps and reimagining paperwork
		For management	Doing “have to” paperwork
		Finding value in paper tools	Communicating
			Being official
	Evaluating paper tools	Finding limitations in paper tools	Paper tools that captured information irrelevant to daily practice
			Paper tools that made staff feel uncomfortable
			Paper tools that took staff too long to complete
		Identifying goodness of fit	Finding fit tools
			Finding unfit tools

Results

Group home paper tools

Paperwork was one of the many different kinds of tools available to staff; others included opportunities for verbal interaction such as informal discussion, handover and team meetings, supervisor support, and reflective opportunities during shifts. Although staff valued non-paper tools, this study focused on their perspectives about paper tools and paperwork. Staff from one group home collectively described 55 paper tools. These tools took different forms, for instance, paper-based forms and folders, and electronic forms and information systems. They were used in different ways – sometimes read and written on by staff, or only read or only written on. Some tools were used every shift or daily while others were used monthly or rarely. Some tools remained in the group home and were only processed for archiving and others moved beyond the group home site. These latter tools, for example, incident reports, typically had multiple authors and were read or processed by a variety of stakeholders including group home staff, support staff from other services, organisational managers, health practitioners, family members, and service auditors. Participants described the paperwork in their workplace and evaluated individual paper tools (see Table 1). Their perspectives are described in the following sections.

Describing paperwork

Staff talked about having a large volume of paperwork to complete: “There is a lot of paperwork” (Beth, Support worker). They described paper tools as fitting in two categories: just for us and for management. The just for us tools primarily helped frontline staff provide good support to residents during everyday activities and events. This category included informal tools like shopping lists, reminder notes in the form of sticky notes for oncoming staff, and shift allocation books. Renae, a support worker, described the communication book as a just for us paper tool: “There’s the communication book; [it’s] just good to have a look at … it’s just for us sort of thing. It doesn’t go any further than us.” For management tools primarily met the needs of stakeholders beyond the group home context, particularly organisational managers. Sometimes staff also described these paper tools as have to paperwork, highlighting their lack of choice over the use of them. These tools were typically formal in nature and included monthly reports, policy, and audit documents. Carol, a supervisor and Tess, a support worker, described the monthly report as a have to tool for “higher uppers”:

Carol:

With the monthly report  … I have to give [it] to my service manager so she’s got an overview of what’s going on in the house and with the residents –

Tess:

[It’s] more for higher uppers [managers]. … It’s just administration have-to work.

The just for us and for management categories were not discrete. Staff often described paper tools as simultaneously meeting the needs of both management and frontline staff. For example, the following excerpts illustrate how Di, a support worker, initially identified the food stickers as a for management tool because staff used these to meet auditing procedural requirements, but they also offered a more resident-focused purpose as a tool that prevented staff from serving expired food to residents:

Yeah we have to [do the food stickers], because we get audited … We have to make sure we do it … It’s probably a good idea [to use the food stickers] because sometimes you might have stuff [food] in there [the fridge] that you don’t know how long it’s been there for. So at least if you have a date on it, you know that it is [okay] … It’s good to know it hasn’t been there for five years and we’re giving it to the guys to eat.

Staff described the extent of paperwork and broke it down into different categories that demonstrated how it related to day-to-day practice on the frontline. However, they spent more time evaluating individual paper tools used in their day-to-day work.

Evaluating paper tools

Staff drew on their context knowledge to critically reflect on how each paper tool and the tasks it entailed helped or restricted them from completing daily work. They found valuable and limiting characteristics, identified goodness of fit, and as a result, found gaps and reimagined paper tools. Overall, staff held nuanced paperwork perspectives; they found paper tools helpful in some instances and problematic in other instances. Alisha, a support worker, demonstrated this nuanced perspective: “[In] one sense it [the paperwork] is okay because … paperwork is for giving information … So it’s good to have paperwork. But for us …  when you [staff] are really busy, sometimes it can be too much.”

Finding value in paper tools

Staff valued paper tools that helped them complete work they considered important in providing good resident support. They highlighted two characteristics of particular value – those that helped staff with communicating and being official.

