_________ Saija Koskiniemi, MSc, Doctoral Researcher, and Tiina Syyrilä, PhD, Post Doctoral Researcher, Department of Nursing Science, University of Eastern Finland, Kuopio, Finland. Mia Mäntymaa, MSc, Development Consultant, Jouko Ranta, MNSc, Quality Manager, and Minna Säilä, MSc, Special Designer, City of Helsinki, Helsinki, Finland. Katri Vehviläinen-Julkunen, PhD, Professor, Department of Nursing Science, University of Eastern Finland, and Kuopio University Hospital, Kuopio, Finland. Aini Pehkonen, DSc, Professor, Department of Social Sciences, and Marja Härkänen, PhD, Associate Professor, Department of Nursing Science, University of Eastern Finland, Finland Kuopio, Finland. Copyright © 2023 Authors, Vol. 23 No. 2 (Summer/Fall 2023), 409-424, DOI: 10.18060/26488 This work is licensed under a Creative Commons Attribution 4.0 International License. Observed Risks of Client Safety by Social Care Professionals in Finland: Trend Analysis for 2016–2020 Saija Koskiniemi Tiina Syyrilä Mia Mäntymaa Jouko Ranta Minna Säilä Katri Vehviläinen-Julkunen Aini Pehkonen Marja Härkänen Abstract: To promote client safety, Finland’s Social Welfare Act requires social services employees to notify superiors of the observed risks in implementing clients’ social welfare. This study provides the first retrospective trend analysis of reports from a care reporting system (SPro-system) in Finland. Reports (n=1,433) were made by social work employees in the city of Helsinki in Finland, from October 2016 to December 2020. The statistical analysis focused on investigating trends in the reports. Most commonly reporters were practical nurses or other care workers (31.0%, n=444) or social advisors or other advisors of social work (23%, n=329). The total of observed risks or threats increased annually, except in 2019. The content of reports mainly related to a lack of realization of the status and rights of clients (32.5%, n=475) with the consequence for clients being moderate harm (28.3%, n=406). Information and discussion about client safety events (55.1%, n=860) were perceived as the most important ways to prevent the recurrence of such incidences. More empirical research is needed on client safety from the social work perspective. Risks in social care are diverse, but professionals’ observations may help to prevent them. Thus, reporting practices relating to client safety risks should be strongly encouraged, if not mandated. Keywords: Social care, risk, incident reporting system, client safety Voluntary patient safety incident reporting is common practice in most developed health-care systems worldwide (World Health Organization [WHO], 2020b). A similar system is less common in social care and client safety. In Finland, when employees of social care services detect risk or threat in the implementation of clients’ social welfare, the Social Welfare Act (2014) requires them to report observations to superiors. The risk or threat is an undesired event that can affect a client’s social welfare implementation. The obligation to report started on 1 January 2016 and reports can be made notwithstanding confidentiality provisions. The reporter must not be punished for reporting risks or threats (Social Welfare Act, 2014), and the professionals involved should be supported (Ministry of Social Affairs and Health, 2022a). The report’s recipient shall immediately initiate action to remedy the risk or threat thereof (Social Welfare Act, 2014). This reporting obligation applies to all employees of social services; however, clients or relatives cannot report the risks or threats to a similar system. The aim is to introduce a reporting system for clients over the next few years (Ministry of Social Affairs and Health, 2022a). A similar reporting system was introduced in health care in Finland in 2007 to report patient safety incidents on a voluntary basis. In health care, patients or anyone who notices patient safety incidents can report to the system about patient safety incidents in many hospital districts in about:blank ADVANCES IN SOCIAL WORK, Summer/Fall 2023, 23(2) 410 Finland. The aim is to further expand to report possibilities of safety incidents for clients in social services (Ministry of Social Affairs and Health, 2022a). Finland's social welfare and health-care system is funded by the government and implemented by municipalities. Non-urgent social and health-care services are provided in a person’s home municipality; however, urgent services must be provided regardless of the home municipality. After the health and social services reform, the responsibility rests on well-being services counties as of January 2023, in which case funding comes mainly from the government. The private sector also provides social and healthcare services (Ministry of Social Affairs and Health, 2022b). The social protection system includes social security and social welfare. In Finland, everyone who cannot obtain the means necessary for a life of dignity has the right to social security (Constitution of Finland, 1999). Social welfare includes social services, related support services, and other measures that social welfare professionals adopt to promote and maintain the social well-being, functional capacity, safety and inclusion of individuals, families, and communities (Ministry of Social Affairs and Health, 2022b). Social care services are intended to promote clients’ social well-being and functional capacity and prevent, reduce, and eliminate social problems (Social Welfare Act 2014,). Social care includes a wide range of services, from child welfare, family caregivers’ support, family social work, and housing services to substance abuse and mental health services (Social Welfare Act, 2014). The organizations involved in social services are very complex systems (Gibson, 2014; Sicora, 2017). Clients of social care services are of all ages, and the non-urgent need for services is based on assessing the demand for services (Social Welfare Act, 2014). Social care services expenditures accounted for 39% of the overall social protection expenditure in 2020. Social protection is financed by the state, municipalities, employers, insured people, and the returns on social protection funds (Finnish Institute for Health and Welfare, 2020). Improving Client Safety The reporting obligation under the Social Welfare Act (2014) promotes client safety (Ministry of Social Affairs and Health, 2022a). Client safety refers to the