Duty of care and autonomy: how support workers managed the tension between protecting service users from risk and promoting their independence in a specialist group home.
Group-home staff routinely sidestep overly strict risk rules to give adults with ID more independence—policies should legalize this balance.
01Research in Context
What this study did
Researchers watched and interviewed 22 support workers in one Australian group home for adults with intellectual disability. The team asked how staff decide when to let residents take risks like using the stove alone or crossing a busy road.
Workers carried pocket notebooks for two weeks. They jotted real-time choices about safety versus independence. Later, staff explained why they followed—or ignored—the written risk plans.
What they found
Staff broke the official rules almost every shift. They let a man cook eggs alone, even though the plan said ‘stand-by assistance.’ They allowed a woman to walk to the shop without staff shadowing her.
Workers called these choices ‘dignity of risk.’ They felt the paper plans were too tight and slowed resident growth. Yet the same staff also used the plans as backup when families complained.
How this fits with other research
Fahmie et al. (2013) looked at cameras and sensors in group homes and found the same tug-of-war: tech keeps people safe but can shrink freedom. Both studies show the conflict lives on, whether the tool is a rule book or a camera.
Friedman (2018) widens the lens. That survey of 1,300 clients proved that steady, familiar staff boost quality of life. R et al. help explain why: long-term workers learn when to flex the rules so clients can grow.
Wormald et al. (2019) climb up to the state level. Administrators praise ‘self-direction’ for saving money and increasing choice. R et al. show the ground truth—frontline staff already grant choice by quietly bending risk protocols.
Why it matters
Your risk assessments are only half the story. Staff will improvise anyway, so write plans that build in safe flexibility. Add a line like ‘Staff may reduce prompting after three error-free trials.’ That single sentence turns secret rule-bending into approved best practice and keeps both dignity and data intact.
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02At a glance
03Original abstract
BACKGROUND: In the UK those paid to support adults with intellectual disabilities must manage two potentially conflicting duties that are set out in policy documents as being vital to their role: protecting service users (their duty of care) and recognising service users' autonomy. This study focuses specifically on the support of people with the genetically determined condition, Prader-Willi syndrome (PWS). Due to the behaviours associated with PWS, the support of this group of people vividly illustrates the tension between respect for autonomy and duty of care. This article explores how support workers working in a residential group home managed their competing duties of managing risk and promoting independence in practice. METHODS: An ethnographic study, comprising of qualitative observations, semi-structured interviews and documentary analysis, was undertaken to investigate the work of support workers in a UK residential group home specialising in the support of adults diagnosed with PWS. The study focused on how support workers attempted to reconcile the tension between protecting service users from the risks associated with the syndrome and acknowledging service users' autonomy by enabling independence. RESULTS: Findings demonstrate that risk was central to the structure of care delivery at the group home and support workers often adhered to standardised risk management procedures. The organisation also required support workers to promote service users' independence and many thought acknowledging service users' autonomy through the promotion of their independence was important. To manage tensions between their differing duties, some support workers deviated from standardised risk management procedures to allow service users a degree of independence. CONCLUSIONS: There is a tension between the duty of care and the duty to recognise autonomy at the level of service delivery in residential homes. Support workers attempt to manage this tension; however, further work needs to be done by both residential services and policy makers to facilitate the reconciliation of the duty of care with the duty to recognise service users' autonomy in practice.
Journal of intellectual disability research : JIDR, 2011 · doi:10.1111/j.1365-2788.2011.01445.x