Passing laws is not enough to change staff practice: The case of legally mandated “incident” reporting in Sweden

ABSTRACT

Background

It is mandatory for staff in Swedish community services for people with intellectual disabilities to report incidents of error or malpractice.

Aim

The aim is to study if incident reports contribute to developing quality in services for people with intellectual disabilities who present with challenging behaviours.

Method

159 reports on incidents from group homes and daily activities services were accessed and analysed using narrative thematic analysis.

Results

Most reports concerned altercations between service users. Analysis focused mainly on the immediate incident and attributes of service users. Amendments were not (obviously) aligned with causes, and neither sufficiently addressed structural shortcomings. Restrictive measures were described, but changes in practices were not mentioned. Reports including Self-injurious behaviour (SIB) were conspicuously absent.

Conclusion

Reports are handled in a seemingly perfunctory manner, without any development. Quality development relying on staff reports and front-line managers’ investigations requires support based on values rather than on the legal framework.

KEYWORDS:

• Intellectual disabilities
• challenging behaviours
• incident reporting
• trauma
• quality development

Swedish people with intellectual disabilities (ID) are supported in community services according to the Act concerning support and service for persons with certain functional impairments (SFS 1993:387; henceforth the Swedish abbreviation LSS will be used). LSS requires that services be of good quality, supporting service users’ self-determination, integrity, and participation.

Identifying and reporting incidents that may threaten the quality of support is part of the continuous quality development. Reports on incidents are a part of the structure for systematic quality improvement required of all services (National Board of Health and Welfare Regulation 2011:9, n.d.). It is mandatory to report acts that are committed as well as actions that due to omission or for some other reason have not been carried out, and which have a potential or manifest negative impact on the life, safety, or physical or mental health of the service user (National Board of Health and Welfare, 2014). The legislation does not differentiate between poor care, such as neglect or abuse, and consequences from mistakes (Ion et al., 2016).

Therefore, all who work in services for people with intellectual disabilities are required to contribute to and safeguard the quality of services (LSS 24a§) through reporting incidents (LSS 24b§). It is mandatory to report any factors that have or could have a negative impact on the quality of services (LSS 24b§), potentially leading to adverse consequences for those accessing the services. People under a duty to report incidents include managers, staff, temporary workers and trainees. To encourage open reporting of incidents neither reports nor the ensuing investigation should focus on or pose a threat to individual staff (National Board of Health and Welfare, 2014).

Incidents that are judged as serious are reported to the Health and Social Care Inspectorate, the government agency responsible for supervising health and social care. Reports contribute to local and national knowledge about structural causes for incidents, thereby supporting service development, nationally and locally.

Supporting people with ID who present with challenging behaviours can prove to be a complex task, requiring continuous monitoring and development of service quality. Although individual factors play an important role in the development of challenging behaviours, contextual factors in the organisation have been identified as having an influence on challenging behaviours in people with intellectual disabilities (Olivier-Pijpers et al., 2018). Strategic planning as well as a suitable infrastructure is required to provide services for people with challenging behaviours (National Institute for Health and Care Excellence (NICE) guideline, 2018).

Using incident reports for quality development in health settings has proven complex, not always leading to the desired quality development (Macrae, 2016; Mitchell et al., 2016). The aim of this study is to investigate if incident reporting contributes to service development in community services for people with ID who present with challenging behaviours, through investigating:

1. What is reported in mandatory incident reports?

2. How these reports are used to identify potential developments in service provision?

Method

The results presented in this paper are part of a larger project running over 3 years. The main aim of the overall project is to identify organisational barriers and facilitators in developing support of high quality for people with ID whose distress challenges the organisation. It is funded through FORTE's (Swedish Research Council for Health, Working Life and Welfare) national program on applied welfare research, with the main author working as a practice-oriented research fellow within and together with the organisation.

The project is designed as an exploratory case study using multiple sources. According to Yin (2014), a case study investigates a contemporary phenomenon in its context where boundaries between context and phenomenon are not clearly evident. A case study method requires data-collection from multiple sources. Data sources in the project include incident reports, surveys, interviews, as well as internal documents.