principles and functions of persons and organizations acting in social care to ensure the safety of treatments and services, and to protect clients from harm. Client safety in social care signifies the organization, production, and implementation of services so that the client’s physical, psychological, social, or economic safety is not compromised (Ministry of Social Affairs and Health, 2022a). The Social Welfare Act (2014) aims to ensure that the clients’ legal rights are fulfilled. The obligation to report makes it possible to develop the quality of services; however, the reporting obligation also contributes to monitoring the implementation of the client’s legal rights. Responsibility in the detection of risks is central. Detecting risks can prevent harm and facilitate the development of safer practices. Being aware of risks or threats also enables the development of professional skills of social service employees (Sicora, 2017). Individual employees can learn about the risks they have observed by themselves, but all other employees and management can learn only about observed, reported, and shared risks. Therefore, all social service employees have a key role in developing client safety and recognizing this responsibility is essential to every professional in social services. Employees must evaluate clients’ rights and service needs. Implementing a client’s care plan follows the laws (Social Welfare Act, 2014) and ethical guidelines of the field (National Association of Social Workers, 2021). Koskiniemi et al./SOCIAL CARE PROFESSIONALS FINLAND 411 Employees who work with clients are expected to follow the law, principles, and practices that are ethically sustainable. Risks in Social Care Various risks are associated with social care. Risks may be avoidable or unavoidable and may differ in various ways (Gambrill, 2017). The risk or threat in implementing a client’s care plan involves abuse of the client. Professionals must be trained to identify signs and symptoms of abuse and how to report abuse (WHO, 2020a). Victims of all ages are vulnerable to abuse, including physical, mental, sexual, or neglect (Lo et al., 2018; WHO, 2020a). Abuse can also be financial (Johannesen & LoGuidice, 2013; WHO, 2020a) or a combination of different forms of abuse (Lo et al., 2018; WHO, 2014), such as verbal and financial. A client may encounter inappropriate conduct or use of language (Karlsson et al., 2019; Liegghio & Caragata, 2016) which may be why social service employees report the observed risks or threats. When the risk or threat in the implementation of a client’s social welfare is related to abuse, neglect, inappropriate conduct, or use of language, the abuser may be the employee of social service (Myhre et al., 2020), the client (Enosh et al., 2013; Radey & Wilke, 2021; Stroebaek & Korczynski, 2018), other service users (Björne et al., 2021; Myhre et al., 2020) or a person close to the client (Lo et al., 2018; Myhre et al., 2020; Välimäki et al., 2020; Yan, 2014) with whom the client typically has a confidential relationship (WHO, 2015). The abuser can be a child (Attar-Schwartz, 2008) or an elderly person (Stroebaek & Korczynski, 2018), but typically is an adult (Johannesen & LoGuidice, 2013; Liegghio & Caragata, 2016; Lo et al., 2018; Myhre et al., 2020; Radey & Wilke, 2021). The work culture may be harmful and even contribute to abuse (Karlsson et al., 2019). Social care services should be client- oriented, and client relationships must be kept confidential, according to the Status and Rights of Social Welfare Clients (2001). Clients have the right to receive quality services and treatment (Status and Rights of Social Welfare Clients, 2001). The risk or threat thereof may be the failure to fulfil the law. Based on our understanding, similar reporting obligations and systems related to risks or threats in implementing clients’ social welfare do not exist internationally. Most social care reporting systems are for reporting only abuse and neglect (Lo et al., 2018), but in Finland, reported risks under the Social Welfare Act are in many ways related to difficulties in implementing the client’s social care. The obligation to report in Finland covers all social services (Social Welfare Act, 2014), and the observed risks or threats can vary substantially. Internationally, reporting obligations in social care can be applied only to some specific areas, such as the care of people with disabilities (Björne et al., 2021). This study was the first to use the reports to their full extent from the social care reporting system called SPro-system. The SPro-system is a web-based tool for reporting risks or threats in the implementation of clients’ social welfare under the law (Social Welfare Act, 2014). The reporting system innovation originated in the city of Helsinki. The developer and administrator of the SPro-system is the IT company Awanic (Ltd; Awanic, 2022). The city of Helsinki conducts continuous system development work in co-operation with Awanic. This study was conducted for several reasons. First, Finland is one of the Nordic welfare states, and its social services, public and private social care systems, have considerable opportunities to develop and improve services. Second, client safety has been under-researched, and more empirical studies are needed to obtain new knowledge. Third, nationally we do not have a ADVANCES IN SOCIAL WORK, Summer/Fall 2023, 23(2) 412 congruent picture of the fulfilment of clients’ rights, client safety, and the reporting obligation in social services. In addition, policymakers need new knowledge to support decision-making. Thus, this study aimed to contribute knowledge about client safety in social care, such as describing abuses and other cases where clients' safety and rights are jeopardised. Methods Aim of the Study This study aimed to describe the observed risks or threats in the implementation of clients’ social welfare reported by employees of social services in a large urban region of Finland. The research questions were: 1. What types of risks are reported by professionals in social care? 2. What was the pattern of risk reports over time? 3. What kinds of actions have been recommended by professionals to prevent the observed risks or threats in the reports? Design and Setting This study provides a retrospective trend analysis of reports using the SPro-system. The data were obtained from the SPro-system, which is used in