Non-technical Skills for
Child Protection
Professionals: The
Importance of Human
Factors
Introduction
We use non-technical skills at work in addition to the technical skills that we acquire through professional training. In fields, like child protection,
where service failures can result in death or serious injury, non-technical skills
are vital. This is because it is not only technical skills and professional
knowledge that contribute to the safety and quality of services. Often, it is
how well we do routine, everyday tasks that is the crucial factor. Besides, it
is usually easier to improve non-technical factors than it is to make significant
advances in technical knowledge. Making small, regular enhancements and
changes to the way that we work can have a profound long-term impact
(Imai, 1986).
An emphasis on non-technical skills is highly congruent with Schön’s (1983)
idea of reflective practice. Professionals, Schön argues, cannot just rely on
technical knowledge. They need to learn from their everyday experiences. He
argues that ‘reflection-in-action’ (in addition to ‘technical-rationality’) is
essential to the development of professional services.
We use the term ‘human factors’ in this paper to mean factors in the work
environment or system impacting on how safely and effectively people operate
at work. Often, the phrases ‘human factors’ and ‘non-technical skills’ are used
interchangeably. Different authors use different classifications of non-technical
skills. The seven skills classification of Flin et al. (2008) is now widely
accepted, but for this continuing professional development paper, we focus
on just three of their skills areas: situation awareness, decision-making and
communication.
Serious Case Review reports reveal that service failings in child protection
frequently involve errors in assessing situations, making decisions and sharing
information. These are also areas in which improvements are likely to make a
significant impact in delivering higher quality and more effective and efficient
services. For example, getting a decision right first time means that a child is
*Correspondence to: Chris Mills, Former Child Protection Social Worker, Devon, UK. E-mail chris.j.
[email protected]
Continuing
Professional
Development
Chris Mills*
Devon, UK
Harry Harrison
Safeguarding Solutions, Whitstable,
UK
Trevor Dale
Atrainability Ltd, Cranleigh, UK
‘In fields, like child
protection, where
service failures can
result in death or
serious injury,
non-technical skills
are vital’
© 2021 John Wiley & Sons, Ltd. Accepted: 03 September 2020
Child Abuse Review Vol. 30: 174–181 (2021)
Published online in Wiley Online Library
(wileyonlinelibrary.com) DOI: 10.1002/car.2676
protected more quickly, and time and effort are saved in not having to revisit
the decision at a later date.
In what follows, we examine how human factors knowledge has developed
and summarise the evidence. We suggest how practitioners might acquire
new knowledge and competence in non-technical skills, progressively
becoming more effective in protecting children. However, achieving lasting
service improvements and creating a responsive safety culture in organisations
is never just a matter of frontline practitioners developing their skills and
knowledge. Managers, policymakers and leaders have crucial roles in creating
cultures where understanding human factors in the workplace flourishes, using
that understanding to develop safer, better and more reliable systems.
Context Setting
Human factors training has its roots in civil aviation. As airliners became more
sophisticated and reliable during the twentieth century, human error was found
to account for a larger proportion of accidents (Wiegmann and Shappell,
2003). Improvements in safety were thus dependent on reducing the impact
of human error. Research findings on pilot error were used to develop short
courses, at first for pilots and then for other flight crew (Helmreich, 2000).
Technical and other ground staff followed. By the mid-1990s, such training
became mandatory for US and European airlines. The methodology was
incorporated into staff appraisals and, indeed, all aspects of work.
A critical issue is the culture of blame. Reason (2000) outlines two
approaches to safer organisations. We can focus on individuals and blame them
for their human failings, resulting in frightened employees who are wary of
discussing how and why things go wrong. More constructively, we can focus
on understanding working practices and seek ways to strengthen our defences
against errors and identify ways to improve quality. This results in widespread
learning, safer systems and better services.
A Dutch psychologist, Dekker (2007), shows that blame frustrates the
development of a reporting culture, in which individuals feel confident to
report safety and quality issues and join in work to reduce or mitigate the
impact of human error. A just reporting culture is one where employees who
make mistakes, committed while acting in good faith, need not fear sanction
or discipline.