Communicating

Staff communicated via paperwork because they often lacked opportunities to communicate verbally: “So we just write [in the note pad] because you … don’t see the afternoon [staff]” (Sue, Support worker). Some paper tools allowed them to share and receive information with their counterparts and other stakeholders, to capture information as a reminder for a later time, or to flag the whereabouts of important information in other paper tools. These characteristics helped staff to improve their practice by being consistent and working together. Renae explained how certain paper tools allowed them to share information with staff working other times and days, and Greer explained how receiving information through paperwork informed their practice:

There’s also a comments book where you can write comments … Like a direct message to someone saying “You need to do this on this shift” … It might be for the next person on or it might be for someone like two days down the track, so that’s communicated. (Renae, Support worker)

By reading notes of what other staff have made then we can help different residents in certain ways, we can change ways of doing things or bring other ideas in to help them. (Greer, Support worker)

Staff also valued paper tools because they facilitated informal communication between them in a similar way that family members living together might communicate. They often threw away informal tools like reminder notes once the message had been communicated with another staff member, as Sue, a support worker, explained: “We just write little notes there [on the note pad], ‘Can you get such and such out for tea’  … It’s just a bit of communication. … We scribble [them] up and chuck [them] in the bin when we’re done.”

Being official

Staff valued paper tools with being official characteristics because these allowed them to evidence their practice, highlight foreseeable risks to staff and residents, and to ensure their legal protection. Overall, tools with these characteristics allowed staff to officially document their good work and demonstrate that their practices were in line with organisational procedures. They preferred to evidence practice through paperwork because it brought a formality to communication that verbal tools could not offer: “When you put something in print, it makes it more official” (Tess, Support worker). Support workers Julie, Magentha and Beth illustrated how staff valued paperwork that enabled staff to formally document service events:

During a team meeting, Julie and Magentha talk about the upcoming local community shows and rate the different shows according to how friendly the shows are for families to attend. All staff agree that the residents should go to one particular show if this is feasible. Beth, who has been taking notes during the meeting, asks the team if she should record this decision in the meeting notes. The team decides on their recommendation to attend the chosen show. Beth scribbles the team’s final decision into the meeting notebook. (Field notes)

Staff valued paper tools that evidenced potential risks to their own health, their counterparts’, or the residents’ health. They believed that by using certain tools to document risks, they could influence the organisation’s actions surrounding the risk. Georgia, a support worker, explained how completing incident reports and evidencing ongoing risks could sway the organisation’s funding allocation:

It is actually about giving people who fund [resident support] the information; the justification for the funding. That’s in the [incident report] paperwork. If you say [to the managers], “We need extra help because she’s becoming completely unmanageable”, then the people who are giving you the money are saying, “But there’s no evidence of that” …  I see paperwork, in that sense, really as very important.

Staff found particular value in covering yourself, that is, using the official nature of paperwork to legally protect themselves and prepare for situations where other stakeholders, such as service managers, might use paperwork to scrutinise staffs’ practice: “If something does come up you can go back and look at the paperwork … It helps to cover you as a worker and you can sort of say what has happened from your perspective” (Renae, Support worker). Paper tools with the characteristics of being official enabled staff to officially document that they provided good resident support and followed procedures accordingly, as Di, a support worker, noted: “So if anything unforeseen happened, we’ve got to have that paper trail for them [managers] to go check back on to make sure there’s been no neglect.  … To see there was nothing that we hadn’t done.” Overall, staff valued paper tools that enabled them to communicate and evidence practice. However, they also found limitations in paper tools.

Finding limitations of paper tools

Staff found paper tools limiting when they mismatched what they required in a paper tool. They highlighted three paper tool characteristics that prevented them from completing work they considered important in providing good resident support: paper tools that required staff to capture information irrelevant to daily practice, made staff feel uncomfortable, or took too long to complete.

Paper tools that captured information irrelevant to daily practice

Staff felt that some tools required them to capture irrelevant information, duplicate information across a number of different tools or limit their notes to pre-defined topics. This meant they often wrote the same information under different headings on the same paper tool, as Alisha explained, or they wrote similar information every day which captured unhelpful information, as Sue described:

We just used to write “Oh yeah he’s [the resident has] been good, blah, blah” – just [capture] the [important] things. Now we have specific things [topics to address]. We have a structured way to write … [But] you are … writing the same things again and again. (Alisha, Support worker)

