Documents, forms and paperwork –
expanding documenting practices in health care and social work

The project's purpose and aim
The project's aim was to compare two fields – both of which are subject to increased audit requirements regarding quality, efficiency and safety - the medical and social work field. Expanding documenting practices were investigated with regard to its consequences for the daily work: what happens to everyday work when documenting practices become an increasingly prominent feature of daily procedures? With an approach informed by the sociology of knowledge, three elements was examined: the documentation as such; the practices associated with it; and the way in which the actors choose to describe it.
The original purpose of the project has gradually broadened and shifted slightly. As more researchers have been linked to the project (unfinanced by the project), the data collection has expanded to include more sites and empirical areas than originally was intended. The "extra material" is foremost gathered on the field of social service. Among other things, this has allowed us to pay more attention to the "user" - both as an idea and as an actor subjected to investigations and treatment. The comparative perspective was toned down when it became obvious that (from an ethnographic perspective) primary care and social services are difficult to separate as distinct and isolated organizations. In many respects, their practices are interconnected, especially within care of the elderly and other areas of cooperation. It was more fruitful to study practices that were similar in both fields, rather than seeking points of comparison.


Main findings
1. Consequences of standardization
Efforts to standardize health care and social work give rise to two tendencies: schematic quality measures and complicated information gathering for creating a basis for assessment. Standardizing quality measurements leads to one-dimensional and reified quality measures: to "have" plans, written agreements, manuals and assessment instruments become synonymous with "having" quality. Quality becomes quantity to have more or less of. Standardizing the assessment procedures appear to lead to complicated preparatory work - particularly in the social services: finding support for fairly obvious needs of the user consists of extensive procedures of data collection that often extends far beyond the immediate problem. We have also found that the government's standardizing efforts are presented as unproblematic, and as a natural part of the "continuous improvement" – a management approach eagerly promoted by the authorities.

2. The documents as (co)actors
The only way to retrospectively demonstrate that health care has occurred is to "inscribe" it on paper or in the digital documentation systems or databases. Thus, the documents are of significant importance for practice: they can be held up as evidence of work carried out, and/or as proof of the right kind of work, but they can also become evidence of the opposite (misconduct or other failures). Some documents govern the conversational order and sometimes even direct professional-patient/client interaction during meetings. Complex documentation systems can insist on the professionals' full attention, and lose the ability to be supportive for various tasks. With the help of ethnographic materials and interactional analyses, we have been able to study these phenomena in detail, finding evidence for how the documents not only are used by the professionals, but also how the documents seem to use (or direct) the professionals.

3. The attraction of paperwork
Unlike many organizational researchers' analyses of new public management and audit procedures as being imposed from above, we have noticed an intense engagement in creating and handling documents among the professionals themselves. This does not prevent the existence of a comprehensive paper work critique: documentation is frequently groaned about, ridiculed and criticized on a general level, while the immediate documentary work tasks often are taken on with great commitment. At times, there seems to be a certain kind of attraction attached to documents, an awe for the aesthetic of documents and their capacity to generate a glow of professionalism. This was particularly significant within the social services where current management trends are newer than within medical primary care. Many documentary initiatives come "from below": checklists and "support templates" to the main templates are constructed, self-initiated statistics on non-documentary practices are created etc. Furthermore, documentary tasks are delimited and specific, and can give the professional a feeling of "getting things done", which may partly explain the attraction of paper work.


New research questions generated by the project
The results of the project have contributed to the formulation of three new research projects:
• A PhD-project: "Managing the social services by numbers." Teres Hjärpe, planned disp. vt 2019. (The project is linked to, but not financed by "Documents, forms and paper work...")
• "An Administrative Eigendynamik. The Interaction of Meetings and Documents." Malin Åkerström och Katarina Jacobsson. Financed by Vetenskapsrådet, and will be carried out 2017-2019.
• "Documentation systems in the social services in focus  - dissemination, language and practice". Lina Ponnert och Elizabeth Martinell Barfoed, research application submitted to Forte 2017.


The project's international network
The project has benefited from contacts with Lindsay Prior and Jaber Gubrium, with whom we have discussed our results continually (workshops, consultation, book chapter). A planned anthology with Gubrium is to be resumed during 2017. In addition, doctoral student Teres Hjärpe spent the autumn semester of 2016 at the Silberman School of Social Work, Hunter College, New York at the invitation of Mimi Abramowitz, whose research is close to some of the project's main research questions. Further exchanges are planned (including a visit by Abramowitz in June 2017). The project (and our department) has also hosted the doctoral student Jochen Devlieghere during the spring semester of 2016. His research on the social services in Belgium is related to ours given the similar development of the Belgian social service field. We have also become members of "Nordic Network of social researchers on digitizing and professionals", led by professor John Storm Pedersen, Department of Sociology, Environmental and Business Economics, University of Southern Denmark, Esbjerg.

Dissemination outside the scientific community
The project has been presented to the National Board of Health in Copenhagen and the Arena Group meeting at Campus Helsingborg. Furthermore, we have offered feedback to the field sites where we conducted observations. Four such visits, with management and staff, have been carried out. Two interviews about the project results: Social Qrage (Vision) and the journalistic book "Det yttersta ansvaret" (SSR). In addition, our stated strategy to write in Swedish, also increases the non-academic interest in our results significantly.

The project's two main publications
1. Jacobsson, Katarina (2016) "Analyzing documents as fieldwork" in David Silverman (ed.), Qualitative Research, 4th ed. London: SAGE.
2. Jacobsson, Katarina and Elizabeth Martinell Barfoed (publ. Oct. 2017). "Socialt arbete på pränt. Digital dokumentering och annat pappersgöra " Malmö: Gleerups.
Publication 1 is based on data from the project and clarify the project's methodological approach in detail. The chapter is also a call for the inclusion of documents in ethnographic research, explicating an analytical approach that differs from traditional document analysis. Publication 2 harbor a wide range of analyses of the material mainly from the social service field.

Publishing strategy
To reach professionals who have an interest in our research, there has been a deliberate strategy to write a book in Swedish, to complement journal articles in English. A book is particularly appropriate for communicating our results to prospective and current professionals in the field. It was an explicit objective to give something back to the field as soon as possible, thus, we have written three reports. Two articles and two book chapters are written in English for an international audience. In addition to the above mentioned international anthology, a special issue of "Socialvetenskaplig Tidskrift" is planned 2017, as well as two English articles (of which one is submitted). The articles published so far can be found in Open Access journals and the following two are also intended for English-language journals with open access.