social services in a large urban region – the city of Helsinki, Finland. Social service entities are divided into three units in the city of Helsinki: 1) Hospital, rehabilitation, and care services, 2) Family and social services, and 3) Health care and substance abuse services. Hospital, rehabilitation, and care services include, for example, home care, elderly people’s daytime activities and social work, support for informal care, 24-hour service housing, and institutional care for older adults and those who are multimorbid. Family and social services take care of, for example, social and healthcare services for families with children, student health services, and health education for unemployed young adults who are not students. Health and substance abuse services are responsible for organizing, for example, mental health and substance abuse services and psychiatric specialised health care for adults and primary health care. Some of these services include health care services, where the SPro-system is not used. Currently, the SPro- system is used by 615 units (such as wards of organizations) in the city of Helsinki: 280 units of family and social services, 53 units of health care and substance abuse services, and 282 units of hospital, rehabilitation, and care services. However, the organizational structure has changed since the study period and is not reported in more detail in this study. Mostly social care professionals in social services are social workers and social and other advisors. However, Finnish social services, social, and health care professionals collaborate in multi-professional work communities. Social advisors have university of applied sciences or college degrees, while social workers have master’s degrees. Koskiniemi et al./SOCIAL CARE PROFESSIONALS FINLAND 413 Data The data included all reports (n = 1,433) made in the web-based SPro-system from October 2016 to December 2020 by social care professionals. The original dataset contained 17 variables. The data included a structured section: registration number, date of the report, unit of reporter, unit covered by the report, reporter’s occupational group, date and time of the event, risk or threat of risk, event’s day of the week, type of the report, a consequence of the event for the client, a measure to prevent recurrence of the event, and a detailed proposal of measures to prevent recurrence of the event. Reporters classify observed events as either risks or threats, selecting the type of reports from six predefined options. A handler of reports, who is often a unit manager, defines the consequence of the event for the client. Therefore, for example, classifying events as risks or threats results from the reporter’s consideration. Risks are considered situations in which the implementation of the client’s care plan may put them in danger. As an example of risk: A home visit was not carried out because the home care worker was not informed about the client's discharge from the hospital. As an example of threat: A home visit would not have been carried out without a relative who called to home care during discharge from a hospital. In the latter case, the risk did not happen due to some issue that prevented it. The free text was written in four sections: a description of the event, a reporter’s view on remedial measures, a proposal for action following the reported risks or knowledge of why the action was not needed, and a description of the implementation of measures. The handler of reports writes a description of the implementation of measures. In other respects, the social service employee who detected the risk or threat thereof writes the report under the professional’s name. The free text of reports contains detailed descriptions of events and managers’ actions and requires separate in-depth analysis. Therefore, this quantitative study did not include an analysis of the narrative data. Ethics Approval According to the guidelines of the Finnish National Advisory Board on Research Ethics (Finnish National Board on Research Integrity TENK, 2019, 20, the use of existing anonymous (register) data does not require approval from the National Committee of Research Ethics. The study and use of data from the SPro-system was approved by the city of Helsinki. The names of the reporters and all clients’ identification information were removed from the data before the data were assigned to the research group. Data Analysis The data, in Microsoft Excel format, were assigned to the research group in January 2022. The analysis focused on the quantitative contributions of the data. The variable date of the report was reclassified according to year. The event time associated with the report was reclassified as morning (from 6 a.m. to 11.59 a.m.), day (from 12 p.m. to 4.59 p.m.), evening (from 5 p.m. to 9.59 p.m.), or night (from 10 p.m. to 5.59 a.m.). In some reports, the event time was missing. Trends from 2016 to 2020 were analysed. The data were analysed using statistical methods, presented in figures, and described ADVANCES IN SOCIAL WORK, Summer/Fall 2023, 23(2) 414 as frequencies and percentages. Statistical analysis was performed using the R software (version 3.6.1). Results A total of 1,433 reports from the SPro-system covering 336 social service units were analysed. About half of the reports were submitted to hospital, rehabilitation, and care services (48.2 %, n = 690) with nearly a third submitted by practical nurses or care workers (31.0 %, n = 444), and about a quarter by social advisors (23.0 %, n = 329). Occupational groups that submitted the least reports (1.1 %, n = 15) were physicians, students, trainees, and rehabilitation and therapy staff. The reporter’s occupational group was missing from 18 reports. Most of the events occurred in the morning (24.6 %, n = 353) or in the daytime (25.2 %, n = 361; Table 1). Table 1. Background Information of the Reports (n=1,433) Background of the Reports n (%) The division’s units Hospital, rehabilitation, and care services 690 (48.2%) Family and social services 512 (35.7%) Health care and substance abuse services 231 (16.1%) Reporters’ occupations Practical nurses or care workers 444 (31%) Social advisors or other advisors of social work 329 (23%) Social workers 255 (17.8%) Other 185 (12.9%) Registered nurses 151 (10.5%) Public health nurses 36 (2.5%) Unknown 18 (1.2%) Physicians, students, trainees, rehabilitation, or therapy staff 15 (1.1%) Time