The context is provided by the Department for Disability Support in a large Swedish municipality. Implementation of a strategic plan on supporting people with ID and challenging behaviours, and the continuous adaptation of services is the contemporary phenomenon. The context and phenomenon are intertwined in an iterative process, the one influencing the other. For example, overarching departmental decisions will influence service provision, and how services develop and adapt will influence the department. Yin (2014) further posits that case studies are a suitable method when the main research questions are “how” and “why”. The aim of the research project is to explore not only factors that are barriers or facilitators for organisational change towards an evidence-based practice, but why these factors are relevant in the current organisational context.

Ethics

This research was given ethical approval by the Regional Ethical Review Board, registration number 2018/838. The main researcher is employed by the municipality as a R&D Coordinator and affiliated to the University of Lund, Sweden. This research was undertaken part-time with the agreement and endorsement of the Municipality.

Setting

The setting for this study and data used were collected from administrative sources for the municipality. 1575 people with ID and/or autism accessed services according to LSS (National Board of Health and Welfare, 2018).

In early 2019, the municipality provided residential services for just under 900 adults in 97 services. In addition, around 800 service users accessed daily activities services, ranging from activity centres with a high degree of support, to supported employment places with occasional support. All services are run by the municipality.

Sample selection and procedure

Incident reports are completed and submitted by staff or front-line managers using a digital online system. This system is accessed and maintained by administrative staff from the Municipality. A total of 1825 incidents were reported in 2018.

278 reports from 1 June to 30 November 2018 were accessed by an officer in early December 2018.

These 278 reports were selected using the following criteria:

• Incidents were reported in residential services or daily activities services for people with a diagnosis of ID and or autism;

• The report included a description of challenging behaviours;

• The report was for a person over the age of 18 years.

These reports were provided to the main researcher (first author) in digital form after being anonymised.

57 reports were excluded as they did not include clear descriptions of challenging behaviours. Where the report was unclear if a challenging behaviour was involved, a conservative approach was applied, and the report excluded. For example, a very short report on clothes being stuffed into a toilet, albeit a material challenge, was excluded, as a description of the incident was lacking, while a report on a similar behaviour was included, if it contained detailed description of other simultaneous challenging behaviours or the context of the incident.

Where one incident involves several service users, one report is written for each person affected, therefore generating several reports, all of which were included.

Reports from the ten residential services and ten daily activities services with the largest number of reports were included in the final analysis, ranging from 3 to 16 reports, with a median of 9 reports for residential services, and 7.5 reports for daily activities services. These 20 services would at a later stage in the research project be approached for interviews. Reports from 20 residential services and 13 daily activities services were excluded.

A final sample of 159 reports, 79 from residential services and 80 from daily activities services, were analysed.

Analysis

The text from the standardised reports was sorted according to the set stages in the reporting process:

• what happened and what was the immediate response;

• what cause(s) is/are identified;

• suggested amendments to the support provided to the service user to prevent re-occurrence and;

• if present, comments from the investigating officer;

All the selected reports were read through as individual documents several times, to achieve an overall understanding of the reports (Gubrium & Holstein, 2008). Then the text from each stage in the reporting process was collated and read as a single narrative, composed of micro-narratives from several services, and analysed thematically from the perspective of “what” (Riessman, 2008):

• what kind of incident is reported;

• what are the causes, and;

• what are the amendments.

That is, each stage of the reports was treated as one case, as one narrative, where the emerging themes reveal how reports may contribute to the development of the services (Riessman, 2008).

After this stage, the complete set of 159 reports was read through again, together with the initial thematic analysis, to identify what is not reported, but would be expected in relation to the legal framework. For example, in some reports on altercations between service users, the description suggested that a “third party” service user engaged in self-injurious behaviour (SIB) during the incident. This SIB should have engendered a separate report with explicit amendments. These reports were lacking.

This was then iterated, as the identification of what is not reported further highlights certain aspects of the reports. Finally, for each stage in the process, the emerging themes were identified.

Narrative thematic analysis was used to analyse the text from the reports (Riessman, 2008). This was undertaken by the main researcher in regular discussion with others in the research team. Discussions on research interviews (Alvesson, 2003; Qu & Dumay, 2011) have also had an impact on how the incident reports were analysed. Interviews can be seen “[a]s situated accounts that must be understood in their own social context” (Qu & Dumay, 2011, p. 241). Incident reports should also be understood and analysed in their context, as part of an organisational narrative. Therefore, staff, managers and officers responsible for strategic processes were involved in the analysis, confirming the results in an iterative process, including dialogue, check-back and three formal meetings. Thus, the meaning of the reports was “sent back” to those involved in writing and handling reports, seeking to confirm the meaning of their content, mimicking the process during a research interview (Kvale & Brinkmann, 2014, p. 47).

