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The importance of documentation

The importance of documentation

Imagine living all your life where people have said things about you like:

  • struggling with feeling empathy
  • lack of variance in tone and facial expressions
  • struggling to understand humour, sarcasm, and other abstract concepts
  • lack of emotional self-awareness  

What would this do for your sense of self-esteem and self-worth.  For many of our participants this has been their life experience. By placing labels on people and what they do, we often overlook what they need from us in our role as support workers. The NDIS provides supports to ensure that we empower our clients to understand what it is that they need to live a successful, happy life and have the resources to achieve it.  Is it our role to be placing a measure on someone’s else’s “happiness”?  We cannot ensure every experience we facilitate will be successful and create positive emotions for every person, however it is our role to be creative and flexible with what we offer and how we do it. Our mindset and attitude are the most important factors. If we are feeling positive about what is ahead, this creates an interoceptive “alliance” with your participant and they can “feel it”, it is no different to grounding yourself when you can feel yourself getting anxious. Our clients coregulate their emotions off us. 

We know everybody has a different idea of what happiness is

You have been supporting Rita and Terry for some time. You have read the different reports and have an understanding of the “why” for some of Rita’s behaviours. Rita was at first ecstatic to receive a formal diagnosis of Autism and ADHD, however each shift with her is getting to be difficult. Rita is ruminating on “what could have been?” Her hyperfixations that you have always included in planning for your time together are no longer holding Rita’s attention or enthusiasm.  The gems and the flowers that Rita has always meticulously kept organised have been relegated to the same focus as the clothing and other “chores” as Rita now views them. 

 You were informed Rita has had a recent medication change and following this you have noticed less interest in hobbies that in the past brought her pleasure. Rita seems to be only able to focus when she is researching autism.  On day 3 of the new medication, the day that Terry put the nail through his hand, Rita had spent 8 full hours complaining to him about what a failed husband he is.  Rita is open in her hostility for being misdiagnosed all her life and poor Terry is facing this daily. During your time supporting Terry he has opened up to you and has shared so many different life experiences that you feel so overwhelmed from what has been described.  Terry has been and continues to be under constant threat from Rita’s coercive, controlling behaviours. 

 At first you were ok with being a “negotiator” between them.  But it has now developed into open hostility from Rita and you feel she shows no compassion for her husband. 

In the shift notes you have attempted to “protect“ both Terry and Rita by not stating the facts about their actions and words to each other and because of this Huma, as shift supervisor, has no idea of the different stressors being placed on you.  Huma has noticed a decline in the quality of the shift notes and what she sees as ambiguity in the details. Huma calls you, and you book an appointment for in a week. You both have busy schedules and when Huma asks if there is anything that you need immediate support with you say there isn’t anything.  

After supporting the family for 5 months the strain is showing through your body.  There are not just the issues at work. You have stopped talking with friends, when the phone rings, you avoid it. You are functioning to attend work and barely anything else.  You cannot remember the last time you ate a full meal, and sleep has evaded you for about 3 weeks. Following the phone call with Huma you reflect on what is happening with all the families that you support and realise that you need to call Huma back. 

How can we as support workers prevent this from happening to us?

Shift notes provide information on what is happening to our people. The idea of shift notes is to provide a clear record in real-time of what is happening, and what is being said. Often, it’s the little things every day that suddenly build up for support workers that become overwhelming. Had Huma been aware of all the different complexities within Rita and Terry’s home she would have been able to provide you with appropriate support and facilitate other appropriate services to assist with this huge life event for Rita.  If we don’t know that there is a problem, how can we help you? Our shift notes are a way for us to understand how to do this best. 

We do not carry the weight of our families on our own. This is what sets Flair & Fine Care apart from others. As a team we support each other. 

As great as Huma is in understanding everyone’s different needs, as shift supervisor she is mandated to have a clear and accurate picture of your workplace. (WHS in the Policies and Procedures manual).

When updating Huma about the different tensions within the home that are impacting you and your sleep, you tell Huma you feel like you did the wrong thing by trying to protect “Terry and Rita”.  When asked why you did it- you answer that you saw it as a reflection on your work performance if you couldn’t manage it.  With hindsight, you tell Huma – if the different services were in place to support Terry and Rita during this time – it would be beneficial for Rita and her recovery. 

Following a meeting between Huma and Rita, supports for counselling are accessed via AUTISM Victoria for both Terry and Rita, at no cost. This resulted in a renewed medical assessment for Rita, and it was found the new medication was not working well for her and they were able to drop the dosage. 

Within 3 days Rita was able to enjoy spending time with her flowers and it was noticeable that the gems, the indoor flowers, and most of all the clothes were all sorted and presented.