You have other days where nothing out of the ordinary’s happened, same old routine, but you’ve still got to write up what they [the residents] did.  … It can get monotonous, where you’ve got the same thing happening every single day, every single shift. (Sue, Support worker)

Paperwork that made staff feel uncomfortable

Some paper tools required staff to capture information in ways that they were not comfortable with or would not naturally adopt. Sue, a support worker, explained how using formal language in paper tools made staff feel incompetent, particularly because they were aware other stakeholders observed their paperwork: “You can’t just say what’s actually happened, like you’ve got to watch what you write.” Staff felt pressured to describe service events using non-descriptive language rather than how they actually occurred, as Josh, a support worker, explained:

Certain paperwork is fucked because you’ve got to be so careful in the way you word things.  … If I write, “[A resident] was agitated,” it means he’s being disruptive, horrendous, attention seeking, ruining everyone else’s night. But you can't really put that. … And that’s really annoying because agitated could be a very personal, private thing …  It’s not descriptive in any way, shape, or form.

This meant that some paper tools did not allow staff to share their own interpretations of events as they could with verbal tools, as June, a support worker, explained:

There’s so much more you can express when you’re talking. You can’t show emotions or anything in writing. So you can kind of go [while talking], “This happened, but I kinda think it’s because of this”. [But] you can’t really write, “Watch out for that person with that person.”

Paperwork that took staff too long to complete

During busy service periods, staff squeezed paperwork around resident support, as Alisha, a support worker, noted: “[There are] so many things you have to do at the same time.” They did not like wasting time on paperwork and found significant limitations with paper tools that took longer to complete a task than using other non-paper tools such as a phone call or informal discussion might. They found some electronic tools particularly challenging for this reason. Georgia described how staff spent unnecessary time locating the electronic daily file notes and recording information in it, and Wendy explained how information technology complications slowed practice:

See, there’s a complete difference between picking this up [picks up a paper-based booklet] and turning the page. I have found what I want immediately [in the paper-based tool], whereas getting into [electronic tool is like] …  “Oh, so obviously nothing happened [for the resident] on the Thursday. Well, what about Wednesday?” So you have to go out of Thursday [paperwork] and find it [the other file] and go into Wednesday [paperwork]. It’s just a longer process, less user friendly. (Georgia, Support worker)

But because this computer’s so slow it’s like, the scanning [process] … To me it’s a time waster. It’s quicker to write something than to get on the computer. (Wendy, Support worker)

Staff were particularly critical of tools that seemingly served no purpose in daily practice. They believed organisations used tools such as these to demonstrate service quality; however, they felt other tools, particularly observation, would better capture service quality:

Tess

They [organisational managers] want [paperwork]. It’s probably a trust factor and they want proof; there’s got to be proof … 

Carol

And it’s got to be the written word … 

Tess

They can’t come in and get the [residents’] parents and feel the feel of the house and see how wonderfully happy their people are … No. Administration have to have paperwork. (Carol, Supervisor, and Tess, Support worker)

Identifying goodness of fit

Staff arrived at their own stance on the value of each paper tool by setting aside organisational logic and drawing on their knowledge to identify tools that were fit and unfit for facilitating good resident support.

Finding fit tools

When staff saw significant value in a paper tool they embraced it with confidence. The communication book was an example of a paper tool considered fit for facilitating good support. The communication book was an A4 paper-based tool that sat on the computer desk in the staff room. It was considered fit for use because it acted as a central tool which staff could quickly flick through to learn about recent events, gather instructions from other staff for the coming shift, or handwrite reminders for others, as Tess and Alisha illustrated:

I think the communication book is a good tool …  The communication book directs staff to more information … The more information you have sometimes, the more informed you are … It’s a benefit for the whole house really, I would say. (Tess, Support worker)

The communication book is very important … because [of] the information you get … If you go through the communication book then [you read]: “[The client] has been to a doctor appointment”, “There has been some changes in her” …  “Please refer [to] these notes on this date”  … Even like sometimes there will be a message for the staff, “Okay cook this food, not this one, this has been in the freezer, blah, blah, there are no ingredients for this one [meal], so you can use this one [another meal]”. So it’s good. (Alisha, Support worker)

Perhaps most importantly, the communication book allowed staff to remain focused on providing good resident support because they were able to use the tool easily within typical group home time pressures, as Alisha, a support worker, demonstrated:

Alisha walks around the lounge room and dining area, opens the curtains, walks outside via the back door, and quickly returns to the lounge room and hangs a piece of linen on a clothes hanger in the corner of the room. She walks to the office.  … and clicks a few buttons on the computer, sits down at the desk and logs onto the computer. She turns her focus to the communication book which was sitting on the desk, quickly writes a few notes and stores it away along with the other books and folders standing vertically on the desk near the computer.  … She walks out the office and towards a resident’s room, knocks on the door then opens it, and says “good morning” to the resident. (Field notes)

Finding unfit tools

When staff found significant limitations in a paper tool or paperwork, they typically rejected the tool. For example, staff in one group home found significant limitations with the sign in book – an A3 paper-based book that sat open on a small desk in the office. Managers expected staff to record the arrival and departure of residents, staff and visitors in the book. Staff felt the tool was unfit for facilitating good support because they were expected to capture what they considered irrelevant information and unnecessarily duplicate information listed in other tools. They considered the tool redundant because they supported the residents to leave the house, and shared information about residents’ whereabouts through informal discussion. They believed the sign in book was unrelated to their primary task of providing good resident support:

That [sign in book] has got to be the most useless [holder of] of information on the planet because it’s [the information is] already in about five different areas already. So we know when the guys are out … because it’s all on daily reports; everyone says where [the residents] are … Here [at this group home] you tend to either do a group thing or maybe one person [resident] or two people go out with a staff member. … So they’re [the residents are] always with a staff person, so you know where they are. You haven’t got residents going for a walk around the block by themselves. (Tess, Support worker)

Finding tool gaps and reimagining paper tools

It made sense to staff that they should have access to paper tools that helped them do their job well, because well-fitting tools enabled them to support residents well: “We do good work and we need good tools … We need to do the job properly; we need to be able to have access to things [tools]” (Olivia, Supervisor). Their ability to evaluate the paper tools and identify fit and unfit tools meant they often found gaps in the tools available for completing necessary tasks. For instance, Wendy, a support worker, found a gap in the tools available for organising housework:

This doona [Wendy points at the quilt on the bed] … I’m just thinking maybe we need to wash that, so I thought, “Well, Tuesday night I’ll come on [shift], I’ll strip it and do it”. But I have no idea when that was washed last because each staff could be just leaving it to me [to do]. It could be months since that’s been done, for all we know. We don’t know. That’s the kind of thing that is lacking through paperwork.

To address tool gaps, staff reimagined paper tools in ways that removed limitations and increased value. For instance, they suggested certain tools could be redesigned to capture more meaningful information and reduce the collection of duplicated or redundant information. Such changes would allow staff to share and receive pertinent information through paper tools rather than using multiple tools to record information. Sue, a support worker, reimagined the resident file notes to collect pertinent information about changes over time in residents’ lives rather than repetitive and unhelpful information:

The bottom line is, you need somewhere to write, “Nil issues” [in the file notes]. Like, to say that you have written [in the notes] but there’s nothing to write [about]. … If there was a terminology that you could put [in the paperwork] that says, “Same routine, nothing out of the ordinary” … If you could just press on a button, that would be a lot easier.  … And then if something out of the ordinary did happen, then write it in [to the file notes], then you know that something’s different and something’s changed [with the resident].

Renae, a support worker, reimagined paper tools having a clear statement of purpose and instructions for use: “Even just have a bit more of an explanation of how to do things [paperwork] at the start [of the tool]? Because I think some of it is sort of left up to the person [staff member] to interpret.” Overall, the approach of staff to paperwork could be seen to reflect an active evaluative process with multiple practice consequences.

Discussion

This study aimed to explore frontline staffs’ perspectives of paperwork in group homes for people with intellectual disability. Staff held nuanced perspectives of paperwork because they evaluated individual paper tools rather than paperwork generally. This finding was unexpected but nevertheless indicates that frontline staff are more critical in their approach to paperwork than conventionally portrayed in the group home literature. Their critical approach reflects Davis et al.’s (2015) findings and suggests that future research in this area should focus on staffs’ perspectives of individual paper tools rather than of paperwork more broadly.