In order to learn from practice, practitioners have to be free to examine what
they do and to reflect on it. Organisations can make that difficult if seniors are
only interested in identifying failures and blameworthy activity. But they can
make it easy, for example, by creating ‘safe spaces’ in which frontline workers
can examine and reflect (Morath and Leary, 2004). The aim should be to move
organisational culture away from blame and shame towards discovery and
understanding. Focusing solely on mistakes ignores the majority of occasions
when a successful outcome occurs. Indeed, learning from good practice is as
vital to developing a continuous improvement culture as learning from things
that go wrong.
Aviation professionals have progressively adopted a just reporting culture
while developing non-technical skills training. Short courses are supplemented
by frequent top-ups. This model has spread to other fields, including other
‘We examine how
human factors
knowledge has
developed and
summarise the
evidence’
‘A just reporting
culture is one where
employees who
make mistakes,
committed while
acting in good faith,
need not fear
sanction or
discipline’
Non-technical Skills for Child Protection 175
© 2021 John Wiley & Sons, Ltd. Child Abuse Rev. Vol. 30: 174–181 (2021)
DOI: 10.1002/car
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transport industries, the nuclear industry, surgery and anaesthesia. A recent
report by Health Education England (2019) notes that this approach results
in ‘positive impacts on patient safety’ and recommends human factors training
be implemented across the NHS (p. 5).
By definition, a non-technical skills approach applies across a wide range of
professions and occupations, focusing on those skills and knowledge that we
use whatever our profession and whatever technology that we use. Child
protection, as a multiprofessional activity, stands to gain significantly by
adopting such an approach. Human factors thinking can provide a framework
in which all child protection professionals and practitioners can create
improvements using a common language.
Brief Summary of the Evidence Base
There is much experimental evidence for the importance of human factors,
drawn from the psychology of human error and the study of organisational
behaviour. The briefest of summaries follows. Unless otherwise stated, the
studies mentioned are North American.
A British psychologist, Reason (1990), sets out the underpinning model.
Human error is inevitable, having its roots in the same skills that we use to
learn and perform at work. The challenge is not to eliminate error, but to
understand it better, build organisational defences and create the conditions
under which people can work to mitigate human fallibility (Reason, 2000).
Research demonstrates that situation awareness is a complex and
error-prone process, especially where information is missing, difficult to access
or misperceived (Endsley, 1995). The small capacity of our working memory
necessitates matching sensory inputs with patterns (or schemas) held in
long-term memory. This creates an unavoidable potential for mismatching
(Reason, 1990).
Experimental subjects asked to pay attention to a situation can demonstrate
inattentional blindness or change blindness (failures to notice very obvious
events or important changes), particularly if they are distracted or fixated by
a task requiring them to concentrate hard on something else (Simons and
Chabris, 1999).
Cognitive biases are systematic errors in thinking that interfere with
situation awareness. Confirmation bias (Nickerson, 1998) is a tendency to
select and focus on information that confirms the preconceptions held by that
individual. It occurs frequently in accounts of British child protection failures
(Munro, 1999).
Research into decision-making reveals a contrast between intuitive decisionmaking and analytic decision-making. In making decisions, we mostly depend
on intuitive processes. We see a situation, assess it, drawing on past experience,
and decide quickly, without much conscious thought. This approach is
necessary because of pressures of time. Usually, it is effective, but it is more
prone to error and bias than the analytic approach (Kahneman, 2011).
In contrast, analytic processes involve the systematic assembly and weighing
of evidence for and against different options. More reliable, generally safer and
more effective, they are often too slow and absorb much energy. Evidence
‘Human factors
thinking can provide
a framework in which
all child protection
professionals and
practitioners can
create improvements
using a common
language’
‘Research into
decision-making
reveals a contrast
between intuitive
decision-making and
analytic decisionmaking’
176 Mills et al.
© 2021 John Wiley & Sons, Ltd. Child Abuse Rev. Vol. 30: 174–181 (2021)
DOI: 10.1002/car
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shows that decision makers will switch between intuitive and analytic modes,
pursuing the latter only if time allows (Croskerry, 2005).