The trustworthiness of the analysis is based on several factors. The incidents are reported from two departments, that in turn are divided into several units. The two units in from daily activities services and the six units for residential services are all represented. Thus, the narrative is composed of several micro-narratives from dispersed parts of the organisation. The results from these narratives are commensurate with research, as well as with official documents at both the national and the local levels, including reports from the municipality, government agencies and NGOs representing people with ID and autism.

Results

Incidents

The themes emerging from what is reported in the incident reports are altercations between service users. There is a lack of mention of cognitive and communicative support, a lack of reports on the use of coercive measures, and a lack of reports on SIB.

Altercations between service users

In 18 of the services, most of the reports describe altercations between service users. These include descriptions of punches, scratches, hair pulling, tearing at clothes, and throwing things at another person (directed and non-directed).

The descriptions are mainly focused on what service users do, how they react, and how staff intervene to stop the incidents.

As the neighbour held the sweater of the service user, the service user started to hit the neighbour [another service user]. [Group home]

The actions of staff are typically physical.

Staff [name] stood in the way to prevent more punches, and to motivate [the service user] to sit in the wheelchair again. [Daily activities]

Sexual abuse has only recently been given its own heading and was only reported in one service. Staff identify that social relationships are difficult, and that physical interaction is rejected by one service user, which is not understood by another.

Lack of cognitive and communicative aids

Cognitive and communicative aids, such as social stories or comic strip conversations, are not mentioned when staff talk with the service users after incidents, nor as a support for the service users to regulate their interactions.

Service users are motivated to return to their own apartments, distracted by staff to focus on something else, or told not to do whatever they are doing. They are also asked why they hit the other person but cannot give an answer. Both persons involved may be offered support by talking to staff, to understand the situation. There is no mention of cognitive or communicative aids used to talk about what has occurred, or how the service user is supported in using the person’s own strategies to handle stress and de-escalating a situation.

Lack of self-injurious behaviour

SIB is mainly mentioned to underscore that service users affect each other, but usually not a topic of its own.

Only one service specifically addresses SIB. The SIB is attributed to anxiety. Focus is on describing and handling the SIB from a staff perspective. There is no description of why anxiety builds towards SIB, except that the service user seems unable to cope with being alone.

In the other services, SIB is only mentioned as a part of the incident, more as an aside, usually in an incident concerning altercations between service users.

This in turn triggers the other service user, who starts to jump and scream. The jumping and screaming triggers [name of service user] and she starts to hit herself and to scream. [Group home]

Lack of reports on coercive measures

Practices that are coercive in nature are mentioned explicitly, in a descriptive manner without mention of their possible legal status and without being the cause for the incident report. A service user is persuaded to accept a solution the person has previously clearly said no to, which causes a challenging behaviour. More obvious breaches of the law are described without due concern:

Two staff stood between the service users and had to hold the service user who tried to … [Daily activities]

However, on some occasions, a restrictive practice is identified as unsuitable:

I ask staff what is happening and am answered that the service user is upset so they have locked the door. I told staff who had locked the door to immediately unlock it, back away … [Group home]

The use of possible euphemisms obscures some probable restraints. A description of how one service user is stopped to approach another by offering hugs is then followed by:

I worked [physically] close to the service user. [Daily activities]

This could signal that the supporting staff member is physically preventing the mobility of the service user. This is then followed by:

I took [the service user] to another room. [Daily activities]

These practices are accepted by the investigating officer as suitable, occasionally commended as it prevents further physical interaction between service users, and the report is closed.

On one occasion, a physical aid is described to be used with the specific intent to restrain mobility. This incident had not been investigated at the time of access to the report.

Causes

The themes emanating from the identified causes are service user attributes and a lack of identifying structural causes.

Service user attributes

Most causes mention attributes or behaviours pertaining to the service user: the service user has autism, is new, has had a challenging behaviour, suffers from mental and/or somatic health problems, throws things, is stressed.

There is a service user who sometimes has challenging behaviours and then screams and cries in the communal area, which scares the other service users. [Group home]

Even when services are aware of the impact of a cognitive disability, lack of cognitive or communicative supports as a cause for incidents is not mentioned.

