Practitioners demand more guidance and training in record-keeping

Most social workers recognise the value of recording but the act of doing so is dogged by confusion and mystery. This need not be so, writes researcher Liz O’Rourke

Recording is regarded by most practitioners as a necessary evil. It is resented as a distraction from the real work. In one inquiry after another, recording has been identified as an area of concern.

Last month, Lord Laming published his progress report on the protection of children in England following the Baby P case. The report emphasised the importance of effective supervision and good information-sharing. Laming also recognised the vital role good record-keeping plays in underpinning supervision and sharing of information.

“Local leaders must ensure that children’s and young people’s information is managed and recorded effectively to reduce their risk of harm,” he states in his report.

Practitioners complain about the amount of paperwork that increasingly dominates the job, about cumbersome and unreliable electronic recording systems, and that recording is seen essentially as an administrative task and back-covering exercise.

Yet, despite this, many practitioners can become reflective when asked to consider the many complex and problematic aspects of the recording task.

Attitudes and experiences

Liz O’Rourke Training Consultancy researched social workers’ attitudes to, and experience of, recording. It revealed ample evidence that recording, far from being boring, is a subject that provokes many contradictory and powerful feelings.

Extended interviews were conducted with 50 qualified social workers from 14 departments, and 460 questionnaires were completed by practitioners in a further 79 departments. As one interviewee explains: “[Recording] is on the one hand pointless, on the other absolutely essential.”

Many workers describe difficulties trying to make sense of other people’s recordings where basic details are missing and so many assumptions made that records are of little use. The puzzle for many practitioners is that such files have invariably been signed off by managers, reinforcing the sense of confusion as to what is an adequate record.

Inconsistency

Given that most qualified social workers say they have never been formally taught how to record, it is unsurprising that more than two-thirds of respondents report inconsistency. Most say they have learned on the job, and 61% say that reading other workers’ files has been a significant influence. Policies on recording are not considered particularly helpful – general statements on the requirement to be accurate, relevant, concise and complete are meaningless without practical examples.

The issue of service users having the right to access their files also affects practitioners’ record-keeping, with many struggling to know how to record embarrassing or problematic information. Many strategies are employed, including the use of veiled language or coded messages, or leaving the problematic information out of the assessment altogether and including it somewhere else in the file.

Computerised systems of recording were a source of much comment in the interviews and the questionnaires. There was a more positive view of computers than might be believed and widespread relief at no longer having to decipher illegible files. Many practitioners – particularly those routinely involved in duty work – recognise the way in which the instant access to information afforded by electronic recording has transformed the way they work. But only 56% say that the system they use enables them to find all relevant information.

Problems with recording

The main frustrations are centred on the way systems are implemented.

Training is often inadequate or badly timed, and not sufficiently geared to the varying skill levels of individual workers. Unreliable and overly complicated systems are further sources of complaint: nearly two-thirds of respondents feel their recording systems involve unnecessary duplication 62% feel recording systems are designed more for management information than for practice.

Form filling

There is also concern at the increasingly prescribed way in which recording is being directed, and a pervasive feeling that assessments have become about form-filling rather than professional judgement. Many of the interviewees describe the difficulty of reducing sometimes highly complex issues to the simplified format of tick-box recording.

A theme in the research is the tension felt by most practitioners between the pressure to record cases and the pressure to process them quickly. Nearly 79% believe that they spend more than half their time recording, and 83% feel they do not have enough time to record the detail required.

They are all too aware of the issue of accountability and need no reminder that “if you haven’t recorded it, it didn’t happen”. But they struggle with the expectation that every action should be recorded in order to evidence what has been done. They describe the strategy of recording in greater detail in more contentious cases – but acknowledge that it is not always possible to anticipate which cases those may be.

Neglected issue

Training staff to record has been identified several times as a neglected issue. Yet it is still regarded by many managers, training officers and even the Department of Health as an essentially administrative task. The assumption is that competence depends on effective writing skills, acquired through formal education, and technical skills in operating a particular recording system, delivered locally. Recording as part of professional practice is ignored. At most there is an awareness of data protection issues, but that seldom extends to how to record often highly problematic information. As a result, workers are left, by and large, to get on as best they can, despite many areas of uncertainty.

Without good training, clearer guidance and support on what constitutes effective recording and how to apply that in practice, social workers will continue to record in a situation of unease and uncertainty. And recording will continue to be cited as an area of concern in future inquiries.

Liz O’Rourke is a social work trainer and researcher

CareSpace thread on record-keeping

Liz O’Rourke’s training agency

Published in the 16 April 2009 edition of Community Care under the heading On the Record