Group decisions, common in child protection, can be effective because
information from a variety of standpoints is shared and the decision-making
process is reviewed by a wider group of people. But group decisions are also
prone to error. Janis (1982) has described the phenomenon called groupthink,
in which the desire for consensus among group members (sometimes driven by
demagogic or aggressive leadership) results in poor, uncritical and irrational
decisions. Harvey (1974) describes the Abilene paradox where group decisions
may conflict with the individual preferences of group members, often because
of a desire not to rock the boat. Stoner (1968) observed risky shift, where group
decisions were more extreme and hazardous than decisions made individually.
Klein (1998) relates how story telling is an important aid to making better
decisions in the fire service. Recounting past experiences, he argues, exposes
firefighters to scenarios which they are yet to encounter, exploring how others
have dealt with specific decision challenges.
Communication failures have characterised many child protection tragedies.
Research reveals straightforward problems of communication, falling into four
categories: the message was sent or received too late; significant individuals did
not receive the message; the message was incomplete or inaccurate; and issues
arising from the message were not resolved (Lingard et al., 2004). Interruption
and distraction can be important impairments to good communication.
Integrated computer records bring new communication challenges.
Difficulties have emerged, reported in a British study, of time-consuming
inputting of data and the inability of some systems to accommodate the
information that practitioners wish to input (Broadhurst et al., 2010). There
is a danger that inputting data to a system displaces appropriate communication
and understanding between individuals.
Dingley et al. (2008) demonstrated that strategies to enhance
communication were successfully implemented in an acute care setting, with
more efficient and effective communication. The use of standardised
communication formats, such as SBAR (NHS Improvement, n.d.), was shown
to be a powerful aid to better communication.
Flight-deck communication failures reveal a tendency for junior crew
members not to speak up when they see things going wrong (Bienefeld and
Grote, 2012). It is clear that, in addition to timeliness and clarity, confidence
to speak up is an important determinant of effective communication. Such
confidence can be fostered by organisational culture. Individuals can also be
trained to be better at speaking up and better at hearing colleagues who have
something to say.
Summary of the Key Learning Points for Practice
Child protection practitioners who have acquired a basic knowledge of human
factors can begin to investigate ways to improve their non-technical skills. The
aim is to achieve higher quality and safer services. The challenge is taking
what is done elsewhere (e.g. in civil aviation and healthcare settings) and
adapting it to the environment of child protection. The journey is one of
gradual and continuous improvement. Organisations should develop reporting
‘Communication
failures have
characterised many
child protection
tragedies’
Non-technical Skills for Child Protection 177
© 2021 John Wiley & Sons, Ltd. Child Abuse Rev. Vol. 30: 174–181 (2021)
DOI: 10.1002/car
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mechanisms, working practices, training and development to support and
nurture an environment in which learning from practice can flourish. The focus
needs to be not merely on what happened, but on how and why it happened, so
discovering ways in which organisational defences can be strengthened and
working practices improved.
Situation Awareness
Observation skills and the ability to evaluate situations are crucial in child
protection. Failures of situation awareness feature strongly in accounts of child
protection tragedies. Sometimes, what looks ‘obvious’ with the benefit of
hindsight is obscured at the time of the incident, a fact that is dramatically
evidenced in the accounts of the deaths of Baby Peter Connelly, Victoria
Climbié, Kyra Ishaq and Daniel Pelka.
Practitioners need to understand how the senses can deceive. They need to
identify factors which lead toward inattentional or change blindness, looking
particularly at how distractions interfere with situation awareness. They also
need to understand factors that promote good situation awareness. Having a
good briefing and regular updating, and avoiding situations in which acquiring
situation awareness is rushed are all important (Flin et al., 2008).
Attention should also be given to minimising overload, stress and fatigue – often
difficult in overstretched organisations. Reducing interruption and distraction may
be achieved by eliminating, wherever possible, multitasking, and creating less
‘noisy’ and distracting working environments. Methods should be devised to
recognise and reduce confirmation bias and similar distortions of thinking.
Frequently reviewing the ‘working hypothesis’ in a case is one approach.
An important way in which to improve situation awareness is to allow
judgements to be challenged and if necessary revised. All team members
require the ability and confidence to speak up if they see things differently.
Everybody should be helped to welcome and accept challenge and dissent.
Such skills can be learned.
