When undertaking a recent interdisciplinary team safeguarding supervision session, there was a theme of reoccurring expressions used such as “something at the back of my mind’, “it didn’t feel quite right”, “my instinct was trying to tell me.” These expressions were being used retrospectively and in relation to families that had only later been subject to safeguarding enquiries. As the discussion moved on to how we might change our practice to identify concerns earlier, the supervisor suggested exercising more professional curiosity.
The term “professional curiosity” is often used in relation to serious case reviews, where staff are identified as accepting things on face value and not asking probing questions to create a clearer picture of events; but what exactly does this mean for practice? This paper will critically review the literature surrounding professional curiosity and discuss the main themes identified, along with their relevance to practice for all health and social care professionals (HSCPs), with a focus on the children and young people (CYP) diabetes clinic.
What is professional curiosity?
Following on from the historic Laming Report (2003) revealing serious shortfalls in the way the health and social care system operated around CYP with safeguarding concerns, The National Service Framework (Department of Health, 2004) clarified that:
“The high cost of abuse and neglect both to individuals (and to society) underpins the duty on all agencies to be proactive in safeguarding children.”
For HSCPs working with CYP with diabetes, the poignancy of this is demonstrated in the direct link between psychosocial adversity and poor diabetes management (NICE, 2015; Delamater et al, 2018). The evidence-based review from Delamater et al (2018) goes as far as to state that:
“Psychosocial factors are the most important influences affecting the care and management of diabetes.”
Yet, nearly 20 years on and the triennial analysis of serious case reviews (SRCs) identify the same shortfalls in practice as Laming (2003); namely, a lack of professional curiosity and inadequate information sharing and communication among and between all agencies (Brandon et al, 2020). Clearly, professional curiosity as a core skill in the HSCPs’ toolkit is still not universally practiced.
As Thacker et al (2019) identify, there is no clear definition of professional curiosity, rather a set of characteristics conducted by HSCPs in order to understand what is truly happening within a family. The consensus is that these involve being open to the unexpected, asking pertinent questions to explore beyond what is seen at face value, and “thinking the unthinkable” (Burton and Revell, 2018.)
“Respectful uncertainty” (Laming, 2003) is a core element of professionally curious practice and relates to HSCPs applying critical evaluation to all information received from families and carers. The complexity of its meaning is highlighted in Phillips et al’s recent paper (2022) exploring professional curiosity within the probation service, where they suggest it takes on a different form depending on a context of risk assessment (safeguarding), therapeutic purposes, or knowledge building.
Similarly, Kidd and Hayden (2015) argue that instead of attempting to define it, the motive for information-seeking should be considered. There is merit to this view; the complexity of safeguarding cases mirror the nuances of professional curiosity, so focusing on the need for a definition perhaps seems trivial.
Burton and Revell (2018) suggested, however, that a cross-agency understanding of the definition would help move towards a shared understanding of how to deploy professional curiosity in practice.
Current understanding within Health and Social Care Practice
There is a notable absence of the term “professional curiosity” among the everyday language used by HSCPs. Most of the literature surrounding the term lies within SCRs and the social work profession, and the resources available to HSCPs are mainly within local safeguarding partnership platforms online. Such resources vary between Trusts and are not ubiquitous across services. As Phillips et al’s (2022) exploratory study demonstrates, within the service of probation in England and Wales, six widely varying definitions of the expression were understood among probation officers. This leads to the question of how other disciplines within HSCPs interpret the meaning of what is meant to be a core skill, practiced by all.
Neither professional curiosity, or respectful uncertainty are clearly defined or even acknowledged within the codes of conduct for nurses, doctors or allied health professionals. Furthermore, this concept appears not to be acknowledged in national policies for all people working with CYP. There appears to be a serious gap in the guidance for HSCP’s practice.
Supporting one another to be professionally curious
Professional curiosity cannot be discussed without recognising its direct relationship with inter-agency working. A recurrent theme in literature and SCRs is that a lack of inter-agency work can limit the benefits of effective professional curiosity (Brandon et al, 2020; Thacker et al, 2019). As Thacker et al (2019) point out, the two are of equal importance; one without the other is less than the sum of its parts. This is exemplified in SCRs where silo-working within and between agencies has led to broken down communication channels and information not reaching agencies who may have identified an issue that others had not perceived as such (Brandon et al, 2020). Essentially the chance to pursue an instinct through the vehicle of professional curiosity was missed.
Burton and Revell (2016, 2018), Thacker et al (2019) and DoH (2020) all identify complex behaviors that can act as barriers to effective professional curiosity. Behaviors from HSCPs include “confirmation bias”, which refers to subconsciously confirming one’s own view, “over-optimism”, which is wanting to belief a more positive truth or “willful blindness”, which is failure to explore a sign or instinct. Other behaviours include “normalisation”, when staff become de-sensitised to certain behaviours or red flag signs, and “knowing but not knowing” which refers to not having the evidence to back up an instinct.
Furthermore, CYP and families/carers may show “disguised compliance” whereby they appear to be co-operating with HSCPs, while hiding concerning behaviors and distracting from chances to be professionally curious. The scope of this article does not allow for a deeper exploration into these areas, but effective inter-agency working is one step to overcoming such barriers. As Thacker et al (2019) make clear, inter-agency working results in improved collation of holistic information, a clearer picture of events and so increases HSCP’s confidence to respectfully question any doubts both to families and other professionals.
