Saturday, 22 February 2014

Human Factors and Child Protection 1: Loss of Situation Awareness

This is the first in a series of posts looking at how knowledge of human factors can inform safer working in child protection. It concerns the important concept of situation awareness.

By situation awareness we mean the ability to know, through attention and perception, what is happening in a particular environment. Having situation awareness means having a true perception and a true interpretation of the environment in which you are working.

In the old days one way in which pilots used to lose situation awareness was by making navigational errors which meant that they were not were they thought they were. Nowadays, with satellite navigation, loss of situation awareness on the flight deck is more likely to arise as a result of misinterpreting computerised displays or being by being overwhelmed by too much information.

Doctors can lose situation awareness by misinterpreting symptoms, ambiguous test results or by clinging to a false diagnosis. All sorts of professionals can be distracted by irrelevant or misleading information.

In child protection, loss of situation awareness often involves failing to perceive correctly the child’s situation, the family’s circumstances or the role and involvement of other agencies and professionals. Professionals can be 'led up the garden path' by manipulative families or have their attention misdirected to the wrong issues. Sometimes professionals become so familiar with a family's circumstances that they fail to notice subtle, but important changes. Sometimes they are just deceived.

Distraction can result from battling bureaucracy or trying to obtain resources. Sometimes parents add to distraction by creating issues and problems.

Many of the most well known child protection tragedies have involved loss of situation awareness on the part of the professionals involved. Victoria ClimbiƩ's social worker did not know the child's real name, thought that her great aunt was her mother and generally saw Victoria's carers as being needy rather than cruel. In the case of Baby Peter Connelly, professionals did not know that two men were living at the child's home. Mother hid bruising from the social worker by smearing the child's face with chocolate. There was a misperception that mother needed support and was basically caring. In the case of Khyra Ishaq mother succeeded in distracting professionals by making accusations of racism against them. In the recent case of Daniel Pelka school staff accepted mother's account that Daniel was suffering from an eating disorder, when in fact he was being starved.

An important cause of loss of situation awareness in child protection is confirmation bias. This term [1] refers to the phenomenon of selectively seeking evidence that confirms what we already think. We construct a hypothesis and confirm it, but we bend the facts to fit the theory. At the same time we ignore disconfirming evidence.

We all have this tendency. Receiving negative feedback is often not very pleasant. We all prefer to receive positive feedback. And we want to have faith in our own judgements. So having our initial assessments confirmed as being correct is satisfying. We were right all along.

Eileen Munro, in a study of 45 reports of inquiries, found that reluctance to revise initial assessments was a frequent cause of disaster in child protection. She writes:

“ … social workers are slow to revise their judgements…. misjudgements about clients that may have been unavoidable on the limited knowledge available when they were made continue to be accepted despite a growing body of evidence against them.”[2]

There are some important clues to loss of situation awareness. One is where there is a lot of professional disagreement. That suggests that different people are assessing the situation differently or are in possession of different information. Rather than trying to defend corners, the correct response is to try to understand why others' perceptions vary.

Feelings of information overload or disorientation are often clues to loss of situation awareness. Rather than being seen as individual professional failings, these should be seen as the tell-tale signs of having lost a true perception of the situation.

Perhaps the most important response to confirmation bias is to recognise that it can and will happen and that we have to be prepared to accept that an assessment may be wrong. As Munro concludes: “To change your mind in the light of new information is a sign of good practice, a sign of strength not weakness.” [3]

A fresh pair of eyes focused on a case from time to time is a good, but not infallible, safeguard against loss of situation awareness. The reviewer should be tasked to explore and challenge the status quo and workers need to be trained and encouraged to welcome challenge constructively. It may be that the dominant hypothesis passes the test and stands its ground. On the other hand testing it may reveal important weaknesses or omissions.

Of course time and resources need to be created for this type of review to take place.

There are also defences against distraction. A simple precaution is to make sure that when there are lots of distracting issues at least one person's attention remains focused exclusively on the needs and circumstances of the child.


[1] Wason, Peter C. (1960), "On the failure to eliminate hypotheses in a conceptual task", Quarterly Journal of Experimental Psychology, 12 (3): 129–140
[2] Munro, E. (1996) “Avoidable and unavoidable mistakes in child protection work”, British Journal of Social Work 26 (6) pp. 793-808
[3] ibid.