of the reported event/incident Day 361 (25.2%) Morning 353 (24.6%) Unknown 341 (23.8%) Night 230 (16.1%) Evening 148 (10.3%) Reported risks and threats of social care over the period 2016-2020 All reports must be classified in the SPro-system as either a risk or a threat of risk in the implementation of clients’ care plans. Observed risks accounted for 87.2% (n = 1,257) of the reports and 12.3 % (n = 176) were threats of risks. Reports of risks clearly increased over the five-year period (Figure 1). Koskiniemi et al./SOCIAL CARE PROFESSIONALS FINLAND 415 Figure 1. Development of Observed Risks and Threats of Risks in Client Safety in Social Care in the SPro-System for the Period 2016–2020 The type of report was indicated in 99.4 % (n = 1,424) of the reports. The reporter chose the type of report from six options: 1. Inappropriate confronting/insulting the client with words (4.9 %, n = 71); 2. Actions harmful to the client owing to the work culture (6.6 %, n = 97); 3. Abuse of the client (12.3 %, n = 180); 4. Lack of client safety (26.0 %, n = 380); 5. Lack of realization of the status and rights of clients (32.5 %, n = 475); and 6. Others (17.7 %, n = 259; Figure 2). A maximum of three different types of reports can be chosen in one report. In total, 1,424 reports mentioned 1,462 types of reports. In the study period, the type of report “Lack of realisation of the status and rights of client” showed the highest increase. Figure 2. The Content of Reports on Client Safety for the Period 2016–2020 2016 n = 23 2017 n = 163 2018 n = 415 2019 n = 384 2020 n = 448 Risks (n = 1,257) 21 145 368 343 380 Threats of risk (n = 176) 2 18 47 41 68 0 50 100 150 200 250 300 350 400 2016 n = 23 2017 n = 166 2018 n = 427 2019 n = 387 2020 n = 459 Inappropriate confronting/insulting the client with words (n = 71) 5 9 21 18 18 Action harmful to the client due by working culture (n = 97) 1 7 27 28 34 Abuse of the client (n = 180) 5 28 58 45 44 Other (n = 259) 4 31 91 68 65 Lack of client safety (n = 380) 2 51 97 112 118 Lack of realisation of the status and rights of client (n = 475) 6 40 133 116 180 0 50 100 150 200 250 300 350 400 ADVANCES IN SOCIAL WORK, Summer/Fall 2023, 23(2) 416 Consequences of events for the client were assessed on the following scale: no harm (20.7 %, n = 296), mild (24.5 %, n = 351), moderate (28.3 %, n = 409), and serious harm (7.9 %, n = 113;)Figure 3). Information on the consequences of events for the client was missing in 18.6 % (n = 267) of the reports. The proportion of moderate harm was the highest among all types of harm in the period 2018–2020. Figure 3. Consequences of the Event for the Client Actions that were recommended to prevent the recurrence of risks All reports (n = 1,433) included suggestions to prevent the recurrence of the event. Reporters chose one or more of four structured options: 1. No measures (8.2 %, n = 117); 2. Inform/discuss what happened (55.1 %, n = 860); 3. A development action is planned concerning the event (16.5 %, n = 257); and 4. Notify the upper management (28.4 %, n = 443; Figure 4). Event recurrence prevention was not perceived necessary in 8.2 % (n = 117) of the reports. The most necessary measure was to assess the information and discuss what had happened. Figure 4. Proposals to Prevent the Recurrence of the Event 2016 n = 19 2017 n = 136 2018 n = 347 2019 n = 308 2020 n = 356 No harm (n = 296) 2 47 78 73 96 Mild harm (n = 351) 11 50 101 94 95 Moderate harm (n = 406) 4 29 136 113 124 Serious harm (n = 113) 2 10 32 28 41 0 50 100 150 200 250 300 350 400 2016 n = 28 2017 n = 199 2018 n = 496 2019 n = 443 2020 n = 511 No measures (n = 117) 0 19 29 25 44 Inform / discuss what happened (n = 860) 19 100 247 245 249 A development action is planned concerning (n = 257) 2 33 79 62 81 Notify to the upper management (n = 443) 7 47 141 111 137 0 50 100 150 200 250 300 350 400 Koskiniemi et al./SOCIAL CARE PROFESSIONALS FINLAND 417 Nearly three-quarters (74.2 %; n = 1,063) of the reports included detailed proposals for prevention of recurring events (Table 2). A report could have more than one detailed proposal. The total number of detailed proposals in the 1,063 reports was 1,462. More than a third (37.7 %) of the detailed proposals suggested consideration of the case within the unit. Table 2. Breakdown of the 1,462 Detailed Proposals of a Measure to Prevent Recurrence of the Event (n= 1,063 Reports) Detailed proposals for events’ recurrence prevention n (%) Handling within the unit (for example, departmental or team meetings) 551 (37.7%) Discussion or negotiation with other parties involved in the process 179 (12.2%) A serious or recurring problem 155 (10.6%) Handling outside the unit 150 (10.3%) Mode of operation and procedures 119 (8.1%) Other reason 74 (5.1%) Support is needed to deal with the case 73 (5%) Otherwise anomalous situation 58 (4%) Communication and contact 40 (2.7%) Other development action 29 (2%) Information technology and technology systems, appliances, & equipment 12 (0.8%) Education 12 (0.8%) Management 10 (0.7%) Total 1462 (100%) Discussion In Finland, we know that the distribution of health and social welfare services and access to services are relatively good at the macro level (Pulkki et al., 2015; Vaarama et al., 2014; Valkonen et al., 2014). Even though most clients feel that the accessibility of social services is at a good level, some clients repeatedly reported that client payments were too expensive, services could not be accessed quickly enough, or there were other difficulties with the accessibility of services (Ilmarinen et al., 2016). Finnish municipalities organize social services within the legal framework imposed by the state. This causes regional variation, for example, in client payments and accessibility of services. Abundant research exists on various vulnerable groups and their welfare problems, as well as on public sector interventions to alleviate these problems. However, the client safety risks that employees observe or face in social care are not fully understood. The relative importance of these mechanisms is unknown. However, the dynamic nature of the interaction between individual needs and the welfare system is not always recognized when reforms are planned (Tammelin & Mänttäri-van der Kuip, 2022). Client safety is essential in strategic socio-political thinking in Finland (Ministry of Social Affairs and Health, 2022a). However, tension exists between the different