Lack of identifying structural causes

Structural causes can be divided into local and/or systems level. For example, at a local level, an incident might be caused by staff not following routines. At a systems level, the reason for not following routines would be identified.

The field for identified causes is used to a varying degree, and causes are mainly identified at a local level, and related to staff: staff lack experience or knowledge, staff do not follow routines, there are no routines, understaffing, temporary staff. A few services identify the role of staff in preventing altercations between service users.

We must pay attention and change routines and how we staff are positioned so the interaction doesn’t become physical. [Daily activities]

There are occasional descriptions of staff forgetting to support the communication of the service users.

Staff didn’t notice signals from the service user and therefore misjudged the situation. [Daily activities]

There are few descriptions of the choreography of service user interaction, and then mainly when the service user is new.

New service user has moved in, not known by the staff yet// … //and didn’t know how [the service user] would react to an activity together with [name of service user]. [Group home]

At a systems level, causes related to, for example, supervision and leadership are lacking entirely.

Amendments

The theme emanating from the suggested amendments is a lack of consistency in the use of phrases, repetitiveness in amendments, and lack of systems level.

In the system for reporting, headings in the form of set phrases can be chosen, with the aim to make reporting amendments more efficient. These headings are then followed by space for free text. Phrases for suggested amendments include, for example, improving information/reporting, adherence to routines, changing routines, dialogue in group, dialogue with the person concerned, dialogue with the service user/legal representative, changing organisation, and training/competence (Table 1).

Table 1. Frequency of amendments.

Amendment	Times used
Dialogue in group	77
Dialogue with service user/legal representative	47
Changing routines	35
Adherence to routines	27
Improving information/reporting	17
Changes in the organisation	15
Training/competence	13

There is a general lack of consistency on how the different phrases are used. For example, the phrase dialogue with the person concerned, used 43 times, can denote talking to the service user who has hit or threatened another person, talking to the service user who has been hit, or talking to the staff person(s) involved in the incident. Talking to a service user, either the one exposed to violence or the one committing the reported act, is also registered under the amendment dialogue with service user/legal representative, used 47 times.

The heading improving information/reporting is used 17 times. On one occasion, a temporary staff person misinterprets a service user and does not follow established routines, which leads to a challenging behaviour. This will be amended by:

changing routines for introduction so that all new staff know what applies to specific services users and their needs. [Daily activities]

On some occasions, the phrase is used to describe a lack of knowledge about the service user, such as knowledge about mental health or possible pain.

We discuss about possible reasons for the service user’s behaviours and are in the process of excluding somatic causes and believe that some of the [challenging behaviours] may be due to the service user being in pain on that occasion. [Group home]

The phrase is also used when there is a lack of routines for how staff should provide support. In one group home, a supervisor is engaged to guide the staff group in how to support service users who are affected by one person’s challenging behaviours.

The supervisor will also produce a support plan for the service user with the challenging behaviour. [Group home]

In a daily activities service, the social interaction between service users must be thoroughly planned and supported to prevent challenging behaviours:

Communication with staff who support the other service user on the other side of the fence should also increase, so that all work on a functioning distance [between service users]. [Daily activities]

The most frequently used phrase dialogue in group, used in 77 of the reports, is mostly unspecified. When specified, it may refer to making routines known to all staff.

All staff and front-line manager have thoroughly gone through the routines for them to be known by all. [Group home]

It may also refer to increasing knowledge in the staff group or making clear that everyone should follow routines and plans.

The phrase adherence to routines, used 27 times, also seems to vary in how it is used. The routines referred to include plans on how to prevent a challenging behaviour, what to do in general when a challenging behaviour occurs, how to specifically protect other service users and staff from a challenging behaviour, or support plans in general. For example, in one service, after a change in front-line manager, there is a note that:

there are currently no routines or plans to prevent the same [kind of] incident to happen. [Group home]

This is preceded by five similar incidents where the amendment suggested is that the staff group should follow routines. Thus, there is a lack of specificity as to which routines are changed and why, connected to the incident reported. The same applies to the phrase changing routines, used 35 times. In one service:

Routines are revised after every incident. [Group home]

Yet the purpose of the revision, for example, which causes for the incident are addressed, is unspecified. Therefore, it is mostly unclear how this phrase is linked to the incident reported, i.e., how the incident is caused by a lack of information/reporting. This unclarity is partly due to few references to routines in descriptions of incidents. That is, there is no clear line from incident to cause (lack in routines or faulty routines), to amendment stating desired outcome, which would be enabled through routines.