Staff valued some paper tools for similar reasons demonstrated by early group home researchers (Quilliam et al., 2015). Like Mansell, Felce, Jenkins, de Kock, and Toogood (1987) suggestions that paper tools should aid inter-staff discussion, act as a central place for sharing and gaining important resident-related information, and direct resident-focused action, this study found that staff valued just for us paper tools as enabling them to focus on support and meet residents’ needs. Our finding that staff valued being official paper tools reflected Felce’s (1989) conceptualisation of paperwork as a way of evidencing staff practices. However, they were subtly different, as staff in this study valued these tools for their evidencing ability because they felt surveilled by service managers, as also demonstrated in Quilliam et al. (2017).

Staffs’ just for us paperwork category highlights the value they found in paperwork. Ultimately, they considered tools that met their need for inter-staff communication as more relevant to their day-to-day practice. Staff understood the purposes of the paperwork they categorised as for management, such as documenting and surveying service provision with the aim of managing risk (Beck, 2001; Lyon, 2001), although its alignment with organisational needs meant these tools were sometimes irrelevant to their day-to-day practice. This reflects Lipsky’s (1980) notion that frontline staff consider some paperwork more useful for managing organisationally focused aims than facilitating service user outcomes. Following Lipsky, staffs’ critical perspectives of paper tools – particularly those they categorise as for management, may to some extent hinder organisations from achieving their specific purposes for paperwork, such as transforming policy aims into practice, surveillance, and managing risk. Further research could explore how staff actually use tools considered primarily for management, and in particular, if at times whether they are used in ways that appear consistent with procedure and perhaps offer staff a sense of legal protection, but have no positive impact on practice.

Staff only described a quarter of the paper tools possibly available to them as listed in a Victorian 2009 group home service manual (55 of 220, respectively, Quilliam et al., 2015). However, it is very possible they only mentioned tools demonstrating points of value or limitation, and did not mention rarely used tools, such as policy documents. It might also be possible, as Garfinkel (1967) explained, that they refrained from talking about some paper tools because they did not feel comfortable doing so. Staffs’ critical stance that some paper tools restricted them from supporting residents, especially those unnecessarily complicating practice and wasting opportunities to engage with residents, suggests that organisations may benefit from rethinking the use of particular tools. For example, staff described electronic paper tools as particularly limiting, which is concerning given the general shift towards electronic tools in disability services (e.g., Department of Health and Human Services, 2016). Rather than simply introducing electronic paper tools, organisations could engage staff in discussions regarding plans to shift from paper-based to electronic tools to ensure they remain relevant in day-to-day practice. Staff also emphasised limitations with paperwork used to record the transformation of organisational policy and procedure into practice. This finding prompts the question: how can policies and procedures guide staffs’ practices without relying on paper tools for confirmation? Laragy, Ramcharan, Fisher, McCraw, and Williams (2013) suggested that organisations should adopt a range of communication tools to engage frontline staff in discussions on service procedures, such as, interactive online platforms, ongoing training, informal supervision which allows opportunities for support worker-led enquiry, and pairing new support workers with counterparts who have developed understanding around service procedures. Our findings support Laragy et al.’s suggestions and we extend these to suggest that a tool such as practice leadership could act as a vehicle for frontline staff to critically and reflectively discuss procedural knowledge and its application to the service context (Beadle-Brown, Bigby, & Bould, 2015).

Finally, staff demonstrated their ability to draw on unique context knowledge accumulated through daily frontline experiences to evaluate paper tools. This finding supports those from a previous study that demonstrates frontline staff hold a unique practice wisdom about the context of their specific workplace and group home practice in general (Quilliam et al., 2017). The present study demonstrates that staff also hold practice wisdom around the specific tools available and those that are most suited for use. In this way group home frontline staff are a stakeholder group with their own particular tool requirements and evaluation methods. This finding reflects both Garfinkel’s (1967) and Lipsky’s (1980) ideas that frontline staff exercise agency in the way they approach paperwork. Agency is rarely discussed in the literature about frontline staff in group homes (e.g., Poppes et al., 2014). This lack of evidence of agency in staffs’ practice is possibly because they are expected to implement rather than critically engage with procedure in practice (Arnott, 2017). Bandura (2006) explained four properties of human agency: intentionality, forethought, self-reactiveness, and self-reflectiveness. The former, intentionality, reflects staffs’ ability to identify goodness of fit in paper tools because it refers to the process of forming of intentions and developing plans to achieve these. The latter, self-reflectiveness, echoes staffs’ ongoing critical reflection on paper tools in day-to-day practice and how it helps achieve the overall goal of supporting people with intellectual disability to live good lives. Frie’s (2011) description of agency as human action within the situated context helps to explain how staffs’ nuanced perspectives of paper tools relate to their unique and situated practice insights. Further research is required to explore if and how staff transform their critical thinking about paperwork into their practice.

