Causal Attribution, Bias, Social Exchange Theory and parent - staff interactions

While searching for references on a 25/500 rule of neonatal resuscitation, I reconnected with the sociology problem of how people attribute behaviour (to dispositional or internal aspects like 'personality', intelligence etc or to situational/external variables like working conditions or work culture) and dived into an area that seems most useful as I process the huge cast that was Sasha's life, particularly my relations with my daughter, wife, hospital staff and other families over the whole course of care. As I wasn't finding links that authoritatively detailed 25/500, I clicked on the search result titled"An American Medic in Britain: Neonatal Opioid Withrdawal" and noticed he was in Fife where I lived awhile and looking around more I noticed a stats service called (listing the American Medic blog at 660) offering up (among many) which lead to an article about the UK deciding to discontinue statistics the author argued proved success where the policy makers decided they were redundant or misconceived ("the government’s desire to cough over the unflattering death stats may represent an entirely new category of bad science: being too dumb to know when you’ve done well.") The author ends with reference to a favorite study: "Unskilled and Unaware of It: How Difficulties in Recognizing One’s Own Incompetence Lead to Inflated Self-Assessments" and this returned me to a paper by NICU nurses on the Guarded Alliance description of partnership which require that when parents and hospital staff engage each other it is based on parent estimation of their own and staff's competence, which creates different degrees of trust, in turn allowing different degrees of parent-staff partnership. I then clicked on a commentor's reference to the fundamental attribution error (also called "correspondance bias") defined as "the tendency for people to over-emphasize dispositional, or personality-based, explanations for behaviors observed in others while under-emphasizing situational explanations. In other words, people have an unjustified tendency to assume that a person's actions depend on what "kind" of person that person is rather than on the social and environmental forces influencing the person. Overattribution is less likely, perhaps even inverted, when people explain their own behavior; this discrepancy is called the actor-observer bias." The article goes on to look at theories of the cause of the error, ways to reduce the error and the findings that this error is more likely to occur when a person is in cognitive overload and in a society that emphasises individualistic over collectivist impulses. This is sociology 101. Another link considered "how individuals "attribute" causes to events and how this cognitive perception affects their usefulness" and this lead to a reference that "the covariation model was developed by Harold Kelley in 1967. It uses three scales to explain the system that people use in order to make an internal or external attribution to a person in a given situation." Since I was born in 1967, I was immediately sensing a connection with Harold Kelly who co-developed social exchange theory with a focus on the processes and manner that we use to attribute causality and was more intrigued to read that his real world application was to view how young couples negotiate and attempt to resolve conflict, leading to two pioneering works on personal relationships, which "encouraged the examination of topics long ignored in social psychology such as attraction, love, commitment, power and conflict in relationships, etc." It makes sense to me to view family and hospital staff interactions with the lens of social exchange theory as defined as follows. "Social exchange theory is a social psychological and sociological perspective that explains social change and stability as a process of negotiated exchanges between parties. Social exchange theory posits that all human relationships are formed by the use of a subjective cost-benefit analysis and the comparison of alternatives. For example, when a person perceives the costs of a relationship as outweighing the perceived benefits, then the theory predicts that the person will choose to leave the relationship. The theory has roots in economics, psychology and sociology. For social exchange theorists, when the costs and benefits are equal in a relationship, then that relationship is defined as equitable. The notion of equity is a core part of social exchange theory. Social exchange theory is tied to rational choice theory and on the other hand to structuralism, and features many of their main assumptions." The article notes interesting critiques of the model (assumption of intimacy, birth during an individualistic 1970s era and lack of utility for cultures based on collectivist mores etc) however it really does seem very useful for investigating parent-staff dynamics by hospital educators. Then I explored the reference to "cognitive overload" and read that "Cognitive Load is a term that refers to the load on working memory during problem solving, thinking and reasoning (including perception, memory, language, etc.) Most would agree that people learn better when they can build on what they already understand (known as a schema). But the more a person has to learn in a shorter amount of time, the more difficult it is to process that information in working memory. Consider the difference between having to study a subject in one's native language versus trying to study a subject in a foreign language. The cognitive load is much higher in the second instance because the brain must work to translate the language while simultaneously trying to understand the new information. Another aspect of cognitive load theory involves understanding how many discrete units of information can be retained in short term memory before information loss occurs. An example that seems to be commonly cited of this principle is the use of 7-digit phone numbers, based on the theory that most people can only retain seven "chunks" of information in their short term memory." This seems very applicable to parent hospital interactions since 1) parents likely either don't have a schema for a situation that is unique in their lives or their schema may be biased or naive in important ways 2) parents have an extremely steep learning curve with hospital staff upon discovering their child has a serious health issue and this learning curve is greatly compounded for any family whose first language is different than hospital staff and 3) the possibility that there could be situations where there was too much information to process quickly. I experienced a type of brain freeze that I always put down to fatigue, or being asked questions when half asleep or waking up etc. However here is another cause. This topic in turn touches on many discussions I have had with parents and staff about what they were told about diagnosis and options and when; the parent default position seems to be: we want you to tell us all, all the time. This tell all approach rubs up against the medical staff dilemma (stated or not) as to whether to share information with parents when it is concrete or to share competing viewpoints or hypotheses etc transparently as they come up. Perhaps sharing all will increase parent trust of the staff who communicate transparently; however the higher information flow may force earlier shut down in the processing by parents due to load; this could leave parents trusting and more dependent on staff guidance; however in the end patient/parent responses to options can clarify for staff what is the best courses of action.

Please share your thoughts on patient/parent and staff biases in attributing causes to care events and their negotiation of the care partnership.


  1. I had to come back and read this a couple of times to be clear that I am understanding what you are saying.
    I agree that not all information is always shared with parents and when information was shared I found that the issue was not revisited in a way that helped me to process the information. Doctors disagreed, staff changed, other things came up, people were pressed for time etc.
    I agree with your closing line - parents and staff can come to an understanding of how best to give information to parents. I think this is at the core of what always resonates with me when I read your blog - a better job can be done of supporting communication and decision making.

  2. Sasha's mom2:11 PM

    Parents have to advocate for their children and understand what their role is in the care of their child. It is up to the parent to persist to get things done and to work with the medical support staff to help the child. There is no model that can prepare anyone for dealing with a sick child, and his/her parents or caregivers. I think it should be recognized that the medical support staff and parents are on the same 'team' help the child get better.
    I think it us to the parent to set the tone for the care of their child. The parent is the only person who can make decisions for their child and it is up to the parent to ask the right questions, and innitiate the lines of communication.

    This is a small bit of my opinion....
    Sasha's mom