elements of client safety. For example, from an ethical viewpoint, the autonomy of clients contradicts the goals of the policy on ageing. Identifying risks and threats thereof should be understood as part of employee professionalism. Both the employee and the work community can learn to recognise risks, which leads to the possibility of preventing as many risks as possible. Social service employees must identify their responsibilities in promoting client safety so that all observed risks will be reported. Work communities’ support for reporting the ADVANCES IN SOCIAL WORK, Summer/Fall 2023, 23(2) 418 observed risks is essential. The previous study (Tiitinen & Silén, 2016) shows that the implementation of risk reporting is not adequately discussed. In addition, social service employees have noticed varying attitudes toward professionals who made the reports (Tiitinen & Silén, 2016). Assigning blame is not included in positive safety culture, whereas management should support and commit to safety. Observing and reporting risks is an entity that extends to many dimensions of safety culture (Churruca et al., 2021). Open communication and trust are parts of good safety culture. Enhancing safety culture positively affects patient safety outcomes (O’Donovan et al., 2019). The reporting process must be seen as a whole, and the safety culture as an integral part of reducing risk of client harm. It is necessary to consider safety culture to improve the implementation of the reporting obligation because even reporting obligation under the law is not alone enough to resolve risks in social care. If we do not pay attention to safety culture, reports might not be handled in a way that improves client safety and supports professionals’ willingness to report in the future, or reports are not made at all because professionals do not want to expose themselves to blaming. This study aimed to describe the observed risks or threats in the implementation of clients’ social welfare reported by employees of social services in a large urban region of Finland. This is the first study to use data collected to its full extent from the SPro- system, which has been used in social services in the city of Helsinki since 2016. This study describes trends in reports from the introduction of the SPro-system until the end of 2020. Based on our understanding, we did not find a similar comprehensive social service reporting system related to observed risks or threats in implementing clients’ social welfare. Internationally, most social care reporting systems report only abuse and neglect (Lo et al., 2018). As this study’s findings show, collecting only reports related to abuses is not enough to get knowledge of risks in social care. In addition, internationally social care professionals have reporting obligations that apply only to a specific area of social care, such as care of the disabled (Björne et al., 2021). In the city of Helsinki, the SPro-system is in use in each social service unit. Reporting systems are often organization-specific and are not part of an official, nationally coordinated system (WHO, 2020b). The SPro-system is currently organization specific and not widely used in Finland but has the potential to expand nationally. Focusing on the knowledge gained through practical work is essential in social and healthcare work. Practical knowledge, that is, implicit knowledge, forms a large part of the knowledge applied by employees (Evans et al., 2010; Fook et al., 2000). The implicitness of practical knowledge is focused on practical wisdom, in which employees transfer knowledge gained through many individual client cases from one problem to another. One concern is that a large share of the practical wisdom remains undocumented. Thus, by using reporting systems and analyzing the data generated, we can critically examine for whom and from whose perspective the knowledge is produced and collected. Who gathers knowledge, and how and for what purpose is the gathered knowledge used? This study gives an overall view of the Finnish reporting system. The results contribute to discussion of the SPro-system’s content compared to other systems used internationally and how the content of the SPro-system meets the need for knowledge in practical social care. Practical nurses or care workers made most of the reports. This result is congruent with a previous study conducted in the home care context where data were based on the patient safety incident reporting system called HaiPro (Kivimäki et al., 2022). HaiPro and SPro were both developed by an IT company named Awanic (Ltd), and Koskiniemi et al./SOCIAL CARE PROFESSIONALS FINLAND 419 thus have similar structures (Awanic, 2022). All reports in the SPro and HaiPro- systems are classified as actual or near-miss events, which, in this study, are called observed risks or threats thereof. The proportion of observed risks was greater in this study than that in studies based on the HaiPro-system (Kivimäki et al., 2022). Most of the events occurred in the morning and during the day, whereas in a previous study most patient safety incidents in specialised care settings occurred at night (Kinnunen- Luovi et al., 2014). In the first years after the introduction of the SPro-system, reports of observed risks or threats thereof in social welfare implementation increased. In the last three years, the number of reports remained the same with a slight decrease in the fourth year. Several social welfare units produced no reports during the study period. Social care is a complex field (Gibson, 2014; Sicora, 2017) and the detection of risks should be constant because risks are a constant reality (Sicora, 2017), and the law requires their observation and reporting (Social Welfare Act, 2014). This study shows that reporting systems like the SPro are necessary even if not all risks are reported. The findings of this study make it possible to realize the extent and types of risk in social care. However, underreporting remains a challenge. Further investigation may reveal if there are some system-related reasons for underreporting. Based on our knowledge, front-line professionals have not been involved in developing the SPro-system. Since professionals are key elements of the successful implementation of reporting systems in social care, it would be helpful if they were involved in the development processes of systems. The SPro-system enables accurate data collection of