Role of the clinic
The CYP diabetes clinic is a perfect set up for inter-agency working with CYP and their families, especially where Trusts practice with a mix of consultants, nurse specialists, psychologists, and dietitians in the room. These teams are also in the unique position of working both in acute services and within the community, thus creating opportunities to develop communication channels across agencies. Where Trust practice involves the nurse specialist reviewing injection sites in a separate room, there is an opportunity for the CYP to express any concerns or feelings they feel unable to do so in the company of their parents/carers. Clinic consultation is a complicated process, however, and the way we communicate is pivotal to enabling a collaborative, person-centred experience for people living with diabetes. As Odiase at al (2021) describe, there is a need to balance the “science” of information gathering, with the “art” of creating a care plan in partnership with CYP and their families. It is well understood that the language used in clinic has a far-reaching impact in terms of building or destroying the rapport with a CYP and their family, and their ability to manage the condition (Lloyd et al, 2018; Phillips et al, 2021).
Hence, it is no surprise that another barrier to practicing professional curiosity is that HSCPs are fearful of ruining existing positive relationships with CYP and their families. Burton and Revell (2018) explore the notion of “tension” during encounters between HSCP and CYP and their families. They identify the emotional toll on HSCPs when inquiries are met with hostility and resistance from family members; it is easier to retain a positive relationship and move away from any topics causing tension. Yet, as Kashdan et al (2013) argue, feeling tense and uncomfortable are all integral to being curious and exploring darker issues. It seems these feelings are inherent to effective professional curiosity. In fact, analysis of SCRs suggest that an already positive relationship between HSCPs and CYP and their families will withstand any tense moments in a consultation, and that good relationships with families are the primary driver for protective practice (Brandon et al, 2020). This further emphasises the important role of the diabetes clinic as a place for exploring any safeguarding risks and the need for professional curiosity to be embedded in consultations.
Creating a culture of curiosity
There is an apparent need for ongoing supervision in practice to support staff in overcoming barriers to practicing professional curiosity. Burton and Revell (2018) point out:
“If avoiding the source of trauma is a natural defensive mechanism to uncomfortable feelings, this poses questions about how we prepare… to engage with tension, uncertainty and be emotionally astute enough to recognise this as a signal to push for further information.”
Conway et al (2020) recognised within their Trust that, due to a lack of relevant skills, HSCPs would refer responsibility for safeguarding concerns to the senior clinician. This was resulting in missed opportunities to be professionally curious. From this, they created a “fishbowl” simulation workshop to build staff confidence and competence in managing CYP safeguarding concerns in Salisbury. The feedback gathered from the 32 HSCPs who attended the workshop was unanimously positive, with staff feeling more confident in practicing professional curiosity and challenging other professionals’ over-optimism (Conway et al, 2020).
Duckett (2021) shows similar findings from their report on the education workshop they developed for safeguarding CYP in Sussex. Again, lived experience case studies were used for role play and reflection. Staff reported that the supervised workshops were invaluable for enlightening them to professional curiosity, encouraging deeper thinking and questioning beyond the obvious (Duckett, 2021). Although limited to participant feedback for analysis of results, both these cases suggest there is huge potential for such training and supervision to support HSCPs in practicing effective professional curiosity. It is proposed here that similar workshops should be rolled out nationally, with rigorous follow-up research to evaluate the longer-term outcomes for CYP with safeguarding concerns.
It has been pointed out that professional curiosity is not yet commonly understood or recognised as a core skill across agencies within health and social care. As supported by Thacker at al (2019), it seems clear that a good starting point for encouraging a culture of curiosity would be to define professional curiosity and embed this within all foundation training for HSCPs.
As Kedge and Appleby (2010) point out, if staff are expected to carry out life-long learning as part of their professional practice, the art of inquisition needs to be taught as a prerequisite skill.
It is widely acknowledged that supporting CYP and their families where there are safeguarding concerns is hugely challenging. Professional curiosity appears to have a great part to play in supporting HSCPs in their assessment and management of safeguarding concerns, yet a shared inter-agency definition and framework to guide its application in practice is absent.
This paper suggests that the recognition of the term within professional codes of conduct and in core curriculums for HSCPs would be a good starting point to an inter-agency comprehension and application within safeguarding practice. Additionally, regular, case-based simulation training as part of safeguarding supervision within Trusts appears to be of huge benefit to HSCP’s confidence and competence in practicing this nuanced skill. This should be done at an inter-agency level to encourage HCSPs to move away from the silo-working that is currently seen in practice. This could be rolled out as a trial and evaluated at varying points to establish the effects on HSCP’s practice, and the outcomes for safeguarding cases.
It is recognised that HSCPs working within the CYP diabetes services are in the unique position of having opportunities to build long-term relationships with families, and of working in both acute care and the community. It is also clear that any safeguarding issues are likely to have a negative impact on a CYP’s ability to manage the condition. Hence, there is particular weight on CYP diabetes services to develop their professional curiosity skills in order to ensure CYP are being safeguarded effectively, and information is being shared appropriately between and within agencies. Ultimately, as Thacker et al (2019) conclude:
“there is no substitute for ‘professional curiosity’ in order to ensure that assessments are holistic, that services are appropriate, and that multi-agency working is effective.” Having highlighted that the current research is predominantly based in social work publications, future research is suggested to explore the role of professional curiosity specifically within the CYP diabetes clinic.