Tuesday, 29 January 2013

Decision-making: a key skill for child protection

Decision-making follows on from situation awareness. Obviously if we have misjudged a situation then our decision-making, however logical, will not result in a good safe service. So step one in any decision-making process demands an assessment of the situation.

But even if we have correctly assessed the situation things can still go wrong.  Plenty of accidents occur when professionals have correctly assessed what is happening but then select the wrong course of action.

Few would doubt that good decision-making is central to effective child protection work. And decision-making permeates the task of making a child safe. Decisions have to be made about whether to refer a particular case, whether to accept the referral, whether emergency protection action is required, whether a child should be made subject to a child protection plan, what services should be offered, whether care proceedings should be started, whether a child should be discharged from hospital, whether parents should be made subject to criminal proceedings: the list is long, if not endless.

Surprisingly there is not a vast literature about decision-making in child protection. And some rather naive assumptions have been made. One such is the idea that procedures can cover most child protection decision-making situations. On the contrary, while there is some scope for rule-based decisions in child protection, the toughest decisions are usually dependent on professional experience and frequently require creative imagination if they are to be effective. Children's best interests are not usually found in a flow-chart.

Sadly voluminous procedural manuals - which I have frequently protested about in this blog - usually result in decision-making becoming bureaucratic and cumbersome with no obvious benefits for the child.  It is wrong to pretend that complex decision-making can be reduced to simple discrete steps when this is manifestly not the case.

The psychological literature on decision-making is comprehensive and I have space here only to make a couple of points that I hope will generally be helpful.  The first is that decisions are often risky and should never be rushed unless the nature of the situation makes this unavoidable. The second is that decisions should always be reviewed before irretrievable actions are taken.  Thirdly decisions always need to be communicated to colleagues in a clear and timely way.

Some airlines use acronyms to help staff remember the stages in decision-making. The British Airways version is DODAR - diagnosis, options, decision, assign tasks, review. Although these sound simple, when applied properly they can be a real support to professionals who are making decisions in urgent and stressful situations. In particular they help ensure that no stages are overlooked.

I believe that child protection professionals can learn to be better decision-makers by examining what is known about decision-making in other fields. But the decision-making context is particularly complex in child protection, not least because it often involves several agencies both making agency-specific decisions and also participating in interagency decision-making.

Thus in the case of Baby Peter the police took a decision not to prosecute the mother. This appears to have influenced the local authority's decision not to start care proceedings. Taken together the two decisions appear to have had the overall impact of lowering the priority of the case across a range of agencies.

Sadly there is little research in this fascinating area of child protection.  I would warmly welcome a major study looking at the opportunities and challenges of decision-making in child protection, especially with a view to examining critical incidents from the perspective of organisational psychology.  Clearly there is much that could be learned from examining whether group-based decision-making processes, such as a child protection conference placing a child on a child protection plan, can be suboptimal because of the effects of 'group think'. Other danger areas might concern what Argyris [1] has called 'skilled incompetence', a phenomenon in which managers of large commercial concerns were observed playing clever games by moderating and weakening their criticisms of plans devised by chief executives. They did not want to be seen as 'yes people' but neither did they wish to dent the ego of their boss too much! Do similar kinds of games take place within and between child protection agencies?

[1] Argyris, C. "Skilled Incompetence" Harvard Business Review, 1 September 1986.

Friday, 25 January 2013

Situation Awareness - a key skill for Child Protection

Situation awareness is all about knowing what is happening in the environment in which you are working. For child protection professionals this includes the child's world, her/his home and family environment, and the network of helping services around the child. Loss of situation awareness can result in serious negative outcomes. For pilots examples are often given of situations in which navigational errors have resulted in mistaken beliefs about where the aircraft is.  Similar problems can occur in child protection when social workers or other professionals become wrongly convinced that an abusing parent is caring for a child appropriately. 

Situation awareness poses some particular problems for child protection. One is that it is often difficult to obtain direct information from children themselves about what is happening, especially when they are very young.  Another problem is that parents and family members may attempt to mislead by telling untruths or distorting reality to protect themselves. 

There is a big literature on situation awareness which I cannot begin to summarise here. Two types of situation awareness error do seem to be particularly relevant to child protection. The first is 'confirmation bias' which involves a professional paying disproportionate attention to information which supports a working hypothesis formed earlier on. It is only too easy for a social worker, who is required to form a relationship with a mother or father, to begin to see their strengths and ignore their weaknesses. Forms of aberrant behaviour may simply be explained away.