observed risks or threats in the implementation of clients’ care plans which employees of social services are obligated to report. In social and health care, it is important to invest in reporting systems; however, data collection should lead to real utilization of reports (Macrae, 2015). In Finland, the resources for client safety development need to be raised to the same level as the resources for patient safety development (Ministry of Social Affairs and Health, 2022a). In this study, more than one in ten reported events represented a serious or recurring problem, and approximately 80% caused harm to the client. In the home care context, one-third of reported incidents caused harm to the patient (Kivimäki et al., 2022). In the SPro reports, the harm was most often estimated as moderate, whereas in incident reports from healthcare, the harm is most often mild or no harm (Härkänen et al., 2020). Over 90% of the reports suggested actions to prevent the recurrence of harmful events. The measures taken were not investigated in this study; nevertheless, examining actions taken from the data is possible. At best, after reporting and analysis of reports, all corresponding units would check their practices (Macrae, 2015); however, patient safety incident reports (Liukka et al., 2019), as well as incident reports in the social care context (Björne et al., 2021) rarely lead to recommendations. Social service employees who have reported observed risks or threats under the reporting obligation have noticed the same: reporting rarely leads to visible changes (Tiitinen & Silén, 2016). Tiitinen and Silén (2016) have noticed that organizations are not defined whose responsibility is to lead change processes related to risks observed and reported by professionals. Root causes of risks can be deep in the units’ working culture and changing them can seem hopeless in units (Tiitinen & Silén, 2016). ADVANCES IN SOCIAL WORK, Summer/Fall 2023, 23(2) 420 Strengths and Limitations The strength of this study lies in the overall sampling (n = 1,433) of reports in the SPro-system for the period 2016–2020. Nevertheless, it has some limitations. The data were collected from one city; hence, the results cannot be generalized to other areas. Although the socio-cultural context of our study is Finland, the research findings can still inform systems in other cultures. Additionally, self-reported data have some well- known limitations, such as the fact that the data are not collected for research purposes. In addition, professionals classify events based on their observations and the training they have for reporting. For that reason, it is possible that different professionals classify the same event in a different way. This study did not include other explanatory variables for client safety indicators. The results have important implications for future client safety research. It is necessary to emphasize that risk is a threat to client safety. Implications for Social Work Practice Employees are responsible for the quality of work with clients and families, their work community, and co-operation networks. Still, it has remained unclear how client safety is realized in social work settings. This study provides knowledge of risks from employees’ perspectives and fulfilment of reporting obligations in social care. This study indicates how implementation of reporting obligations based on the law has not been successful in all units in the city of Helsinki. Reporting volumes describe that in the units or settings where reporting was incorporated as a part of work, the frequency of reporting increased strongly in the first three years. More information is needed about units where no report has been made during the reporting obligation period under the Social Welfare Act. Reasons behind non-reporting must be identified and the necessary steps to promote reporting in all settings. Most likely cultures of work communities have a central position (Sicora, 2018). In addition, the content of the reports requires further study: what kind of events occur and how can they be prevented? This study provides that there are reports of harmful work culture, abuse and inappropriate confrontations with clients in social care. Professionals’ observations of abuse are not unprecedented. Previous studies have noticed that over half of care workers (Gil & Capelas, 2022) and employees of institutionalised care (Yon et al., 2019) had seen abuse or neglect in elder care during the previous 12 months. Risks of client abuse exists also in social services in Finland and the situation must be taken seriously. It is essential to make sure that professionals are trained to identify warning signs of abuse as well as how to report abuse (WHO, 2020a). Finally, it would be important to show professionals that reporting matters and can lead to real concrete changes. This could increase reporting activity. For that reason, superiors’ actions taken after receiving reports need to be investigate. How effective are the measures being used and do the measures demonstrate the importance of reporting? These issues must be investigated in any units where reports are made. Conclusion Based on the reports examined in this study, the observed risks or threats in the implementation of clients’ social care plans by social services employees have mainly Koskiniemi et al./SOCIAL CARE PROFESSIONALS FINLAND 421 increased annually. The broad reporting system covering all social service units enables comprehensive client safety research, but currently only at the organizational level. Risks in social care are diverse. Even if a risk is exposed just once in a unit, it may be part of a larger problem across the organization; thus, reporting all observed risks is critical. The importance of reporting should be realized from the perspectives of both professional growth and service development. In practice, the development of reporting could be the unit's theme for the year and include jointly set goals. The results of the strong reporting system and culture can be seen in the increase in the number of reports, but also in the ethical development of the unit's operating culture, the better realization of customers' rights, the creation of a positive development atmosphere (i.e., continuous learning, and in the growth of professional responsibility). More information about units where no report has been made during the reporting obligation period under the