Training/competence, used 13 times, is used together with dialogue in group. There is no mention of long-term plans for the development of competence in the staff group.

Changes in the organisation, used 15 times, includes increase in staffing, introduction of personal alarms, staff and service user choreography, change in staff roster, changes to the building, for example, to prevent service users from meeting.

A few of the reports conclude that no amendment is required. One reason given is that a service user being hit by another does not seem to react, which is taken to imply that the punch or slap was not hard. Another reason would be that service users trigger each other.

There are no amendments related to leadership.

Reviewing the reports

Most of the reports are approved with only a short comment that amendments are sufficient. Occasionally the service is asked to be observant, or to continue working with prevention of recurring incidents. On one occasion the immediate restraining action taken by staff is commended, as it prevented further harm. The service is not required to provide a plan for restraint reduction.

Discussion

The aim of reports on incidents is to identify and amend structural shortcomings to prevent further incidents to occur. The information gathered through these reports is intended to be part of the long term and systematic improvement of service quality. This requires that front-line managers and direct care staff recognise incidents, and correctly describe them. They must also be competent to identify pertinent causes and suitable amendments to be implemented. The officer who reviews the reports must be able to see beyond obvious surface detail to be able to see alternative causes, seek further information and further amendments to service provision.

The general impression is that incidents are handled in a perfunctory manner, just getting them through the system. There seldom is an analysis as to the causes, and amendments are therefore not obviously linked to the incident. It is also notable that some serious incidents reported early in the sample period have not been handled by managers by the end of the period. The recurrence of incidents of a similar character that do not seem to raise the alarm in a service, the repetitiveness during the whole period of the same identified causes and amendments that seemingly have no effect, contribute to the impression of routine without engagement.

Lack of reports on the use of coercive measures

The presence of challenging behaviours contributes to the use of coercive practices in services for people with ID (Fitton & Jones, 2018; McGill et al., 2009; Sturmey, 2018; Webber et al., 2019) including seclusion, denied access to personal belongings, physical and chemical restraints (Dörenberg et al., 2018). The use of such practices might put the person at great risk. In Sweden, the Instrument of Government protects the freedoms and rights of everyone, prohibiting any use of coercive practices. Accessing community services for people with ID does not change this legislation (LSS, 4§). It is the responsibility of managers to ensure that staff are informed about this.

The Health and Social Care Inspectorate (2019) as well as the National Board of Health and Welfare (2018) have in their annual reports highlighted the fact that coercive measures are being used in services for people with disabilities. The use of a coercive measure should be reported as an incident as the practice puts the service user at risk (National Board of Health and Welfare, 2014). Such measures are mentioned both explicitly and more indirectly in the description of incidents, but only one incident is reported due to the use of coercive measures. Subsequently, amendments in only one service addresses coercive measure. There is otherwise no mention of the reduction of coercive measures.

Strong legislation is intended to protect all persons from the use of coercive measures, with special focus on vulnerable groups, and it would therefore be expected that services where such measures are mentioned indirectly, filed reports specifically about these measures. The fact that coercive measures are unrecorded could indicate that knowledge about such practices is low, or that they are not identified (Schippers et al., 2018), that methods and plans for reducing coercive measures are not being used, or that services have normalised the use of coercive measures. Service users are potentially subject to illegal and harmful measures without their being noticed or amended.

Altercations between service users

In 18 of the services, most of the reports describe altercations between service users. This is consistent with the yearly internal analysis of incident reports and is also reported by the Health and Social Care Inspectorate (2019).

All service users should feel safe in their environment, especially in their home. Most of the reports concern situations where challenging behaviours of one service user affect another. The data include reports where one service user hits another, others where the physical altercation is mutual. One might question the view in reports that a slap or punch is not considered serious, thus not requiring any amendments, if the affected service user does not show a noticeable reaction. Such a lack of reaction on part of the service user is not necessarily a measure of degree of how serious the incident is. It could be a sign of resignation to the situation, or an inability to protest. Adverse life events have been shown to have an impact on people with ID (Hughes et al., 2019; Rittmannsberger et al., 2019), and continuously being at risk for physical abuse, albeit not leading to tissue damage or obvious emotional reactions, should be of concern (Northway, Melsome, et al., 2013).