Another type of situation awareness failing is 'fixation error'. This occurs when professionals become too focused on one task or aspect of the work to the exclusion of more important tasks. For example the pilots of a wide-bodied airliner were preoccupied with a landing gear warning light during an approach to Miami International Airport, so much so that they failed to notice that the plane was losing height. It eventually crashed into the Everglades with large loss of life.  In child protection work professionals may become too focused on one child in a family, to the exclusion of siblings, or become focused on the needs of the carer rather than the child.  Manipulative parents can exacerbate fixation errors by feeding erroneous information to the worker.

Being aware of the possibility of confirmation bias and fixation error is the first step on the road to recognising them in one's own practice and the practice of others.  In the long-term we may be able to design services and the working environment so as to minimise the likelihood of these types of failings occurring.

Thursday, 24 January 2013

Human factors thinking is central to child protection

I believe human factors thinking is central to child protection. It is not just another add-on and certainly not the latest passing fashion.  It is central because child protection activities are not only inescapably error-prone but also because child protection activities are inescapably connected to human relationships. In the final analysis a child is protected from abuse and neglect because another human being - a professional or practitioner - understands the situation, forms a relationship with the child and the family, influences other professionals and practitioners and those who control resources, communicates accurately about the problems, makes sound decisions and works creatively with others to make the child safe.

Thus it is most appropriate for human factors to be a focus of training for child protection workers. They need to develop and maintain the necessary skills. And human factors thinking can also provide a framework for monitoring services and evaluating staff.  That is because service quality crucially depends on how effective individuals are in maintaining an appropriate portfolio of human factors skills. So staff should be regualrly assessed. 

And human factors thinking also provides a foundation for the design of child protection services.  Designs which promote attention to the work environment, good decision making, clear communication and effective teamwork, while reducing employee stress and fatigue, should be the aim.

Different commentators classify human factors skills differently. Flin et al, in their generally excellent book [1], talk of seven skills - see my previous post. I would add assertiveness as an additional separate category, which Flin et al deal with under the broad heading of communication. I am also inclined to combine managing stress and fatigue into a single category

So my list of human factors skills looks like this:

Situation awareness 
Managing stress and fatigue

In the next few posts I am going to say just a little about each. To learn more try reading Flin et al or consider taking a human factors course (e.g. http://www.atrainability.co.uk/). 

[1] Flin, R. O'Connor, P. and Crichton, M. "Safety at the Sharp End" Ashgate 2008

Thursday, 3 January 2013

Human Factors – the key to safer practice

Pick up any book or training manual on what are variously referred to as ‘human factors’, ‘non-technical skills’ or ‘crew resource management’ [1] and you will see reference to a set of skills that are important for the safe performance of tasks in any safety critical industry.

For example a recent textbook [2] lists the following seven areas:

  • Situational awareness / being aware of the work environment
  • Making decisions
  • Communication
  • Teamwork
  • Leadership
  • Managing stress
  • Coping with fatigue

Human factors training, now mandatory in all western airlines and increasingly used in medicine and a variety of transport and engineering industries, concentrates on increasing employees’ skills in these areas.

The assumption is that we are all prone to error. We work in organisations and environments that have imperfect defences against human error [3]. The human being - the employee, the professional - is the last defence against what may turn out to be a catastrophic failure. So it follows that the employee must be best equipped to detect, avoid and mitigate errors as they arise in the workplace.

Learning some simple, non-technical skills to address each of the seven areas is not difficult. For example being aware of the possibility of confirmation bias [4] (a natural tendency to select evidence that confirms what we already believe to be the truth) helps decision-makers review the evidence again more critically.

Being better equipped to communicate more clearly and assertively, and to listen more attentively, especially to junior colleagues, can help avoid the kind of misunderstandings that contributed to the Tenerife (Los Rodeos) and Kegworth air disasters [5] [6].

And understanding the impact of stress and fatigue helps us avoid overloading colleagues, and indeed ourselves, to the point where our ability to make sound decisions is impaired.

The relevance of all this to child protection seems to me self-evident. Children like Maria Colwell, Jasmine Beckford, Tyra Henry, Victoria ClimbiƩ, Peter Connelly and Khyra Ishaq died NOT because those responsible for their care were professionally incompetent or negligent. Rather the failures stemmed from skills deficits that might have been rectified had those concerned studied and trained in human factors.