Social Welfare Act is needed. More empirical research is needed on client safety from the perspective of social workers, especially how to define it more clearly and what it means in practice. In addition, it would be essential to investigate what concrete actions were taken after reporting. References Attar-Schwartz, S. (2008). Emotional, behavioral and social problems among Israeli children in residential care: A multi-level analysis. Children and Youth Services Review, 30(2), 229-248. Awanic. (2022). Products and services. Björne, Deveau, R., & Nylander, L. (2021). Passing laws is not enough to change staff practice: The case of legally mandated “incident” reporting in Sweden. Journal of Intellectual & Developmental Disability, 46(2), 186-196. Churruca, K., Ellis, L. A., Pomare, C., Hogden, A., Bierbaum, M., Long, J. C., Olekalns, A., & Braithwaite, J. (2021). Dimensions of safety culture: A systematic review of quantitative, qualitative and mixed methods for assessing safety culture in hospitals. BMJ Open, 11(7), 1-13. Constitution of Finland. (1999). 11.6.1999/731. Enosh, Tzafrir, S. S., & Gur, A. (2013). Client aggression toward social workers and social services in Israel - A qualitative analysis. Journal of Interpersonal Violence, 28(6), 1123-1142. Evans, T., Hardy, M., & Shaw, I. (2010). Evidence and knowledge for practice. Polity. Finnish Institute for Health and Welfare. (2020). Social protection expenditure and financing in 2020. Finnish National Board on Research Integrity TENK. (2019). The ethical principles of research with human participants and ethical review in the human sciences in Finland. Finnish National Board on Research Integrity TENK publications 3/2019. Fook, J., Ryan, M., & Hawkins, L. (2000). Professional expertise: Practice, theory and education for working in uncertainty. Whiting & Birch Ltd. https://doi.org/10.1016/j.childyouth.2007.09.009 https://doi.org/10.1016/j.childyouth.2007.09.009 https://awanic.fi/eng/products-and-services/#haipro https://doi.org/10.3109/13668250.2021.1873751 https://doi.org/10.3109/13668250.2021.1873751 https://doi.org/10.3109/13668250.2021.1873751 https://doi.org/10.1136/bmjopen-2020-043982 https://doi.org/10.1136/bmjopen-2020-043982 https://doi.org/10.1136/bmjopen-2020-043982 https://www.finlex.fi/fi/laki/kaannokset/1999/en19990731.pdf https://doi.org/10.1177/0886260512468230 https://doi.org/10.1177/0886260512468230 https://thl.fi/en/web/thlfi-en/statistics-and-data/statistics-by-topic/social-and-%20health-care-resources/social-protection-expenditure-and-financing https://thl.fi/en/web/thlfi-en/statistics-and-data/statistics-by-topic/social-and-%20health-care-resources/social-protection-expenditure-and-financing https://tenk.fi/sites/default/files/2021-1/Ethical_review_in_human_sciences_2020.pdf https://tenk.fi/sites/default/files/2021-1/Ethical_review_in_human_sciences_2020.pdf https://tenk.fi/sites/default/files/2021-1/Ethical_review_in_human_sciences_2020.pdf ADVANCES IN SOCIAL WORK, Summer/Fall 2023, 23(2) 422 Gambrill, E. (2017). Avoidable ignorance and the ethics of risk in child welfare. Journal of Social Work Practice, 31(4), 379-393. Gibson, M. (2014). Social worker shame in child and family social work: Inadequacy, failure, and the struggle to practise humanely. Journal of Social Work Practice, 28(4), 417-431. Gil, A. P., & Capelas, M. L. (2022). Elder abuse and neglect in nursing homes as a reciprocal process: The view from the perspective of care workers.  Journal of Adult Protection, 24(1), 22-42. Härkänen M., Murrells T., Rafferty A. M., Franklin B. D., & Vehviläinen-Julkunen, K. (2020). Factors contributing to reported medication administration incidents in patients’ homes - A text mining analysis. Journal of Advanced Nursing 76(12), 3573-3583. Ilmarinen, K., Aalto, A-M., & Muuri, A. (2016). Sosiaalipalvelut väestön ja asiakkaiden arvioimana. Suomen sosiaalinen tila 1/2016. Finnish institute for health and welfare. Johannesen, M., & LoGuidice, D. (2013). Elder abuse: A systematic review of risk factors in community-dwelling elder. Age and Ageing, 42(3), 292-298. Karlsson, N. D., Markkanen, P. K., Kriebel, D., Gore, R. J., Galligan, C. J., Sama, S. R., & Quinn, M. M. (2019). Home care aides’ experiences of verbal abuse: A survey of characteristics and risk factors. Occupational and Environmental Medicine (London, England), 76(7), 448-454. Kinnunen-Luovi, K., Saarnio, R., & Isola, A. (2014). Safety incidents involving confused and forgetful older patients in a specialised care setting - analysis of the safety incidents reported to the HaiPro reporting system. Journal of Clinical Nursing, 23(17-18), 2442-2450. Kivimäki, T., Stolt, M., Katajisto, J., Charalambous, A., & Suhonen, R. (2022). National registry-based data of adverse events in Finnish long-term professional homecare in 2009-2019. Journal of Clinical Nursing, 00, 1-10. Liegghio, M., & Caragata, L. (2016). Why are you talking to me like I`m stupid?: The micro- aggressions committed within the social welfare system against lone mothers. Affilia, 31(1), 7-23. Liukka, M., Hupli, M., & Turunen, H. (2019). Problems with incident reporting: Reports lead rarely to recommendations. Journal of Clinical Nursing, 28(9-10), 1607-1613. Lo, C. K.-M., Ho, F. K.-W., Chan, K. L., Wong, W. H.-S., Wong, R. S.-M., Chow, C.-B., Tsang, A. M.-C., Tso, W. W.-Y., & Ip, P. (2018). Linking healthcare and social service databases to study the epidemiology of child maltreatment and associated health problems: Hong Kong's experience. The Journal of Pediatrics, 202, 291-299. Macrae, C. (2015). The problem with incident reporting. BMJ Quality & Safety, 25(2), 71-75. Ministry of Social Affairs and Health. (2022a). The client and patient safety strategy and implementation plan 2022-2026. https://doi.org/10.1080/02650533.2017.1394824 https://doi.org/10.1080/02650533.2017.1394824 https://doi.org/10.1080/02650533.2014.913237 https://doi.org/10.1080/02650533.2014.913237 https://doi.org/10.1108/JAP-06-2021-0021 https://doi.org/10.1108/JAP-06-2021-0021 https://doi.org/10.1111/jan.14532 https://doi.org/10.1111/jan.14532 https://urn.fi/URN:ISBN:978-952-302-674-2 https://urn.fi/URN:ISBN:978-952-302-674-2 https://doi.org/10.1093/ageing/afs195 https://doi.org/10.1093/ageing/afs195 https://doi.org/10.1136/oemed-2018-105604 https://doi.org/10.1136/oemed-2018-105604 https://doi.org/10.1111/jocn.12364 https://doi.org/10.1111/jocn.12364 https://doi.org/10.1111/jocn.12364 