Some services judge an incident involving one service user hitting another as not serious, as the affected service user does not show a reaction, for example, in the form of pain or withdrawal. Given that many persons with ID live a large part of their lives in supported accommodations, they may not know they do not have to accept a slap or punch from another person, especially not in their own home.

It is common for people with ID who tell about abuse not to be believed (Northway, Bennett, et al., 2013). In one service, the incidents are not considered to require further amendments, even though the descriptions involve punches to the head, as the service users “trigger” each other. In the word “triggering” lies a possibly derogatory and demeaning assumption that the service users have themselves to blame and that their experiences are not taken seriously.

One must wonder, if the same conclusion would be drawn if the description involved a woman or child being slapped or punched. We are probably well beyond times when a woman “deserved” a slap from her husband, as she “triggered” him. Even if a service user does not react or protest to a situation, the supporting staff should never accept these incidents. Instead of normalising the situation, staff should provide both service users with a well-developed support that prevents stress and promotes choreographed and friendly interactions.

Self-injurious behaviour

Challenging behaviours in the form of SIB are common in persons with autism and ID, particularly in those with lower cognitive abilities (Cooper et al., 2009; Folch et al., 2018; Poppes et al., 2010) and certain genetic syndromes (Arron et al., 2011). Given the prevalence of SIB in people with ID, it is notable that SIB is the primary incitement for reports in only one service. In the other services, SIB is mentioned but not the focus of attention. There is not enough information in the data to analyse the reasons for this, but if staff attribute less control over SIB (Dilworth et al., 2011), they may not identify the presence of SIB as an irregularity, but rather as a set part of ID.

Quality and sustainability

The system for reporting incidents and using the knowledge for service development relies on the presupposition that staff are competent enough to identify incidents, that there is enough data and knowledge to identify structural causes for the irregularity; and that there is enough data and knowledge to identify structural and organisational amendments.

As pointed out by Schalock et al. (2016), the development of an organisation that meets the needs of service users is not a discrete event, but requires a multidimensional approach. All levels in an organisation must be ready and capable to change (Schalock et al., 2016; Weiner, 2009). Collaborative assessment plays a critical role in the organisational development, by promoting systematic inquiry at both the personal and organisational level, through knowledge, self-determination, and self-critique (Schalock et al., 2016). The reporting of incidents is an essential part of this assessment. For incident reports to generate the intended change, they must be honest and mirror the current state of the services, rather than a desired image (Alvesson, 2013).

Input, throughput, output, and outcomes should be aligned vertically (between structure-level processes and the organisation-level practices) as well as horizontally (Schalock & Verdugo, 2012). To reach desired and intended outcomes, the throughput (reporting on incidents) should follow logically from the input (intention of legislation). Then the output, the compiled analysis from reports on incidents, would contribute to the outcome, high-quality services where vulnerable people are appreciated, supported, and safe.

The main researcher read all the reports several times as a cluster. This is not the usual way they are handled. A front-line manager usually handles one report at a time. This could to some extent explain why the reports mostly appear to be treated as discrete instances, rather than part of an organisational structure. In the services with the largest number of reports, another incident was mentioned occasionally. References were made mainly when the same incident seems to have caused several reports due to more than one service user being affected on the occasion. There are no references to a compilation of the most obvious data, such as time of day, activities preceding the incident, factors that cause stress, factors that trigger or sustain a behaviour, preventative interventions, or if a similar incident has occurred previously. That is, the fields for comments are used sparingly, revealing little about analysis or systematic work towards change between the incidents.

In relation to the total number of staff reports, only a few are investigated further by an independent officer and sent to the department’s executive sub-committee. There is little reflection or feedback built into the system, as the comments from the officers are scarce. Feedback may be given verbally but is not recorded. This means that a fair amount of energy is put into reporting incidents that early on should be able to provide crucial information about how services could develop, if at any point in the process a thorough analysis was made.

Staff and managers would possibly be helped by a readily available document providing support about when and how to fill out the reports on incidents. Currently, one document describes the legislation and one video shows how the digital tool for reporting works. When reporting, there is brief information within the program on how to proceed when writing a report, but there is no support for creating consistency in reporting. That is, at the basic level there is no support for alignment horizontally of the organisation-level practices. Nor is the practice put into a context with the system-level processes, and the overarching intention of the legislation: to develop organisations that provide people with ID with high quality services.