Decision-Making
Poor decision-making is common in child protection cases that result in Serious
Case Reviews. Practitioners must find more ways to engage in analytic decisionmaking, but often pressures of time and resources make this difficult. The people
who are best placed to make intuitive decisions, often they are the most
experienced, need to be in key frontline roles. A culture of confidently
reviewing, questioning and challenging decisions should be created and sustained. Less experienced people should not be placed unnecessarily in positions
requiring them to make intuitive decisions for which they are ill-equipped.
Analysis and improvement should be focused on group processes, such as
child protection conferences. Attendees, particularly those who chair, must
be alert to dysfunctional group dynamics and reduce irrational pressures
towards achieving consensus. New approaches must help participants to
express dissenting views constructively and confidently.
There is clearly potential in child protection for ‘story telling’ as an aid to
better decision-making. Revisiting past decisions and rehearsing scenarios
are straightforward techniques for building confidence, especially among less
‘The focus needs to
be not merely on
what happened, but
on how and why it
happened’
‘Everybody should
be helped to
welcome and accept
challenge and
dissent’
178 Mills et al.
© 2021 John Wiley & Sons, Ltd. Child Abuse Rev. Vol. 30: 174–181 (2021)
DOI: 10.1002/car
10990852, 2021, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/car.2676 by Flinders University Library, Wiley Online Library on [26/03/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
experienced practitioners. ‘Safe spaces’ need to be created in busy professional
lives for this to happen.
Communication
Reducing background ‘noise’ and distraction is central to a good communications strategy focused on achieving timely, clear and well-understood
communications. The introduction of standardised communication formats
should be considered, alongside systematic approaches ensuring that
communications are received, understood and acted on appropriately. A culture
in which everybody is confident of speaking up if uncertainties arise during
communication should be developed.
Test your Knowledge
1 Which ONE of the following best describes non-technical skills?
a Skills used at work
b Skills used at work in addition to technical skills
c Skills acquired during professional training
d Less important work skills
2 Which ONE of the following is NOT a means of creating a responsive safety
culture?
a Understanding the conditions under which people work
b Building stronger organisational defences against error
c Identifying erring practitioners and calling them to account
d Developing a reporting culture
3 Which ONE of the following best describes confirmation bias?
a A tendency to focus on information that confirms the preconceptions held by that
individual
b A failure to notice very obvious events or important changes
c A tendency to focus on details that do not matter
d A tendency to focus on information which is true
4 Which ONE of the following statements is FALSE?
a Group decisions may conflict with the individual preferences of group members
b Groups always make safer decisions than individuals acting alone
c Analytic decision-making is slower, but safer, than intuitive decision-making
d Decision makers can swap between analytic and intuitive modes
5 Which ONE of the following is demonstrated by a study reported in this paper?
a Communication strategies cannot be implemented in acute settings
b Junior flight crew members sometimes fail to speak up when they see things
going wrong
c Standardised communication formats are of little practical value
d Distraction and interruption are not usually important factors impinging on safety.
The answers can be found at the end of the paper.
‘A culture in which
everybody is
confident of
speaking up if
uncertainties arise
during
communication
should be developed’
Non-technical Skills for Child Protection 179
© 2021 John Wiley & Sons, Ltd. Child Abuse Rev. Vol. 30: 174–181 (2021)
DOI: 10.1002/car
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Reflection
Child protection practitioners, of all kinds, can improve their non-technical
skills by acquiring human factors knowledge and applying it in their
workplaces. Good outcomes are often achieved when an individual reflects
on his or her own day-to-day work and gains an understanding of the factors
which dispose to good or poor practice. The aim is to identify working
practices, procedures and organisational arrangements that can result in safer
and higher quality services. Small and frequent improvements have the
potential to cumulate and thereby to create significantly better services. An
important contextual factor is the creation of a just reporting culture, without
which it is hard for workers to reflect and learn from the outcomes of their
work.
Acknowledgements
We are indebted to Pat Cooper and Emily Arkell for their helpful comments on
an early version of this article.
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Answers: Test Your Knowledge
1 b; 2 c; 3 a; 4 b; 5 b.
Non-technical Skills for Child Protection 181
© 2021 John Wiley & Sons, Ltd. Child Abuse Rev. Vol. 30: 174–181 (2021)
DOI: 10.1002/car
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