Limitations

This study is the first to explore frontline staffs’ perspectives of paperwork in group homes for people with intellectual disability, although as with all research, there are limitations. The findings illustrate how staff conceptualise paperwork and evaluate paper tools, but offer only partial insight into staffs’ experiences because it is part of a broader enquiry exploring paperwork in group homes. In line with Charmaz’s suggestion that CGT offers a systemic approach to theorising as “an ongoing activity” (2014, p. 244), the findings arising from this study show the importance exploring staffs’ paperwork experiences, and suggest avenues for further research with the aim of generating theory around staffs’ experiences for guiding practices in disability service organisations. For instance, the findings suggest that staff perceive tools in ways that make sense to them, from their position in group homes. Further research could explore how staff use contextual knowledge and to what extent their critical perspectives about paperwork impact on their use of it in their everyday practice. The findings from this study, in conjunction with those demonstrating staffs’ paperwork practices could, in time, reveal broader processes underpinning staffs’ decisions around tool use in practice.

In line with the constructivist lens of the study, the findings are particular to the staff, group homes, and organisations that participated – all of which are located in one Australian state jurisdiction. Further research could explore whether group home staffs’ evaluation of paper tools reflect the perspectives of frontline staff in other disability services, for instance day services, and also in other Australian states or countries.

Further research could also use different theoretical lenses to build knowledge around staffs’ paperwork experiences. For example, building on these findings that staff felt compelled to complete paperwork in ways that positively benefited the organisation rather than their practice of supporting service users, future research could adopt a Foucauldian lens to explore paper tools as technologies of power that reinforce dominant service discourses. Research using this lens could also explore staffs’ reproduction of paperwork as tools for supporting people with intellectual disability to lead full lives (Foucault, 1972). An action research design (see Brydon-Miller, Kral, Maguire, Noffke, & Sabhlok, 2011) could ground the research in the frontline perspective, whereby staff select and analyse paper tools with researchers.

The findings in this study were constructed from the experiences of frontline staff, who – due to their low hierarchical position in their workplace – could be described as a vulnerable group (see Liamputtong, 2007; Quilliam et al., 2017). It was difficult to recruit prospective participants because they feared losing their jobs. Many participants were careful with the information they provided to researchers and others asked researchers to refrain from publishing certain data, for fear of being identified. Initial concerns that the limitations to data collection and dissemination with this vulnerable group could impair the credibility of the study (Charmaz, 2014) were dismissed when the first author’s experience as a group home support worker appeared to foster the development of rapport with participants, and thus the collection of novel insights into staffs’ perspectives.

Conclusion

This study, which has enhanced understanding about how staff think about paperwork, demonstrates they have nuanced paperwork perspectives grounded in the service context and important insight into the goodness of fit of paper tools. Staffs’ critical reflections suggest that some paperwork may actually prevent them from effectively supporting residents to live good lives, rather than transforming well-meaning organisational intentions into service action. These perspectives and insights qualify frontline staff to be listened to by other stakeholders. Organisations could use the paper tool characteristics identified in this study as a conversational starting point with staff to explore the development of paper tools that meet their requirements to facilitate good resident support, for instance, tools that enable communication between peers. Organisations could also consult staff about paper tools preventing them from supporting residents well. Future research could explore how frontline staff use paper tools in group homes or other disability services, and could focus on how they use paper tools they consider as having limiting characteristics.

Acknowledgements

We presented an earlier version of this work orally at the 2016 International Association for the Scientific Study of Intellectual and Developmental Disabilities World Congress. Thank you to the participating organisations and participants for their valuable contributions to the project.

Disclosure statement

No potential conflict of interest was reported by the authors.

ORCID

Claire Quilliam http://orcid.org/0000-0002-7344-0133

Christine Bigby http://orcid.org/0000-0001-7001-8976

Jacinta Douglas http://orcid.org/0000-0003-0940-6624