Recently, reports are being discussed and analysed at higher management levels. Time will show if this practice at the systems level contributes to a deeper understanding of the needed structural changes within the organisation, both vertically and horizontally.

Adverse life events

People with ID are exposed to adverse events that might have both physical and psychological impacts, immediately and cumulatively (Hughes et al., 2019; Northway, Melsome, et al., 2013; Rittmannsberger et al., 2019). Environmental stressors include: poverty, domestic violence, interpersonal abuse, and carer violence (Wigham & Emerson, 2015). Adverse life events constitute a strain and thereby compromise the resilience of a person with ID. Such events can be high impact, traumatic events, maybe occurring only once, or they have a cumulative impact by occurring repeatedly (Ford & Courtois, 2020; SAMHSA, 2014). Trauma-related symptoms have been associated with challenging behaviours (Rittmannsberger et al., 2020), but may be difficult to identify (Daveney et al., 2019; Kildahl et al., 2019).

The majority of reports are related to altercations between service users. These recur over time, in settings that should be safe for the person. There is no way they can escape or change their situation. Instead of raising substantial concern and powerful amendments, services for people with ID seem to ignore or accept the cumulative impact such continued altercations will have on service users (Health and Social Care Inspectorate, 2019). Instead, incidents are normalised. Comments that the incident was probably not serious as the service user did not react, or that service users trigger each other, show a lack of awareness and understanding of the long-term impact of adverse life events and trauma. Therefore, there is a risk that a service contributes to the continued strain on service users, thereby not preventing the distressed reaction in the form of a challenging behaviour.

Limitations of the study

The intention of the Swedish national research program on applied welfare research in general, and the practice-oriented research fellows in particular, is that research should effect change in services. The main author is a research fellow nested in the context where the research is taking place. As the topic of identifying “mistakes” is sensitive at all levels of the organisation, this might introduce biases at several stages of the study, including accessing reports and the inclusion/exclusion of reports in the final analysis.

The main researcher has attempted to overcome these biases through an iterative process, involving officers, managers and staff in continuous dialogues and check backs. Thus, after identifying that reports that included descriptions of SIB were absent, the main researcher conferred with the officers if some part of the initial search had inadvertently omitted such reports.

This study includes reports from services that appear to struggle in using the system for reporting incidents in a feedback loop for quality development. Services that are successful in this respect, and services that fail to report incidents are not included. This would be an important area for future research.

Being part of the organisation provided the main researcher a unique access to the “inner workings” of the structures and personnel. Awareness of the influence of organisational narratives of “good” and “poor” services led to a great deal of reflection and external researchers have constructively questioned potential preconceptions and supported the research development and analysis.

Conclusion

Reports are handled in a seemingly perfunctory manner, complying with the demands of the digital tool. The input is generally limited to the set phrases or headings, and these are used inconsistently, which circumscribes learning and development. This could be a consequence of the system for reporting, which supports routine measures without engagement. It could also be due to a lack in supporting structures, or in the ability to identify more efficient and pertinent amendments.

There are few reflections on staff roles and how these roles depend on factors in the context of the organisation. Given the repetitiveness in suggested amendments to prevent further incidents, and the fact that similar incidents recur within a service over a period of six months, the aim of the legislation does not seem to be met.

Therefore, the system for reporting incidents, investigation and amendments is not clearly contributing to services of good quality for persons with challenging behaviours. If quality development is to rely on staff reports and front-line managers’ investigations, there is a need for better support, based on values, leadership, and clear organisational visions. A suggestion would be to develop the structure for reporting incidents within a framework of trauma-informed care. Trauma-informed care “presents an opportunity to create not only a culture in which individuals might thrive, but also one in which direct care staff may succeed” (Keesler, 2014)

Acknowledgments

The main researcher wishes to thank Ulf Jönsson and Linda Byrin for support in accessing data, Åsa Andersson, City of Malmö and the VBE-group, Lund University, for feedback on a draft of the manuscript, and staff and managers of the Department for Disability Support in Malmö, Sweden for participating in the analysis. Two anonymous reviewers provided helpful comments on the manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The main researcher is funded through FORTE [grant number 2018-01336].