Child protection must be no exception. If human factors training is good enough for other safety critical sectors, such as airline pilots and surgeons, child protection professionals must also embrace this way of thinking. The result will be safer practice and safer children.     

Want to find out more? Look at:


[1] Wiener, E. Kanki, B and Helmreich, R. (1993) (eds.) Cockpit Resource Management. SanDiego: Academic Press

[2] Flin, R. O’Connor, P and Crichton, M. (2008) Safety at the Sharp End: a guide to non-technical skills. Farnham: Ashgate.

[3] Reason, J. (1997) Managing the Risks of Organisational Accidents. Aldershot: Ashgate.

[4] Wason, Peter C. (1960), "On the failure to eliminate hypotheses in a conceptual task", Quarterly Journal of Experimental Psychology (Psychology Press) 12 (3): 129–140, doi:10.1080/17470216008416717, ISSN 1747-0226

[5] Weick, K (1991) “The vulnerable system: an analysis of the Tenerife air disater.” Journal of Management 16, pp 571-593

[6] AAIB (1990) Report on the Accident to Boeing 737-400 G-OBME near Kegworth, Leicestershire on 8th January 1989.  Air Accident Report 4/90. London: HMSO

Second thoughts about IT for A&E?

Since writing my recent post cautiously welcoming the new IT system for A&E I have been quite impressed by some of the arguments against the system! 

A letter in the Guardian from Dr Richard Turner makes a good point that a possible “… unintended consequence that worried parents will delay or avoid seeking a medical opinion” is an obvious risk. http://www.guardian.co.uk/society/2013/jan/01/protect-children-from-abuse

A similar point is made elsewhere by someone with whom I do not often agree, Frank Ferudi. http://www.spiked-online.com/site/article/13219/

I think that it is sensible that people treating a child in A&E should know whether the child is subject to a child protection plan. Surely that’s what we hope to achieve by such a plan – that all professionals coming into contact with the child will be aware that this is a child believed to be at risk. And it is essential that medical professionals are aware that a child is in care, because the local authority has parental rights.

So a simple database containing these facts can be justified. 

The problems come when considering what else the proposed IT system will do, and sadly the reports I have read are a bit vague about this. Any form of crude flagging based on total visits to A&E strikes me as both silly and potentially dangerous. That might easily cause people to think twice about taking an injured child to hospital.

I hope this is not what is proposed, but experience of NHS, in particular, and government IT projects, in general, always makes me cautious and pessimistic.

Wednesday, 2 January 2013

Attitudes to Child Sexual Abuse

There was an interesting discussion this morning on BBC Radio 4’s Today programme. Baroness Butler Sloss, a former High Court Judge who used to head up the family courts, was interviewed about the implications of the Jimmy Savile sexual abuse case. She was rather pessimistic about whether attitudes had fundamentally changed and she was critical of some police officers and other public officials who, she thought, still see some children and young people as wrong doers rather than as victims.

Peter Davies, lead for child protection for the Association of Chief Police Officers and Chief Executive of the Child Exploitation and Online Protection Centre, was also interviewed. He was more optimistic, claiming that police attitudes were changing.

I think the law also needs to change. Young people under 16 can still be arrested for prostitution offences. The Sexual Offences Act 2003 criminalises young people under 16 who engage in sexual acts as well as adults who may exploit them. No wonder that some sexually exploited young people are reluctant to turn to the police for help.

Both speakers stressed the need for people to bring concerns about sexual abuse to the attention of the authorities. Interestingly, I thought neither looked at the issue from the child’s perspective. It seems to me that a crucial issue is how we can make it easier and safer for children and young people to report abuse. 

Research shows that many sexually abused children only discuss the abuse with family and friends and do not report it to social workers or the police. Not surprisingly they are fearful of the consequences of disclosure. 

So the issue is how do we reduce that fear. In addition to ensuring that the law does not criminalise victims, we need to begin by very careful thinking about the experience of a child or young person making a disclosure. Where does disclosure happen, who hears the disclosure, how does that person behave towards the child, how safe does the child feel?

The story that the Today programme interviewer put to Peter Davies is salutatory. Apparently in a recording of a police officer interviewing a girl, who was one of the victims of sexual exploitation in Rochdale, the officer can be heard loudly yawning as the young person details what happened to her.