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September 2023

An epic failure, confirmation bias and the Japanese art of kintsugi

Estimated reading time: 7 minutes

Last month I had a face to face meeting with Heather, the board chair. We were meeting roughly halfway between Norwich and the Lincolnshire Wolds, where Heather lives. We were getting together to do some planning, to map out what is happening. There’s a lot going on at the moment:

  • seven ‘live’ Safeguarding Adults Reviews
  • a peer review with Wigan SAB
  • the development of a framework document (for thinking about safeguarding concerns between health providers and the local authority)
  • planning for the board development day
  • getting the annual report published … to name just a few things.

After joining a quick meeting with national colleagues, I was running a bit late. No worries, I knew where I had to be.

My journey had lots of tractor action, but no worries, I was going to make the meeting on time. I arrived and found the venue and still had six minutes to spare!

I was feeling very pleased with myself. A helpful woman greeted me on reception. I explained that I had come for a meeting with a colleague but i got a mystified response. She checked the room booking diary and it was blank!

Could it be MY mistake? A quick call to the board chair and YES, it was. I had managed to arrive:

-  At the wrong venue
-  In the wrong town
-  In the WRONG county!

I should have been at Wisbech library, not the library in Spalding! I felt embarrassed and rather foolish. 55 minutes later I arrived where I should have been.

As I drove the across South Holland into Cambridgeshire, berating myself as I went, I tried to understand why I had made such a mistake. It is not like Wisbech and Spalding have similar names!

I realised in planning my schedule I was looking for information to confirm what I thought I would be doing. In the rush to leave the house on time, I guess I used information which supported my anticipated day’s work:

‘I must be at my meeting on time, the A47 and A17 are going to be busy, I don’t want to be late, better get my skates on.
I need to get to … Spalding’.

The more I used this information, the more it compounded the mistake. When asking my colleague to set up this meeting at a venue between our two locations, I’d said, ‘Try Spalding library, they have meeting rooms’.

Just before I closed the laptop I did a final check on Google Maps, ‘travel time to … Spalding’.

Confirmation bias

This is confirmation bias. A tendency to search for, interpret, favour and recall information in a way that confirms or supports one's prior beliefs or values (and ignoring information that is inconsistent with these beliefs). It occurs when we filter out potentially useful facts and opinions that don't coincide with our perception. See Confirmation Bias In Psychology: Definition & Examples.

This biased approach to decision making is largely unintentional. These beliefs can include a person’s expectations in a given situation and their predictions about a particular outcome. People are especially likely to process information to support their own beliefs when an issue is important to them. One of the elements of confirmation bias is biased memory. To confirm their current beliefs, people may remember/recall information selectively. My memory that morning was the venue was the library in Spalding, so I set off to Spalding without searching for information to the contrary.

We need to understand confirmation bias and take steps to guard against it, as it prevents us from working in a person-focused way or effectively assessing the risks that the adult faces. It means we naturally seek to find evidence that supports the fixed view we may hold, and objective ‘data’ or information is avoided, ignored or disregarded.

Cognitive bias blunts our opportunities for professional curiosity. The bias degrades our judgements when our initial beliefs are wrong because we might fail to discover what is really happening until it is too late.

In an excellent article called ‘Could curiosity save lives? An exploration into the value of employing professional curiosity and partnership work in safeguarding adults under the Care Act 2014’, Helen Thacker, Ann Anka and Bridget Penhale say:

‘Observations from practice, and evidence drawn from a number of SARs, suggest that confirmation bias occurs when we filter out potentially useful facts and opinions that do not match our preconceived ideas. When this happens, thinking around a case becomes ‘fixed’ and there is a lack of openness to new knowledge that could alter the established paradigm.’

 Thacker, Anka and Penhale describe a Safeguarding Adults Review (SAR) published by West Sussex Safeguarding Adults Board (Boxall, 2018), concerning two men with profound learning disabilities, cerebral palsy and osteoporosis. Both men lived in the same residential care home, and both were admitted to hospital and found to have suffered fractures to their femurs. At an early stage, handling and moving was the emerging explanation, and this was never strongly challenged:

‘Confirmation basis appears to have reduced ‘professional curiosity’, leading to the lack of consideration of other possibilities’ (point 8.5 Safeguarding Adult Review In respect of Matthew Bates and Gary Lewis)

It takes effort and time to reflect, but we must do it if we are to make accurate observations, appropriate judgements and good decisions in safeguarding of people at risk.

A different kind of ‘failure’?

In her new book – Right Kind of Wrong: Why Learning to Fail Can Teach Us to Thrive, Dr Amy Edmondson Novartis (Professor of Leadership and Management at Harvard Business School) argues that most people view failure as what it says about us and how our life is going – ie. if it is going well, you’re not experiencing failures. So we think that avoiding failure is obviously the right goal. This instinct is so strong that we can find ourselves upset about the smallest missteps, even the comment that falls flat in a meeting (I would add not turning up at right place for the meeting in the first place!). See The big idea: why we need to learn to fail better The Guardian 28 August 2023.

Dr Edmondson makes a compelling argument that:

‘In our lives, and in our organisations, most of us would benefit from experiencing more failures, not fewer.’ She argues that the idea of failing well (‘intelligent failures’) - where the upside more than compensates for the downside – can be learned.'

Be kind to yourself

When my colleague stopped laughing after I had told her the story of my epic fail and how cross I was with myself, she said:

‘Well, it happens to us all, be kind to yourself.’

A few days later, an unrelated email arrives from a colleague at the University of East Anglia with information about 'mini Kintsugi' projects.

Not knowing the first thing about Kintsugi I had to look it up. Kintsugi (‘golden joinery / to join with gold’) is the Japanese art of repairing broken pottery by mending the cracks with lacquer dusted or mixed with powdered gold, silver, or platinum.

For the Japanese, it’s part of a broader philosophy of embracing the imperfection and transience of life (wabi-sabi). Using 'gold' to join the broken parts in kintsugi highlights the object’s unique beauty as a whole - How the philosophy behind the Japanese art form of kintsugi can help us navigate failure (The Conversation 08 November 2022). Also see Kintsugi: Japan’s ancient art of embracing imperfection BBC Travel 08 January 2021.

It's a 15th-century practice reminder to stay optimistic when things fall apart and to celebrate the flaws and missteps of life as valuable opportunities in themselves.

Driving to the wrong venue, in the wrong town, in the wrong county is certainly a misstep (!) but without that journey,
I would not have had time to think about confirmation bias and its importance in safeguarding adults practice.

Thank you.

Walter Lloyd-Smith

NSAB Board Manager

Email: [email protected]