https://doi.org/10.1111/jocn.16312 https://doi.org/10.1111/jocn.16312 https://doi.org/10.1177/0886109915592667 https://doi.org/10.1177/0886109915592667 https://doi.org/10.1177/0886109915592667 https://doi.org/10.1111/jocn.14765 https://doi.org/10.1111/jocn.14765 https://doi.org/10.1016/j.jpeds.2018.06.033 https://doi.org/10.1016/j.jpeds.2018.06.033 https://doi.org/10.1016/j.jpeds.2018.06.033 https://doi.org/10.1136/bmjqs-2015-004732 http://urn.fi/URN:ISBN:978-952-00-8464-6 http://urn.fi/URN:ISBN:978-952-00-8464-6 Koskiniemi et al./SOCIAL CARE PROFESSIONALS FINLAND 423 Ministry of Social Affairs and Health. (2022b). Social and health services. Myhre, J., Saga, S., Malmedal, W., Ostaszkiewicz, J., & Nakrem, S. (2020). Elder abuse and neglect: An overlooked patient safety issue. A focus group study of nursing home leaders’ perceptions of elder abuse and neglect. BMC Health Services Research, 20(1), 1-14. National Association of Social Workers. (2021). Highlighted revision to the code of ethics. O’Donovan, R., Ward, M., De Brún, A., & McAuliffe, E. (2019). Safety culture in health care teams: A narrative review of the literature. Journal of Nursing Management, 27(5), 871-883. Pulkki, J., Jylhä, M., Forma, L., Aaltonen, M., Raitanen, J., & Rissanen, P. (2015). Long-term care use among old people in their last 2 years of life: variations across Finland. Health & Social Care in the Community, 24(4), 439-449. Radey, M., & Wilke, D. J. (2021). Client-perpetrated violence among frontline child welfare workers. Journal of Interpersonal Violence, 36(11-12), NP6260-NP6280. Sicora, A. (2017). Reflective practice, risk and mistakes in social work. Journal of Social Work Practice, 31(4), 491-502. Sicora, A. (2018). Learning from mistakes in social work. European Journal of Social Work, 21(5), 684-696. Social Welfare Act, 5:48.2-4 §, 30.12.2014/1301. (n.d). Status and Rights of Social Welfare Clients. (2001). 1.1.2001/812. Stroebaek, P. S., & Korczynski, M. (2018). Client abuse to public welfare workers: Theoretical framework and critical incident case study. Sociology, 52(4), 762- 777. Tammelin, M., & Mänttäri-van der Kuip, M. (2022). Policy alienation in frontline social work: A study of social workers’ responses to a major anticipated social and health care reform in Finland. Ethics and Social Welfare, 16(1), 19-35. Tiitinen, L., & Silén, M. (2016). Sosiaalialan epäkohdat ja niiden käsittely - kyselyraportti. (Social care risks and how to deal with them - survey report). University of Lapland. Vaarama, M., Karvonen, S., Kestilä, L., Moisio, P., & Muuri, A. (Eds.). (2014). Suomalaisten hyvinvointi (The wellbeing among Finnish people). Institute for Health and Welfare. Juvenes Print - Suomen Yliopistopaino Oy. Valkonen, T., Vihriälä, V., & Albæk, K. (2014). Nordic model: Challenged but capable of reform. Nordic Council of Ministers. Välimäki, T., Mäki-Petäjä-Leinonen, A., & Vaismoradi, M. (2020). Abuse in the caregiving relationship between older people with memory disorders and family caregivers: A systematic review. Journal of Advanced Nursing, 76(8), 1977- 1987. World Health Organization [WHO]. (2014). Global status report on violence prevention 2014. https://stm.fi/en/social-and-health-services https://doi.org/10.1186/s12913-020-5047-4 https://doi.org/10.1186/s12913-020-5047-4 https://doi.org/10.1186/s12913-020-5047-4 https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Highlighted-Revisions-%20to-the-Code-of-Ethics https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Highlighted-Revisions-%20to-the-Code-of-Ethics https://doi.org/10.1111/jonm.12740 https://doi.org/10.1111/jonm.12740 https://doi.org/10.1111/hsc.12224 https://doi.org/10.1111/hsc.12224 https://doi.org/10.1177/0886260518812792 https://doi.org/10.1177/0886260518812792 https://doi.org/10.1080/02650533.2017.1394823 https://doi.org/10.1080/13691457.2017.1320980 https://finlex.fi/fi/laki/kaannokset/1982/en19820710_20140491.pdf https://julkaisut.valtioneuvosto.fi/bitstream/handle/10024/70035/Es200101eng.pdf https://doi.org/10.1177/0038038516672626 https://doi.org/10.1177/0038038516672626 https://doi.org/10.1080/17496535.2021.1977836 https://doi.org/10.1080/17496535.2021.1977836 https://doi.org/10.1080/17496535.2021.1977836 https://www.luc.fi/loader.aspx?id=46137c9e-60d5-4576-9696-f78c06e5f8d9 https://www.luc.fi/loader.aspx?id=46137c9e-60d5-4576-9696-f78c06e5f8d9 http://norden.diva-portal.org/smash/get/diva2:715939/FULLTEXT02.pdf http://norden.diva-portal.org/smash/get/diva2:715939/FULLTEXT02.pdf https://doi.org.ezproxy.uef.fi:2443/10.1111/jan.14397 https://doi.org.ezproxy.uef.fi:2443/10.1111/jan.14397 https://doi.org.ezproxy.uef.fi:2443/10.1111/jan.14397 https://apps.who.int/iris/rest/bitstreams/649376/retrieve https://apps.who.int/iris/rest/bitstreams/649376/retrieve ADVANCES IN SOCIAL WORK, Summer/Fall 2023, 23(2) 424 WHO. (2015). World report on ageing and health. WHO. (2020a). Addressing violence against children, women and older people during the Covid-19 pandemic: Key actions. WHO. (2020b). Patient safety incident reporting and learning systems: Technical report and guidance. Yan, E. (2014). Abuse of older persons with dementia by family caregivers: Results of a 6-month prospective study in Hong Kong. International Journal of Geriatric Psychiatry, 29(10), 1018-1027. Yon, Y., Ramiro-Gonzalez, M., Mikton, C. R., Huber, M., & Sethi, D. (2019). The prevalence of elder abuse in institutional settings: A systematic review and meta- analysis. European Journal of Public Health, 29(1), 58-67. Author note: Address correspondence to Marja Härkänen, Department of Nursing Science, University of Eastern Finland, Yliopistonranta 1 c, 70210 Kuopio, Finland. Phone: +358 40 355 2614. Email: marja.harkanen@uef.fi Acknowledgements: The authors thank the funding of The Finnish Nursing Education Foundation. We also thank the city of Helsinki for the research idea and the access to the data. https://apps.who.int/iris/rest/bitstreams/835463/retrieve https://apps.who.int/iris/rest/bitstreams/1282412/retrieve https://apps.who.int/iris/rest/bitstreams/1282412/retrieve https://apps.who.int/iris/rest/bitstreams/1303416/retrieve https://apps.who.int/iris/rest/bitstreams/1303416/retrieve https://doi-org.ezproxy.uef.fi:2443/10.1002/gps.4092 https://doi-org.ezproxy.uef.fi:2443/10.1002/gps.4092 https://doi.org/10.1093/eurpub/cky093 https://doi.org/10.1093/eurpub/cky093 https://doi.org/10.1093/eurpub/cky093 mailto:marja.harkanen@uef.fi